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Insurance - GCI Construction, Inc. - 2020-04-20-r 76 AcoRa CERTIFICATE OF LIABILITY INSURANCE �4�' DATE (MM/DD/YYYY) 1 9/29/2020 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 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 Compass Direct Insurance Services, Inc. 13681 Newport Ave., Ste 8 #622 Tustin, CA 92780 CONTACT NAME: Jeremy Seltzer PHONE 714-665-9800 n. X No): 714-665-9801 E-MAIL ADDRESS: 'erem cdisi.com INSURERS AFFORDING COVERAGE NAIC # INSURER A: Greenwich Insurance Company 22322 www.cdisi.com License #01-116100 INSURED INSURER B : Everest National Insurance Company 10120 GCI Construction, Inc. 1031 Calle Recodo, Ste. D San Clemente CA 92673 INSURER C : Westchester Surplus Lines Insurance Co 10172 INSURER D: American Zurich Insurance Company 40142 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 57842758 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. INSR LTR OF INSURANCE ADDLSUBRTYPE INSD WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM DDNYYY LIMITS A ✓ COMMERCIAL GENERAL LIABILITY ✓ ✓ NPC-1003310-00 4/1/2020 4/1/2021 EACH OCCURRENCE $1 000 000 CLAIMS -MADE F✓ OCCUR DAMAGE TO RENTED PREMISES Ea occurrence) $ 5O 000 ✓ MED EXP (Any one person) $ Excluded Owner's/Cont. Pro ✓ XCU/Deductible $5 000 PERSONAL & ADV INJURY $1 00O 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 RO POLICY ✓❑ ECT LOC PRODUCTS - COMP/OP AGG $ 2 000 000 Employee Benifits $1 000 000 OTHER: A AUTOMOBILE LIABILITY ✓ ✓ NBA-1003312-00 4/1/2020 4/1/2021 CMBNED Ea accl dentSINGLE LIMIT $1 00O 000 BODILY INJURY (Per person) $ ✓ ANY AUTO BODILY INJURY (Per accident) $ OWNED SCHEDULED AUTOS ONLY AUTOS PeOa�a DAMAGE $ HIRED NON -OWNED ✓ AUTOS ONLY ✓ AUTOS NLYY Comp/Coll Ded $1,000 $ No Liability Deductible A v/ UMBRELLA LIAB �/ OCCUR NEC-6006091-00 4/1/2020 4/1/2021 EACH OCCURRENCE $4 000 000 AGGREGATE $4 00O 000 EXCESS LIAR CLAIMS -MADE $0 Deductible TENT DED REION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y ✓ 7600019322201 8/1/2020 8/1/2021 �/ SPER TATUTE ERH E.L. EACH ACCIDENT $1 000 000 OFFICER/MEMBEREXCLUDED? N / A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below $0 Deductible E.L. DISEASE - EA EMPLOYEE $1.000.000 E.L. DISEASE - POLICY LIMIT I $1,000,000 A IM-Eqp./Lesd-Hrd-R NIM-1003311-00 4/1/2020 4/1/2021 Sch/Per:481K/100K Deductible $1,000 A BPP NIM-1003311-00 4/1/2020 4/1/2021 $100,000 Deductible $1,000 C Pollution G46866435 003 2/2/2020 2/2/2021 2,000,000 Deductible 5,000 D Builders Risk ER73782799 10/05/2020 10/05/2021 1,626,100 Deductible $1,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The Costa Mesa Sanitary District, it's elected and appointed officials, agents, officers, volunteers and employees are additional insureds as per attached endorsements with respects to the operations of the named insured as per contract. GCI Job# 616 Job Name: #318 President Pump Station Reconstruction Project No. 318 CERTIFICATE HOLDER CANCELLATION GCI Job #616 Costa Mesa Sanitary District 290 Paularino Avenue Costa Mesa CA 92626 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Jeremy Seltzer ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 57842758 120-21 GL AU UMB WC ZME/LHR I Nina Lautenschlager 1 9/29/2020 9:41:14 AM (PDT) I Page 1 of 9 POLICY NUMBER: NPC-1003310-00 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AID • A I • •' • ' I • ' • ' , • ' ' • This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) I Location And Description Of ComMeted Operations lanket as required by written contract. JBlanket as required by written contract. I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section 11 — 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 04 13 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. ©Insurance Services Office, Inc., 2012 57842758 1 20-21 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 9/29/2020 9:41:14 AM (PDT) I Page 2 of 9 Page 1 of 1 POLICY NUMBER: NPC-1003310-00 COMMERCIAL GENERAL LIABILITY CG20100413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organizations) I Location(s) Of Covered Operations Blanket as required by written contract. Blanket as required by written contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section 11 - 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", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. 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 10 04 13 B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. O Insurance Services Office, Inc., 2012 57842758 1 20-21 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 9/29/2020 9:41:14 AM (PDT) I Page 3 of 9 Page 1 of 2 C. 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. Page 2 of 2 ©Insurance Services Office, Inc., 2012 CG 2010 04 13 57842758 1 20-21 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 9/29/2020 9:41:14 AM (PDT) I Page 4 of 9 POLICY NUMBER: NPc-1003310-00 COMMERCIAL GENERAL LIABILITY CG 25 03 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Project(s): Policy aggregate limit applies per work site. I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. For all sums which the insured becomes legally 3. Any payments made under Coverage A for obligated to pay as damages caused by 'occur- damages or under Coverage C for medical rences" under Section I — Coverage A, and for all expenses shall reduce the Designated Con - medical expenses caused by accidents under struction Project General Aggregate Limit for Section I — Coverage C, which can be attributed that designated construction project. Such only to ongoing operations at a single designated payments shall not reduce the General Ag- construction project shown in the Schedule gregate Limit shown in the Declarations nor above: shall they reduce any other Designated Con- 1. A separate Designated Construction Project struction Project General Aggregate Limit for General Aggregate Limit applies to each des- any other designated construction project ignated construction project, and that limit is shown in the Schedule above. equal to the amount of the General Aggregate 4. The limits shown in the Declarations for Each Limit shown in the Declarations. Occurrence, Damage To Premises Rented To 2. The Designated Construction Project General You and Medical Expense continue to apply. Aggregate Limit is the most we will pay for the However, instead of being subject to the sum of all damages under Coverage A, ex- General Aggregate Limit shown in the Decla- cept damages because of "bodily injury" or rations, such limits will be subject to the appli- "property damage" included in the "products- cable Designated Construction Project Gen - completed operations hazard", and for medi- eral Aggregate Limit. cal expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits". CG 25 03 05 09 © Insurance Services Office, Inc., 2008 57842758 1 20-21 GL AU UMB WC IME/LHR ( Nina Lautenschlager 1 9/29/2020 9:41:14 AM (PDT) I Page 5 of 9 Page 1 of 2 ❑ B. For all sums which the insured becomes legally obligated to pay as damages caused by "occur- rences" under Section I — Coverage A, and for all medical expenses caused by accidents under Section I — Coverage C, which cannot be at- tributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the amount available under the General Aggregate Limit or the Products -completed Operations Aggregate Limit, whichever is applicable; and 2. Such payments shall not reduce any Desig- nated Construction Project General Aggre- gate Limit. Page 2of2 C. When coverage for liability arising out of the "products -completed operations hazard" is pro- vided, any payments for damages because of "bodily injury" or "property damage" included in the "products -completed operations hazard" will reduce the Products -completed Operations Ag- gregate Limit, and not reduce the General Ag- gregate Limit nor the Designated Construction Project General Aggregate Limit. D. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contract- ing parties deviate from plans, blueprints, de- signs, specifications or timetables, the project will still be deemed to be the same construction pro- ject. E. The provisions of Section III — Limits Of Insur- ance not otherwise modified by this endorsement shall continue to apply as stipulated. © Insurance Services Office, Inc., 2008 57842758 1 20-21 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 9/29/2020 9:41:14 AM (PDT) I Page 6 of 9 CG 25 03 05 09 0 Policy Number: NPC-1003310-00 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 010413 C Insurance Services Office, Inc., 2012 Page 1 of 1 57842758 1 20-21 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 9/29/2020 9:41:14 AM (PDT) I Page 7 of 9 Policy Number: NPC-1003310-00 BLANKET WAIVER OF SUBROGATION The following is added to Section IV -Commercial General Liability Conditions: Waiver of Subrogation We waive any right of recovery we may have against any person or organization because of payments we make for injury or damage arising out of premises owned or occupied or rented or loaned to you; ongoing operations performed by you or on your behalf, done under a contract with that person or organization; "your work"; or "your products". We waive this right where you have agreed to do so as part of a written contract, executed by you prior to loss. Form XIL 436 1208 © 2008, XL America, Inc. Page 7 of 8 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 57842758 1 20-21 GL AU UMS WC IME/LHR I Nina Lautenschlager 1 9/29/2020 9:41:14 AM (PDT) I Page 8 of 9 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - 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.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2% of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOM THE BLANKET WAIVER OF SUBROGATION NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: 8i1i2020 Insured: GCI Construction, Inc. Policy No. 7600019322201 Endorsement No. 001 Premium $ INCL. Insurance Company: Everest National Insurance Company Countersigned By: t r r r+rr� -1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual -1999. 57842758 1 20-21 GL AU UMB WC IME/LHR I Nina Lautenschlager 1 9/29/2020 9:41:14 AM (PDT) I Page 9 of 9