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Insurance - John Dickens, Inc. - 2023-07-05JOHNDIC-01 LAUREN '4—Rn CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 7/5/2023 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 CONTACT -NAME: Goodman Insurance Services PHONE FAX (A/C, No, Ext): (949) 769-3100 (A/c No): 949) 769-3930 EMAIL 27042 Towne Centre Drive, Suite 120 - — Foothill Ranch, CA 92610 A - _ �_ ,----- DDRESS: INSURED John Dickens, Inc. PO Box 1882 Costa Mesa, CA 92628 INSURER(S) AFFORDING COVERAGE NAIC # INSURERA_GuldeOne Insurance_Ciom_pai_u 15032 INSURER B__Benchmark Insurance Company - 41394 INSURER C : INSURER D: INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY INSURER E: INSURER F: EACH OCCURRENCE $ -DA—MAGE-TORR rr)VFRAr.FR rI=RT11=IrATG All111ARC0- oevlelnsl nn Ieeceo. 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ -DA—MAGE-TORR 1,000'000 CLAIMS -MADE X OCCUR 70K101141-01 7/1/2023 7/1/2024 X X ENTED PREMISES tEa occurrence) S 100,000 MED EXP _(Any one erson $ 5,000 PERSONAL & ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2'000'000 POLICY X JEef LOC PRODUCTS - COMP/OP AGG S 2,000,000 OTHER: IS A AUTOMOBILE LIABILITY _—_ COMBINED SINGLE LIMIT -(Ea_accidentl __ 1,000,000 X ANY AUTO X X 70K101141-01 7/1/2023 7/1/2024 BODILY INJURY (Peron ) S OWNED SCHEDULED - AUTOS ONLY AUTOS BODILY INJURY (Per accidents - S X HIRED X NON -OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accidentS !S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS -MADE! AGGREGATE S _ DED RETENTIONS S B WORKERS COMPENSATIONPER X OTH- AND EMPLOYERS' LIABILITY _STATUTE ER __ _- -___ ANY PROPRIETOR/PARTNER/EXECUTIVE _YN X CST5025623 6/17/2023 6/17/2024 YN / A E LEACH ACCIDENT S 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) 1'000'000 If yes, describe under DESCRIPTION OF OPERATIONS below . EL DISEASE- EA EMPLOYEE: S E.L. DISEASE -POLICY LIMIT S 1000000 ' ' DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The certificate holder(s), is/are named additional insured per the attached forms, including primary wording, where required by written contract, with regard to the following project: Project: Parking Lot Certificate holders continued: Costa Mesa Sanitary District, its directors, officials, officers, employees, agents and volunteers rFRTIGI(-ATG' Wr)l n;=P PAAIf`CI I ATIr'1AI AL;URD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Costa Mesa Sanitary District ry 628 W 19th St Costa Mesa, CA 92627, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE f r AL;URD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 70K101141 01 00 CA COMMERCIAL GENERAL LIABILITY CG 20 10 12 19 (Blkt) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED — OWNERS,OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 4911 Name Of Additional Insured Person(s) Or Organization(s) Locations Of Covered Operations Blanket as required by written contract and effective Primary Insurance applies: It is agreed that such during the policy period as stated on the policy insurance as is afforded by this policy for the declarations. benefit of the additional insured shown shall be primary insurance, and any other insurance maintained by the additional insured(s) shall be excess and noncontributory as respects any claim, loss or liability allegedly arising out of the operations of the named insured or its subcontractors, provided however that this insurance will not apply to any claim loss or liability which is determined to be solely the result of the additional insured's negligence or solely the additional insured's responsibility. 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. 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 CG 20 10 12 19 (Blkt) © Insurance Services Office, Inc., 2018 Page 1 of 2 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. 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 insurance; whichever is less. This endorsement shall applicable limits of insurance applicable limits of not increase the Page 2 of 2 © Insurance Services Office, Inc., 2018 CG 20 10 12 19 (BIkt) POLICY NUMBER: 70K101141 01 00 CA COMMERCIAL GENERAL LIABILITY CG 20 37 12 19 (Blkt) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS 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) Location And Description Of Completed Operations Blanket as required by written contract and Primary Insurance applies: It is agreed that such effective during the policy period as stated on the insurance as is afforded by this policy for the policy declarations. benefit of the additional insured shown shall be primary insurance, and any other insurance maintained by the additional insured(s) shall be excess and noncontributory as respects any claim, loss or liability allegedly arising out of the operations of the named insured, provided however that this insurance will not apply to any claim loss or liability which is determined to be solely the result of the additional insured's negligence or solely the additional insured's responsibility. This insurance also does not apply to any structure intended to be occupied as a private residence, not including apartments. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — 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". 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. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: However: If coverage provided to the additional insured is 1. The insurance afforded to such additional required by a contract or agreement, the most we insured only applies to the extent permitted by will pay on behalf of the additional insured is the law; and amount of insurance: 1. Required by the contract or agreement; or CG 20 37 1219 (Blkt) © Insurance Services Office, Inc., 2018 Page 1 of 2 2. Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. Page 2 of 2 © Insurance Services Office, Inc., 2018 CG 20 37 12 19 (Blkt) POLICY NUMBER: 70K101141 01 00 CA COMMERCIAL GENERAL LIABILITY CG 24 04 12 19 (Blkt) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person(s) Or Organization(s): Blanket as required by written contract and effective during the policy period as stated on the policy declarations. I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 0412 19 (Blkt) © Insurance Services Office, Inc., 2018 Page 1 of 1 POLICY NUMBER: 70K101141 01 00 CA COMMERCIAL GENERAL LIABILITY CG 25 03 05 09 (Away) 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 Designated Construction Project(s): This endorsement applies only to your projects away from premises owned by or rented to you. 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 obli- gated to pay as damages caused by "occurrences" under Section I — Coverage A, and for all medical expenses caused by accidents under Section I — Coverage C, which can be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. A separate Designated Construction Project Gen- eral Aggregate Limit applies to each designated construction project, and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2. The Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A, except damages because of "bodily injury" or "property damage" included in the "products -completed op- erations hazard", and for medical 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". 3. Any payments made under Coverage A for dam- ages or under Coverage C for medical expenses shall reduce the Designated Construction Project General Aggregate Limit for that designated con- struction project. Such payments shall not reduce the General Aggregate Limit shown in the Decla- rations nor shall they reduce any other Designat- ed Construction Project General Aggregate Limit for any other designated construction project shown in the Schedule above. 4. The limits shown in the Declarations for Each Occurrence, Damage To Premises Rented To You and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Designated Construction Project General Aggregate Limit. CG 25 03 05 09 (Away) C Insurance Services Office, Inc., 2008 Page 1 of 2 B. For all sums which the insured becomes legally obli- C. gated to pay as damages caused by "occurrences" under Section I — Coverage A, and for all medical expenses caused by accidents under Section I — Coverage C, which cannot be attributed only to ongo- ing operations at a single designated construction project shown in the Schedule above: 1. Any payments made under Coverage A for dam- ages or under Coverage C for medical expenses D. shall reduce the amount available under the Gen- eral Aggregate Limit or the Products -completed Operations Aggregate Limit, whichever is appli- cable; and 2. Such payments shall not reduce any Designated Construction Project General Aggregate Limit. When coverage for liability arising out of the "prod- ucts -completed operations hazard" is provided, any payments for damages because of "bodily injury" or "property damage" included in the "products - completed operations hazard" will reduce the Prod- ucts -completed Operations Aggregate Limit, and not reduce the General Aggregate Limit nor the Desig- nated Construction Project General Aggregate Limit. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contracting parties de- viate from plans, blueprints, designs, specifications or timetables, the project will still be deemed to be the same construction project. E. The provisions of Section III — Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. Page 2 of 2 © Insurance Services Office, Inc., 2008 CG 25 03 05 09 (Away) POLICY NUMBER: 70K101141 01 00 CA COMMERCIAL AUTO GO CA Al 2003 (07 20) (Blkt) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. I Q k 1 [0] L Al 0 1 LT&J111qk Ce This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM This Pndnr-.Pmpnt rhnnript, tip nr)lir.v inffinnfix/ta nn the inrizntinn rinfiz of the= nn[irx/ unlace nnnthar rinta is inAit-citinrl hiMlnlAl Endorsement effective GuideOne Insurance Company Named Insured Countersigned by John Dickens Incorporated (Authorized Representative) WHO IS AN INSURED (under Section 11— Liability Coverage, A.1) is amended to include as an "insured" the person or organization shown in the Schedule with respect to the operation, maintenance, or use of a covered "auto" you own if: 1) You are obligated to add that person or organization, as an additional insured to this policy by: a. an expressed provision of an "insured contract", or written agreement; or b. an expressed condition of a written permit issued to you by a governmental or public authority; and 2) The "bodily injury" or "property damage" is caused by an "accident" which takes place after: a. You executed the "insured contract" or written agreement; or b. The permit has been issued to you. SCHEDULE Name Address Blanket as required by an expressed provision of an "insured contract", or written agreement; or an expressed condition of a written permit issued to you by a governmental or public authority and effective during the policy period as stated on the policy declarations. GO CA Al 2003 (07 20) (Blkt) Page 1 of 1 POLICY NUMBER: 70K101141 01 00 CA COMMERCIAL AUTO CA 04 44 10 13 (AutoBlktWaiver) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: John Dickens Incorporated Endorsement Effective Date: Name(s) Of Person(s) Or Organization (s): Blanket where required by written contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization. CA 04 44 10 13 (AutoBlktWaiver) © Insurance Services Office, Inc., 2011 Page 1 of 1