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Insurance - Sancon Technologies, Inc. - 10-05-2019i7 0 ACOOR" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 10/05/2019 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(les) must have ADDITIONAL INSURED provisions or 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 Pamela Paulino NAME: Poms & Associates Insurance Brokers ACNE Ext): (800) 578-8802 _FAX C No : (818) 449-9321 CA License #0814733 E-MAIL ppaulino@pomsassoc.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # 5700 Canoga Ave. #400 Woodland Hills CA 91367 INSURERA: Admiral Insurance 24856 INSURED INSURER B: Ohio Casualty Insurance Company 24074 Sancon Technologies, Inc. INSURER C : State Compensation Ins. Fund (SCIF) 35076 5841 Engineer Drive INSURER D: INSURER E: INSURER F: Huntington Beach CA 92649 rnVGRAn=Q r=RTI=IrAT= All IMRGR- 19-20 GL/BAU/XS/WC OcAnQlnAI All IMRGI?• 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. I LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF MM DD/YYYY POLICY EXP MM DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 F;z0_1 CLAIMS -MADE OCCUR DAMAGE TO RENTE PREMISES Ea ccur ence $ 100,000 MED EXP (Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 A Y FEIECC2281003 10/01/2019 10/01/2020 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑X PRO JECT LOC PRODUCTS -COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident BODILY INJURY (Per person) $ X ANY AUTO B OWNED SCHEDULED AUTOS ONLY AUTOS BAA2056177090 10/01/2019 10/01/2020 BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident X HIRED X NON -OWNED AUTOS ONLY /� AUTOS ONLY $ X Comp: $500 X Coll: $500 UMBRELLA LIABX OCCUR EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 A X EXCESS LIAB CLAIMS -MADE FEIEXS2281103 10/01/2019 10/01/2020 DED I I RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N/A Y 9018172-2019 10/01/2019 10/01/2020 X STATUTE EPER ORH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Job No. T19099 - #324 Sewer Manhole Rehabilitation Costa Mesa Sanitary District, its officers, officials, employees, and agents are Included as Additional Insured. Said Insurance is Primary Non -Contributory. Waiver of Subrogation for the Workers Comp applies in favor of same entities. Endorsements per attached. Cancellation Provision also Enclosed. RFC ED CERTIFICATE HOLDER JHIV 1 a LULU CANCELLATION Costa Mesa Sanitary District SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Costa Mesa Sanitiary District ACCORDANCE WITH THE POLICY PROVISIONS. 290 Paularino Avenue �,� AUTHORIZED REPRESENTATIVE �� Costa Mesa CA 92626 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Sancon Technologies, Inc. Endorsement Number: 5 Automatic Additional Insured — Owners, Lessees or Contractors This endorsement, effective 10/01/2019 attaches to and forms a part of Policy Number FEI-ECC-22810-03. This endorsement changes the Policy. Please read it carefullv. ECC -319-0712 In consideration of an additional premium of $Applied, this endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Any person(s) or organization(s) whom the Named Insured agrees, in a written contract, to name as an additional insured. However, this status exists only for the project specified in that contract. The person or organization shown in this Schedule is included as an insured, but only with respect to that person's or organization's vicarious liability arising out of your ongoing operations performed for that insured. Sancon Technologies, Inc. Endorsement Number: 30 Additional Insured — Owners, Lessees or Contractors — Completed Operations This endorsement, effective 10/01/2019 attaches to and forms a part of Policy Number FEI-ECC-22810-03. This endorsement changes the Policy. Please read it carefully. In consideration of an additional premium of $Applied, this endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART cr•uFr)T TT F Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operations Any person(s) or organization(s) whom the Named Insured Those project locations where this agrees, in a written contract, to name as an additional insured. endorsement is required by contract. However, this status exists only for the project specified in that contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 37 0413 © ISO Properties, Inc., 2016 Sancon Technologies, Inc. Endorsement Number: 30 AD�!!!lR*M=W=r B. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 37 0413 © ISO Properties, Inc., 2016 Sancon Technologies, Inc. Endorsement Number: 16 AM N W4L *X=W=r Automatic Primary and Non-Contributory Insurance Endorsement Designated Work Or Project(s) This endorsement, effective 10/01/2019 attaches to and forms a part of Policy Number FEI-ECC-22810-03. This endorsement changes the Policy. Please read it carefully. This endorsement modifies insurance provided under the Coverage Part(s) indicated below: COMMERCIAL GENERAL LIABILITY COVERAGE CONTRACTORS POLLUTION LIABILITY COVERAGE SCHEDULE Name of Person or Organization: Any person(s) or organization(s) whom the Named Insured agrees, in a written contract, to provide Primary and/or Non-contributory status of this insurance. However, this status exists only for the project specified in that contract. In consideration of an additional premium of $Applied and notwithstanding anything contained in this policy to the contrary, it is hereby agreed that this policy shall be considered primary to any similar insurance held by third parties in respect to work performed by you under any written contractual agreement with such third party. It is further agreed that any other insurance which the person(s) or organization(s) named in the schedule may have is excess and non- contributory to this insurance. ECC -548-0317 Sancon Technologies, Inc. Endorsement Number: 1 AM at Common Policy Conditions Endorsement This endorsement, effective 10/01/2019 attaches to and forms a part of Policy Number FEIEXS2281103. This endorsement changes the Policy. Please read it carefully. In consideration of the premium charged, and notwithstanding anything contained in this policy to the contrary, it is hereby agreed that all coverage parts included in this policy are subject to the following conditions: A. CANCELLATION The named insured may cancel this policy by mailing to the Company written notice stating when thereafter such cancellation shall become effective. The Company may cancel this policy by mailing to the named insured, at the mailing address specified the Declarations, written notice stating when not less than thirty (30) days thereafter such cancellation shall become effective, except in the event of the named insured's nonpayment of premium, not less than ten (10) days advance notice of cancellation shall be given. The mailing of notice as aforesaid, shall be sufficient proof of either party's intent to cancel. The effective date of cancellation specified in such notice shall terminate this policy period. Delivery of such notice shall be equivalent to mailing. If the named insured cancels, the earned premium shall be computed in accordance with the customary short rate table. If the Company cancels, the earned premium shall be computed pro rata. The Company will tender any return premium subject to retaining a minimum earned premium equal to 25% of the amount specified in the Declarations. Premium adjustment may be made either at the time cancellation is effective or as soon as practicable thereafter, but tender of the unearned premium or return of this policy, shall not be conditions precedent to cancellation hereunder. B. CHANGES No provision of this policy may be amended, waived or otherwise changed, except by endorsement hereto. EXS-211-0712 o- ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BAS I S HOME OFFICE SAN FRANCISCO EFFECTIVE OCTOBER 1, 2019 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING OCTOBER 1, 2020 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME SANCON TECHNOLOGIES, INC. 5841 ENGINEER DR HUNTINGTON BEACH, CA 92649 WE HAVE THE RIGHT TO RECOVER OUR PAYMENTS FROM ANYONE LIABLE FOR AN INJURY COVERED BY THIS POLICY. WE WILL NOT ENFORCE OUR RIGHT AGAINST THE PERSON OR ORGANIZATION NAMED IN THE SCHEDULE. THIS AGREEMENT APPLIES ONLY TO THE EXTENT THAT YOU PERFORM WORK UNDER A WRITTEN CONTRACT THAT REQUIRES YOU TO OBTAIN THIS AGREEMENT FROM US. THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 2.00% OF THE TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER JOB DESCRIPTION BLANKET WAIVER OF SUBROGATION REP D1 9018172-19-2 RENEWAL Sc 9-85-41-12 PAGE 1 OF NOTHING IN THIS ENDORSEMENT SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS ABOVE STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS IN THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 110 -«z-�- AUTHORIZED REPRESENT IVE PRESIDENT AND CEO SCIF FORM 10217 (REV.4-2018) 1 2572 OLO DP 217