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Insurance - Costa Mesa Community Athletic Association DBA: Costa Mesa United 2022-09-20A� U® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 9/20/2022 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(les) must 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 Wigmore Insurance Agency Inc. 880 W. 19th St. License #0811959 Costa Mesa CA 92627 CONTACT NAME: Ken Noden, CPCU FAX paHic,N Ext: (714) 979-6543 A/C NO: (710549-2943 E-MAIL ADDRESS: commercial@wigmoreins.com INSURERS) AFFORDING COVERAGE NAIC # INSURERA:United States Liability Ins. Company 25895 INSURED Costa Mesa Community Athletic Association DBA: Costa Mesa United 1700 Adams Ave #212 Costa Mesa CA 92626 INSURER B: INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMRER-22/23 ALL LINES 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 TYpE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF MM/DD POLICY EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X CLAIMS -MADE FIOCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 X Hired & Non—Owned Auto X NBP1564027 5/31/2022 5/31/2023 Included PERSONAL & ADV INJURY $ 2,000,000 GENERALAGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: X POLICY 1 JECOT- LOC PRODUCTS - COMP/OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS X BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED 71 RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N t A E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 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 named as additional insured per ADDITIONAL INSURED STATE OR POLITICAL SUBDIVISIONS - PERMITS BP 04 52 01 06. CERTIFICATE HOLDER CANCELLATION scarroll@crosdca.gov SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Costa Mesa Sanitary District 290 Paularino Avenue '(7� THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Costa Mesa, CA 92626 i�YY �Q ` AUTHORIZED REPRESENTATIVE a Timothy Wigmore/K140W ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) POLICY NUMBER: NBP1564027 BUSINESSOWNERS BP 04 52 01 06 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR POLITICAL SUBDIVISIONS - PERMITS This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE PART SCHEDULE State or Political Subdivision: Effective Date: 09/12/2022 12:01 AM THE COSTA MESA SANITARY DISTRICT, IT'S ELECTED AND APPOINTED OFFICIALS, AGENTS, OFFICERS, VOLUNTEERS AND EMPLOYEES ARE ADDITIONAL INSUREDS. 290 PAULARINO AVENUE COSTA MESA, CA 92626 information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph C. Who Is An b. This insurance does not apply to: Insured in Section 11- Liability: (1) "Bodily injury", "property damage" or "personal 3. Any state or political subdivision shown in the and advertising injury" arising out of Schedule is also an insured, subject to the following operations performed for the state or provisions: municipality; or a. This insurance applies only with respect to (2) "Bodily injury" or "property damage" included operations performed by you or on your behalf within the "products -completed operations for which the state or political subdivision has hazard". issued a permit. BP 04 52 0106 © ISO Properties, Inc., 2004 Page 1 of 1