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Project 183 - GCI Construction - 2008-07-14 II I I I ACORD CERTIFICATE OF LIABILITY INSURANCE GCI A 1 DAo��ia oe PRODUCER I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION I I ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Seltzer Insurance Services I HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 140 Centennial ,Way I ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Tustin CA 92867 I Phone' 714 665 9800 Fax 714 665 9801 INSURERS AFFORDING COVERAGE NAIC# INSURED ' INSURER A. Lazo.ngtan In e. Co. (AIG Group) 19437 GCI Construction, Inc INSURER a: Granite State (MG Group) 23809 iInc. I Pacfic Equipment, LLC INSURERC .Nat. Un. Fir In.. Co (AIG Gr.) I 19445 245 Fischer Ave. , Ste 83 INSURERD !Redwood Fire & Casualty 11673 Costa Mesa CA 92626 INSURER E. I Firmane,and/Ass. CO. oL Arter. 21873 COVERAGES i I THE POLICES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS I I7 ME ! I TYPE OF INSURANCE I POLICY NUMBER DPADTE MMNO/YY)E IPDATE(MMND Y) I LIMITS GENERAL UABILDY I i I EACH OCCURRENCE 31000000 I UAMA(,E IU NLNI EU A X COMMERCIAL GENERAL LIABILITY 1260420 I 04/01/08; 04/01/09 I PREMISES(Ea cwFance) $50000 �Fl CLAIMS MADE I X I OCCUR I MED EXP(Any me perms) S X Owner s/Cont. Pro PERSONAL BADV INJURY S 1000000 X XCU/IIeductible $10 000 GENERAL AGGREGATE $2000000 GENII AGGREGATE PER 1 I PRODUCTS-COMP/OPAGG 32000000 I . CY x I PRO- I Lcc , Emp. I Ben. 1000000 AUTOMOBILE LIABILITY i COMBINED SINGLE LIMIT Si 000 000 B X X ANY AUTO 02-CA-009349089-0 04/01/08 04/01/09 IEaacadenD ALL OWNED AUTOS BODILY INJURY 3 SCHEDULED AUTOS (Per person) X HIRED AUTOS i BODILY INJURY X NON-CWNED AUTOS (Pe accident) 3 X Comp/Coll Ded 1 81000 PROPERTY DAMAGE 5 XlNo Liab. Ded/SIR IP, accident) GARAGE UABIUTY I AUTO ONLY-EA ACCIDENT S II ANY AUTO EA ACC S OTHER THAN AUTO ONLY. AGG 5 EEXXCESS/UMBRELLAUABILITY EACH OCCURRENCE $4000000 C X IOCCL4t I IOAIMSMADE BE9219788 04/01/08 04/01/09 AGGREGATE 54000000 4T-" I S 1 I EDUCTIBLE 3 II RETENTION 3 I I 3 IAIU- tH- WORRERSCDMPENSATIDNANO TORWCY S LIMITS I XI DER EMPLOYERS'LIABIUTY D ANYPROPRIETOR/PARTNER/EXECUTIVE 4403006113-081 03/17/08 03/17/09 E.L.EACH ACCIDENT $1000000 OFFICERIMEMBEREXCLUDED? 1 EL DISEASE-EAEI,' .DYE $1000000 Syes,C AL:�O mover POLICY OMIT I$1000000 SPECIAL PROVISIONS below E L DISEASE- I OTHER I E IIM-Eqp /Lead Hrd R MXI98401780 04/01/08 04/01/09 ' Sch Limit 1 8M/838k/5 , COC1 - I2urich 3R67721425 06/12/08 06/12/091 Limit 172095 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Certificate holder along with the City of Costa Mesa are additional insured with regards to operations of named insured for project Victoria St & Harbor•Blivd, SW Main Replacement City of Costa Mesa as per contract as per attached blanket endorsements •10-day notice of cancellation for non-payment of premium CERTIFICATE HOLDER CANCELLATION . SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION I DATE THEREOF THE ISSUING INSURER WILL�IL 30 DAYS WRITTEN i NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT F Costa Mesa Sanitary District 1 I its agents and employees 1 628 W 19th Street .(((( coota Mean CA 92627 2716 AUTHORRLORCFRESGNTATIVC �w 19. '. ! ACORD 25(2001/08) I ©A •Ri, ORPORATION I 1 I I I GCI Construction Inc POLICYNUMBER ENDORSEMENT COMMERCIAL GENERAL LIABILITY 1260420 CO 20 37 10 01 THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY ADDITIONAL INSWED - OMNE.RS, LESSEES OR OONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization. Blanket As Required By Written Contract This endorsement applies to work performed on Commercial Projects only and excludes any and all Residential Structures work as defined by LX 9911 (02/06) on the policy Location And Description of Completed Operations: Additional Premium: Ilf no entry appears above, information required to complete this endorsement will be shown in the Declara- tions as applicable to this endorsement.) Section II Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work at the location designated and described in the schedule of this endorsement performed for that insured and included in the products-completed operations hazard" CG 20 37 10 01 ©ISO Properties, Inc. 2000 Page 1 of 1 ❑ 1x9604 ENDORSEMENT This endorsement. effective 12:01 AM 04/01/2008 Forms a part of policy no 1260420 Issued to GCI CONSTRUCTION INC B y• LEXINGTON INSURANCE COMPANY WAIVER OF SUBROGATION (BLANKET) It is agreed that we, in the event of a payment under this policy, waive our right of subrogation against any person or organization where the insured has waived liability of such person or organization as part of a written contractual agreement between the insured and such person or organization entered into prior to the occurrence or offense. All other terms and conditions remain unchanged. pe 7 Au orized Representative eprresese ntative OR Countersignature (In states where applicable) LEXOCC234 111■031 ENDORSEMENT This endorsement, effective 12:01 AM 04/01/2008 Forms a part of policy no 1260920 Issued to. GC I CONSTRUCTION I NC By. LEXINGTON INSURANCE COMPANY PRIMARY/NON CONTRIBUTORY ENDORSEMENT This endorsement modifies insurance provided by the policy Notwithstanding any other provision of the policy to the contrary, the insurance afforded by this policy for the benefit of the Additional Insured shall be primary insurance, but only with respect to any claim, loss or liability arising out of the Named Insured's operations; and any insurance maintained by the Additional Insured shall be non-contributing. All other terms and conditions of the policy remain the same. 4 thorixed Representative OR Countersignature (ln states where applicable) LX8836(05)05) a WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY FORM NUMBER INSURER REDWOOD FIRE & CASUALTY INSURANCE COMPANY WC-99-03-06 CALIFORNIA WAIVER OF SUBROGATION We agree that in consideration of the additional premium charged, the Right of Subrogation Clause contained in this policy is hereby waived as respects the following persons or entities: Any person or organization to whom you are obligated by valid written contract wherein you have agreed to furnish this waiver. This endorsement applies only to those persons or entities listed in the foregoing paragraph. The insured agrees to maintain contract records in order to determine for which jobs this waiver will apply.That information will be verified by the insurer at final audit. A surcharge of 1%shall be applied to the risk's Standard Premium, subject to a minimum charge of$500, and will be collected upon completion of the final audit. 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: 03/17/2008 Policy No. 4403006113-081 Endorsement No. 1 Insured: GC!CONSTRUCTION, INC.(A CORP) Insurance Company Countersigned by: Redwood Fire And Casualty Insurance Company