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Insurance - OSTS, Inc - 2022-04-13ACC> br CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 04/13/2022 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 Pacific Lighthouse Insurance Agency CONTACT NAME: Marilu Maciel _ 625 The City Drive South, Suite 330 iFAX PHONE Ext): (657)667-0225 (A/C No (657)667-0227 E-MAIL E-MAI@p g ADDRESS: ____ Marilu acificli hthouseins.com Orange, CA 92868 License #: OG22040 —_________ INSURER(S) AFFORDING COVERAGE NAIC # OTHER: 5 — INSURERA: Penn Star Insurance Company */--- 10673 INSURED ___ INSURER B: California Automobile Insurance Compan38342 Inc. __ INSURER C: National Union Fire Insurance Company of Pittsb ' P 19445 14650 14650 Central Ave INSURER D: Oak River InsuraAce Companyy 34630 Chino, CA 91710-9504 INSURER E_ AP Special _ - _ 24856 S INSURER F : COVERAGES CERTIFICATE NUMBER: 00000506-160040 RFVICInN til IMR1'R* 2n4 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 CONTRACTOR 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 ADDL;SUBR, - --- ----- � POLICY EFF ! POLICY EXP _-- --_- — ---------- ._____________—__ LTR TYPE OF INSURANCE WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS 290 Paularino Avenue A F X COMMERCIAL GENERAL LIABILITY Y Y CPV0048281 08/05/2021 08/05/2022 :, EACH OCCURRENCE $ 1 000 000 DAMAGE TO RENTED CLAIMS -MADE x OCCUR PREMISES(Ea occurrences100,000 _ _ - - MED EXP (Anyone person) 5,000 k -Non-Contributory------ PERSONAL & ADV INJURY S 11000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S ^- 2,000,000 PRO- - LOC - - - ---- POLICY JECT PRODUCTS - COMP/OP AGG T S 2,000,000 OTHER: 5 B `AUTOMOBILE LIABILITYY Y BA040000067210 04/17/2022 04/17/2023 ! a ccideD SINGLE LIMIT S 1000 OOQ_ n ANY AUTO BODILY INJURY (Per person) $ OWNEDSCHEDULED BODILY INJURY AUTOS ONLY , X AUTOS (Per accident) ; S HIRED NON -OWNED - - PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per S `` X .UMBRELLA LIAB X occuR EBU 048185552 04/17/2022 1 08/05/2022: EACH OCCURRENCE S 2,000,000 EXCESS UAB CLAIMS -MADE AGGREGATE S _ - 2,000,000 - -..-. DED ! X RETENTIONS 10 000 Prod-Compl. Op. $ D :, WORKERS COMPENSATION Y OSWC309981 04/17/2022 04/17/2023 X • PER STATUTE 0TH - AND EMPLOYERS' LIABILITY Y/ N — _SER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT S N / a 1,000,000 OFFICER/MEMBER EXCLUDED? A' __- (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE S 1,000,000 If yes, describe under -------- DESCRIPTION OF OPERATIONS below ~ E.L. DISEASE -POLICY LIMIT S 1,000,000 E 1 E&O E0000052837-02 11/06/2021 11/06/2022 Limit/Aggregate 2,000,000 E personal injury E0000052837-02 11/06/2021 11/06/2022 Limit $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: All Opertations The Costa Mesa Sanitary District, their elected and appointed officials, agents, officers, volunteers, and employees listed as additional insured - Pursuant to attached endorsement. Policy shall not terminate, nor shall it be canceled nor the coverage reduced, until thirty (30) (continued on ACORD 101 Additional Remarks Schedule) CERTIFICATE HOLDER coNCFI I ATIr)N ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Printed by MLM on 04/13/2022 at 05:21 PM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Costa Mesa Sanitary District rY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 290 Paularino Avenue Costa Mesa, CA 92626 1 AUTHORIZED REPRESENTATIVE ,-MLM ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Printed by MLM on 04/13/2022 at 05:21 PM Insured: OSTS, Inc Policy # CPV0048281 COMMERCIAL GENERAL LIABILITY CG 20 01 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ` • •W •' • ' ' ` • • This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR 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 01 12 19 O Insurance Services Office, Inc., 2018 Page 1 of 1 Insured: OSTS, Inc. COMMERCIAL GENERAL LIABILITY Policy # CPV0048281 CG 20 33 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured 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. However, the insurance afforded to such additional insured: 1. Only applies to the extent permitted by law; and 2. Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: 1. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or the failure to render any professional architectural, engineering or surveying services. CG 2033 04 13 Page 1 of 2 © Insurance Services Office, Inc. 2012 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 ��/�D�/D��� ���� �7��� ��U� RIGHTS K�)�` RECOVERY ' .'-- . --_- ..- TRANSFER .,. ���.~.~~= ,,� AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE ame of Person or Organization: nyperson ororganization for whom you are required to waive your right of recovery on this Coverage Part un written contract or agreement The following is added to Paragraph 0, Transfer Of Righty Of Recovery Against Others To 0y of Section IV - Conditions: Wcwaive any right ofrecovery wnmay have against the person or organization shown in the Schedule above because of payments we make for injury or dmnuge arising oun of your ongoing operations or "Your vvork" done under acontrao| with that person or organization and included in the "products - completed operations hozard"This waiver applies only to the person or organization shown in the Schedule above. O324 04 05 09 @{nmmnce Services Office, |nc,2008 Page |of| WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC990410C (Ed. 01-19) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -CALIFORNIA BLANKET BASIS 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 calculated by applying a factor of 2% to the total manual premium, with a minimum initial charge of $350, then applying all other pricing factors for the policy to this calculated charge to derive the final cost of this endorsement. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule Blanket Waiver Person/Organization Blanket Waiver — Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. Job Description Waiver Premium (prior to adjustments) All CA Operations 350.00 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: 04/17/2022 Policy No.: OSWC309981 Endorsement No.: Insured: Premium $ Insurance Company: Oak River Insurance Company Countersigned by WC990410C (Ed. 01-19)