Insurance - C & R Drains 2019-04-22AC"R " CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DDIYYYY)
DOCUMENT WITH RESPECT TO WHICH THIS
4/22/2019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT
NAME:_ Lamle Bingham
Wood Gutmann & Bogart Insurance BrokersPHONE
_
FAX
15901 Red Hill Ave., Suite 100
• 714-824-8380 A/C No: 714-573-1770
AD RIESS: Jamie w bib.com
Insurance License #0679263
INSURERS) AFFORDING COVERAGE NAIC #
------------
Tustin CA 92780
PERSONAL & ADV INJURY $ 1,000,000
INSURER A: Kinsale Insurance Company
INSURER B : Westchester Surplus Linesw'
INSURED C&RDR-1
C & R Drains, Inc
_ _ _ _ _ _ _
CompWest Insurance Company 12177
1525 W. Macarthur Blvd.#11
INSURER C: - -
Costa Mesa CA 92626
INSURER D:
INSURER E:
COMBINED SINGLE LIMIT $
(Ea accident}
INSURER F :
COVERAGES CERTIFICATE NUMBER: 1405394537 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER
DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED
HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
_ `ADDL',SUBR` POLICY EFF POLICY EXP
INSR'
_
TYPE OF INSURANCE
LTR . I POLICY NUMBER MMIDD/YYYY MMlDDIYYYY
LIMITS
A
X COMMERCIAL GENERAL LIABILITY Y Y 01000649031 4/11/2019 4/11/2020
EACH OCCURRENCE $ 1,000.000
CLAIMS -MADE X OCCUR
DAMAGE TC3 RENTED _ ,_ __..... _.__.. _
PREMISES_(Ea occurrence} _.;. $ 100,040
MED EXP (Any one person) $ excluded
-
—:_-- ------ .. ._-.- __-_ _
PERSONAL & ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $ 2.040,000
POLICY PRO LOC
JECT
PRODUCTS COMPr"OP AGG $ 2,000,040
OTHER:
$
AUTOMOBILE LIABILITY
___,
COMBINED SINGLE LIMIT $
(Ea accident}
ANY AUTO
BODILY INJURY (Per person) $
ALL OWNED. ALL
BODILY INJURY (Per accident) $
AUTOS AUTOS_
-
NON -OWNED
PROPERTY DAMAGE $
HIRED AUTOS AUTOS
(Pe,raccident)
UMBRELLA LIAB OCCUREACH
OCCURRENCE $
_
LIAB CLAIMS -MADE
'EXCESS $.
AGGREGATE
DED i RETENTION $
$
C WORKERS COMPENSATIONWCV5502648 9!1012018 9110/2019
X PER OTH-
STATUTE ER
AND EMPLOYERS' LIABILITY Y!N
____._. _ __ #.
ANY PROPRIETORiPARTNERlEXECUTIVE
E.L. EACH ACCIDENT $1,000.000
N t A
OFFICER/MEMBER EXCLUDED? FD
_.... - _ _ .. _ —
(Mandatory in NH)
E.L. DISEASE - EA EMPLOYEE; $ 1,000.000
If yes. describe under
_ _
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT ' $ 1,000,000
B ;Pollution Liability 671117200002 4/11/2019 4/11/2020
Each Pollution Condit $1,000=000
General Aggregate $2,000.000
Deductible $2.500
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Certificate holder is named as additional insured per the attached endorsements as required by written contract and subject to the terms & conditions of the
policy:
GL Additional Insured - Primary and Non- Contributory per Form CG20120509 & CAS50010717
GL 30 -day Notice of Cancellation per Form ADF90270418
GL Waiver of Subrogation per Form CAS4008 0110
See Attached...
CERTIFICATE HOLDER CANCELLATION
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
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SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Costa Mesa Sanitary District
290 Paularino
AUTHORIZED REPRESENTATIVE
,
Costa Mesa CA 92626
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
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"i 11111 k I
AGENCY CUSTOMER ID: C&RDR-1
LOC #:
Page 1 of 1
AGENCY
Wood Gutmann & Bogart Insurance Brokers
NAMEDINSURED
C & R Drains, Inc
1525 W. Macarthur BIvd.#1 1
Costa Mesa CA 92626
POLICY NUMBER
CARRIER
MAIC CODE
EFFECTIVE DATE:
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25
FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE
CERTIFICATE HOLDER VESTING:
DISTRICT, its directors, officials, officers, employees, agents, and volunteers
ACORD 101 (2008/01) 0 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
Attached To and Forming Part of Policy Effective Date of Endorsement
Named Insured
0100064903-1 04/11/2019 12:01AM at the Named Insured
C & R Drains Inc
address shown on the Declarations
Additional Premium: Return Premium:
L -$O $0
This endorsement modifies insurance provided under the following:
ALL COVERAGE FORMS
The CANCELLATION section of the CONDITIONS section of this Policy are amended by adding the following:
Notice of Policy Termination To:
Costa Mesa Sanitary District
290 Paularino Avenue, Costa Mesa, CA 92626
If we send notice of termination of this policy to the insured, we will also send written notification of such termination to
the person or organization shown in the Schedule above at the address shown above. We will mail this notice in
accordance with the Cancellation and Nonrenewal terms and conditions of this policy. If notice is mailed, proof of mailing
will be sufficient proof of notice.
No policy rights are conferred to the person or organization shown in the Schedule above. Failure to provide notice as
described in this endorsement shall impose no obligation or liability of any kind upon the Company.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - STATE OR GOVERNMENTAL
AGENCY OR SUBDIVISION OR POLITICAL
SUBDIVISION - PERMITS OR AUTHORIZATIONS
Attached To and Forming Part of Policy
Effective Date of Endorsement
Named Insured
0100064903-1
04/11/2019 12:01AM at the Named Insured
C & R Drains Inc
address shown on the Declarations
Additional Premium:
Return Premium:
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
State or Governmental Agency or Subdivision or Political Subdivision:
Costa Mesa Sanitary District
290 Paularino Avenue, Costa Mesa, CA 92626
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
SeudonU—VVbmbAnhmsuredis amended toinclude asan 2. This insurance does not apply to:
insured any state orgovernmental agency or subdivision a. "Bodily injury", "property damage" or "personalor political subdivision shown in the Schedule, subject to and advertising injury" arising out of operations
the following provisions: performed for the federal government, state or
1. This insurance applies only with respect to operations municipality; or
performed byyou oronyour behalf for which the state b. "Bodily injury" or "property damage" included
or governmental agency or subdivision or political within the "products -completed operations
subdivision has issued apermit orauthorization. hazard.
ALL OTHER TERMS AND CONDITIONS OFTHE POLICY REMAIN UNCHANGED.
CG 20 12 05 09 (D Insurance Services Office, Inc., 2008 Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ [TCAREFULLY.
Attached To and Forming Part of Policy
Effective Date of Endorsement Named Insured
0100064903-1
04/11/2019 12:01AM at the Named Insured C & R Drains Inc
address shown on the Declarations
Additional Premium:
Return Premium:
This endorsement modifies insurance provided under the following -
COMMERCIAL GENERAL LIABILITY
oUowing-
COKHKnERCQ\LGENERALUAB|UTY COVERAGE
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE
;T40 14 -Dffx
Name and Address ufAdditional Insured Person(s) or Organization(s):
Costa Mesa Sanitary District
J9OPau|arinoAvenue, Costa Mesa, CA 92626
A. SECTION U - WHO |S AN INSURED is amended to include any person or organization shown in the above Schedule as an
Additional Insured but only for the vicarious liability imposed on the Additional Insured provided that such liability is
caused by the sole negligent conduct of the Named Insured and is proximately caused by "your work" or "'your
product" for the Additional Insured.
B. The insurance provided to the Additional Insured under this endorsement is limited as follows:
2. The insurance provided tothe Additional Insured shall beexcess with respect toany other valid and collectible
insurance available to the Additional Insured unless the written contract specifically requires that this insurance
apply on a primary and non-contributory basis, in which case this insurance shall be primary and non-contributory,
2. In the event the written contract requires Limits of Insurance in excess of the Limits of Insurance provided by this
policy, the Limits of insurance provided by this policy shall apply and not the limits required by the written
contract. This endorsement shall not increase the Limits of Insurance stated in the Declarations of this policy.
3. This insurance does not apply to "bodily injury" or "property damage" arising out of "your work or "'your product"
included in the "products -completed operations hazard" unless you are required to provide such insurance by
written contract. If required, then insurance is provided only for "bodily injury" or "property damage" that occurs
during the policy period arising out of "your work" or "your product".
4. Where there isnoduty todefend the Named Insured, there isnoduty todefend the Additional Insured. Where
there is no duty to indemnify the Named Insured, there is no duty to indemnify the Additional Insured.
5. This insurance does not apply to "bodily injury" or "property damage" arising out of:
a. The sole negligence of the Additional insured or any employee of the Additional Insured; or
b. Any obligation of the Additional insured to indemnify another because of damages arising out of such injury or
damage.
C. Duties of the Additional Insured in the event of "occurrence", claim or "suit":
l. The Additional Insured must promptly give notice ufan"occurnence" aclaim which ismade ora"suh",toany
other insurer which has insurance for a loss to which this insurance may apply.
[AS500I0727 Page lof2
Z. The Additional Insured must promptly tender the defense of any claim made or "suit "toany other insurer which
also issued insurance to the Additional Insured as a Named Insured or to which the Additional Insured may qualify
as an Additional Insured for a loss to which this insurance may apply.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
7113VOWN
Za�
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ [TCAREFULLY.
Attached To and Forming Part of Policy
Effective Octe of Endorsement
Named Insured
0100064903-1
04/11/2019 12:01AM at the Named Insured
C & R Drains Inc
address shown on the Declarations
Additional Premium:
Return Premium:
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE
PROD UCTS/CO M PLETED OPERATIONS LIABILITY COVERAGE
SCHEDULE
Name of Person or Organization:
Costa Mesa Sanitary District
29OPau|ahnoAvenue, Costa Mesa, CA 92626
SECTION IV—CONOITIONS,&lransfer of Rights of Recovery against Others to Us is amended by the addition of the
We waive any right of recovery we may have against the person or organization shown in the Schedule above because of
payments we make for injury or damage arising out of "your work" done under a written contract with that person or
organization wherein you have agreed toprovide this waiver. This waiver applies only tothe person ororganization shown
inthe Schedule above and only tothe extent ofwritten agreement.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
Page 1 of 1
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