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Insurance - Robotic Sewer Solutions, Inc. 2021-12-01ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 12/1/2021 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). PRODUCERCONTACT Bolton Insurance Services LLC NAME: 3475 E. Foothill Blvd., Suite 100 Pasadena, CA 91107 PHOAHCNNo Ext): (626) 799-7000 a/c, No): (626) 583-2117 -- E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # www.boltonco.com 6004772 INSURER A: James River Insurance Company 12203 _ _— - INSURED _ INSURER B: StarStone National Insurance Company 25496 — Y -- Robotic Sewer Solutions, Inc._--- INSURERC: State Compensation Insurance Fund 35076 2722 Foothill Blvd. La Crescenta CA 91214 INSURER D: INSURERE: INSURER F: CLJVCRALiF_'S CFR I IFICA 11- NI IMIRFR• AG')Arloor D9Z1/lQlnKi Al11M91CD- 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 PP TYPE OF INSURANCE IADDLiSUBR, -POLICY EFF POLICY EXP LTR i IN512 I WVD ! POLICY NUMBER MM/DD/YYYY MM/DD/YYYY ' LIMITS A ✓i' COMMERCIAL GENERAL LIABILITY ✓ 0005062711 11/22/2021 11/22/2022 ;EACH OCCURRENCE $1,000,000 CLAIMS MADE �/ j OCCUR DAMAGE TO RENTED T _ PREMISES (Ea occurrence $ 50,000 -- ✓ ;Per Project Aggregate MED EXP (Any one person) $1,000 - 1 --- - --- -- - --- ✓ Capped at $5,000,000 PERSONAL &ADV INJURY $1,000,000 GE_N'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 — — --- POLICY - ✓ PE � -„ LOC PRODUCTS -COMP/OP AGG S 2,000,000 OTHER: ' — -� s AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY (Per person) r— OWNED r SCHEDULED BODILY INJURY (Per accident); $ AUTOS ONLY AUTOS _ HIRED -OWNED PROPERTY DAMAGE $ _ AUTOS ONLY AUTOS ONLY (Per accident) _ s B UMBRELLA LIAR OCCUR 87446H218AL1 11/22/2021 11/22/2022 EACH OCCURRENCE $4,000,000 — �/ EXCESS LIAR _ CLAIMS -MADE AGGREGATE Y $ 4,000,000 DED ! ✓ RETENTIONSO $ C WORKERS COMPENSATION ✓ 1980264 11/22/2021 11/22/2022 �/ 'SPER TATUTE EORH AND EMPLOYERS' LIABILITY Y / N ! --- -- - — --- ANYPROPRIETOR/PARTNER/EXECUTIVE I OFFICER/MEMBER EXCLUDED? �Y N / A E.L. EACH ACCIDENT $ $1,000,000 — (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under $1 000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT 1 $ $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: All Operations of the Named Insured - #314 Grade 5 Repairs Phase 7. GL Additional Insured applies per CG20120413 attached, only if required by written contract/agreement. GL Primary wording applies per AP5031 US (04-10) attached. Additional Insured(s): The Costa Mesa Sanitary District, its elected and appointed officials, agents, officers, volunteers and employees. The Certificate of Insurance is subject to policy terms, conditions, limitations and exclusions. it.crc 1 IriuA 1 c flULUr-M UANC:tL-L.A I IUN All Operations 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 Alisa Lopez ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 65250995 I ROBOSEW-01 1 21-22 GL, XS & WC I Cory Hospedales 1 12/1/2021 4:58:21 PM (PST) I Page 1 of 3 POLICY NUMBER: 0005062711 COMMERCIAL GENERAL LIABILITY CG 20 12 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR GOVERNMENTAL AGENCY OR SUBDIVISION OR POLITICAL SUBDIVISION - PERMITS OR AUTHORIZATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: e Costa Mesa Sanitary District, its elected and appointed officials, ents, officers, volunteers and employees. 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 any state or governmental agency or subdivision or political subdivision shown in the Schedule, subject to the following provisions: 1. This insurance applies only with respect to operations performed by you or on your behalf for which the state or governmental agency or subdivision or political subdivision has issued a permit or authorization. However: a. The insurance afforded to such additional insured only applies to the extent permitted by law; and b. 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 12 0413 2. This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the federal government, state or municipality; or b. "Bodily injury" or "property damage" included within the "products -completed operations hazard". 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 65250995 1 ROBOSEW-01 1 21-22 GL, XS & WC I Cory Hospedales 1 12/1/2021 4:58:21 PM (PST) I Page 2 of 3 Page 1 of 1 0005062711 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ENDORSEMENTPRIMARY AND NON CONTRIBUTORY This endorsement modifies insurance provided under the following: ALL COVERAGE PARTS Name Of Additional Insured Person(s) Or Organization(s): Where Required By Written Contract or Agreement If no entry appears above, this endorsement applies to all Additional Insureds covered under this policy. Any coverage provided to an Additional Insured under this policy shall be excess over any other valid and collectible insurance available to such Additional Insured whether primary, excess, contingent or on any other basis unless a written contract or written agreement specifically requires that this insurance apply on a primary and noncontributory basis. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. AP5031 US 04-10 Page 1 of 1 65250995 1 ROBOSEW-01 1 21-22 GL, XS & WC I Cory Hospedales 1 12/1/2021 4:58:21 PM (PST) I Page 3 of 3