Insurance - Second Chance Orange County - 2021-10-21"0016% qL, S jFAM X_WiPF - CERTIFICATE CSF LIABILITY I NSU RANCE
DAT 012112 Q/YYYY)
10!2112021
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 1 NSU RANCE DOES NOT CO NSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),
AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THECERTIFICATE 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
CONTACT
NAME: Chuck Hyneman
Chuck Hyneman
PHONE
FAX
18371-A Lemon Drive
(A/C, No, EXT): 714-777-9823
(A/C, No): 714-777-9898
Yorba Linda, CA 92886
E-MAIL
ADDRESS: II
INSURER(S)AFFORDING COVERAGE NAIC#
INSURED
INSURERA: US Liability
INSURER B:
Second Chance Orange County
290 N Paularino Avenue
INSURER C:
INSURER D:
Costa Mesa, CA 92628
INSURER E:
_
_...._._.__._...._ ..._. -- .... .- _.
INSURER F:
------------ ._.-._.__-- -_ ._-__., - _-.-____-. ____. --------- ------------------ - ------ -,..-_-..
COVERAGES CERTIFICATE NUMBER.
_.-. -. _ _ ------ - .. ------------ -----_... -
REVISION NUMBER:
THIS IS TO CERTI FY THATTHE POLICIES OF INSURANCE LISTED BELOV-4 HAVE BEEN ISSUEDTO THE INSURED NAMEABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY
REQUIREMENT TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT 10 WHICH THIS CERTIFICATE MIRY BEISSUED OR MAY PERTAIN, -THE INSURANCE AFFORDED BY THE
POLICIES DESCRIBED HEREIN IS SUBJECTTO.ALLTHETERMS, EXCLUSIONS AND vflNDITIONS OF SUCH POLICIES. dt-AITSSHOWNMAY HAVE BEEN REDUCED BY PAID CLAIMS.
IL RR
TYPEOFINSURANCE
AIDN�TDL
SVW�
POLICYNUMBER
POLICY EFF POLICY EXP
(MM/DD/YYYY) (MM/DD/YYYY)
LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,00C
CLAIMS -MADE X OCCUR
DAMAGE TO RENTED
PREtvISE5 Ec 0 ccurrence)
' 1 Qtl QQ
MED EXP (Any one parson)
S 5,00C
PERSONA-&, ADV INIURY
1,flO0,00
A
Y
NPP1578344D
09/14/2021 09114/2022
GEN`L AGGREGATE LIMIT APPLIES PER:
X POLICY ❑ PROJECT F� LOC
GENERAL AGGREGATE
$ Z 000 QQ
PRODUCTS-COMP/OPAGG
$ Include
OTHER:
$
AUTOMOBILE LIABILITY
COMBINEDSING ELIMIT
(Ea accident)
$ 1,0Qfl,QQ
ANY AUTO
(
BODILY INJURY (Per person)
$
A
OWNEDAUT7SSCHEDULED
Pi ONLY F1 AUTOS
NPP167341 D
09/14/2021 09/14/2422
BOD--YINJURY (Per accident)
Iv HIREDAUTC)5 �(� NON-OWNEDPROPERTY
tj/x ONLY � X ( AU OS ONLY
DAMAGE
(Per accident)
$
HUMBRELLA
UAB
HOCCUR
EACH OCCURRE14CE
I$
EXCESS LIAB
CLAIMS -MADE
AGGREGATE
4
DED RETENTION
Is
WORKERS COMPENSATION
AND EMPLOYERS` LIABILITY
PER
( L-STATUTEOTHER—is
ANY PROPRIETOR/PARTNER; Y/N
EXECUTIVE OFFICER/MEMBER
N/A
E.L. EACH ACCIDENT
- -----------------------
$
_
E.L. DISEASE- EA EMPLOYEE
EXCLUDED % (Mandatory in NH)
If yes, describe under DESCRIPTION OF
OPERA11ONS below
E.L. DISEASE- POLICY LIMIT
S �
-
A
- -- - --------------------------._._.._.. . - ....
Professional E & O Liability
EPLI
------------------
---------------
- - - -------- -
NPP157341D
------------- --------- ._-...... ----------------- ------------------------ ---- ----- ---
09/14/2021 0911412011
--- --------------------------------- -------------------------------------------
$1,000,000 -Each Inc.
$2,000,000-Agg
------------ __�
$1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
All operations: Costa Mesa Sanitary District, their elected and appointed officials, agents, officers, volunteers and employees
Said policy should not teminate, nor shall it be cancelled nor the coverage reduced, unit) (30) days after written notice is given to the named insured
CERTIFICATE HOLDER CANCELLATION
Costa Mesa Sanitary District
290 PaUI arino Avenue I�`,
CDsta Mesa, CA 92628
SHOULD ANYOFTHEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2016/03) G1988-2015ACORD CORPORATION. All Rights Reserved
31-1769 11-15 The ACORD name and logo are registered marks of ACORD
POUCYNUMBER: NPP15783410 COMMERCIAL GENERAL LIABILITY
CG 20 26 0413
THUS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name ofAdditional hsuredPonaon(s) Or{Jq@anizatimn(a):
Effective Date: 10/15/2021 12:01 AM
COSTA MBA SANITARY DISTRICT, THEIR ELECTED AND APPOINTED OFFICIALS, AGENTS, OFFICERS,
VOLUNTEERS AND EMPLOYEES, BUT ONLY WHERE REQUIRED BYWRITTEN CONTRACT
2BDPAULAR|NOAVENUE
COSTA MESA, CA 92626
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
4^Section 11 - Who Us AnInsured |aamended toinclude
as anadditional insured the permnn(o)ororgun|zaton(o)
shown inthe Schedule, but only with respect toliability
for "bodily |n]ur/'."property damage" or"personal and
advertising injury" caused, inwhole orinpart, byyour
acts n/omissions orthe acts oromissions nfthose acting
onyour behalf:
1. Inthe performance cfyour ongoing operations; or
2` |nconnection with your premises owned byor
rented toyou.
However:
I. The insurance afforded tosuch additional insured
only applies to the extent permitted by law; and
2. |fcoverage provided hothe additional insured is
required byacontract or agreement, the insurance
afforded tosuch additional insured will not be
broader than that which you are required bythe
contract oragreement boprovide for such additional
insured.
B. With respect tothe insurance afforded tothese
additional insureds, the following |oadded to
Section III - Limits Of Insurance:
|fcoverage provided tothe additional insured is
required by a contract oragreement, the most we
will pay onbehalf ofthe additional insured imthe
amount ofinsurance:
1. Required bythe contract mragreement or
2. Available under the applicable Limits of
Insurance shown inthe Declarations;
whichever ioless.
This endorsement shall not increase the applicable
Limits ofInsurance shown }nthe Declarations.
oGuoo6w^1u xoInsurance Services Office, mc..2o12 Page 3of 3
UNITED STATES LIABILITY INSURANCE GROUP
WAYNE, PENNSYLVANIA
This endorsement modifies inNurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
Primary And Non -Contributory -'written Contract
Name of Person or Organization:
Effective Date: 10/1.5/2021 12:01 AM
COSTA MESA SANITARY DISTRICT, THEIR ELECTED AND APPOINTED OFFICIALS. AGENTS, OFFICERS,
VOLUNTEERS AND EMPLOYEES, BUT ONLY WHERE REQUIRED BY WRITTEN CONTRACT
290 PAULARINO AVENUE
COSTA ME, -,A, CA 92626
(If no entry appears above, the information required to complete this endorsement will be shown in the Declarations as applicable to this
endorsement)
SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, Paragraph 4. OTHER
INSURANCE, a. Primary Insurance is amended with the addition of the following:
The coverage afforded by this policy to the person(s) or organization (s) listed above is primary and non-
contributoty if:
1. This insurance is required to be primary and non-contributory under a written contract; and
2. The loss to be covered occurs on or after the effective date of the written contract; and
3. The loss to be covered resulted solely and exclusively from your ongoing acts or omissions or the
ongoing acts or omissions of those acting on YOUT behalf in perfon-ning -your work" under a written
contract referred to above.
4. The person(s) or organization{s)
s) is an additional insured Linder this policy.
However, the coverage provided by this endorsement does not apply to any coverage provided for an "auto"
on a "non -owned auto". "hired auto", uninsured motorists coverage, underinsured motorists coverage, personal
injury protection, property protection or similar no-fault coverage by whatever name catled and/or an "auto'"
coverage of any type,
SECTION V - DEFINITIONS is hereby amended by the addition of the following:
Z__
"Hired auto"" means any "auto" you lease, hire, rent or borrow. This does not include any
auto"' you lease for a period of more than thirty (30) consecutive days nor does it include
any ",auto" you lease, hire, rent or borrow from any of your "employees"',your partner or
Your "executive officers" or members of their household.
"Non -owned auto" means any "auto" you do not own, lease, hire, rent or borrow which is
used in connection with your business. However, if you are a partnership, a "non -owned
auto" does not include any "auto" owned by any partner.
All other terms and conditions of this policy remain unchanged. This endorsement is a part of your policy and
takes effect on the effective date of your policy unless another effective date is shown.
L 776 (10-13) Page 3 of