Insurance - Nikola - 2007-03-05 ACORD, CERTIFICATE OF LIABILITY INSURANCE OP ID
DATE(MMDD VYYY)
NICHO-1� 03/05/07
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
CLARKE MARINE INSURANCE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
245 FISCHER AVENUE, SUITE D-8 nn �(('�� `/ ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COSTA Phone MESA-444 2679 Fax 714-441�A�t&E I v E D
INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA: Gemini Insurance Company _
Nikola Construction MAR — 7 2007 INSURERS state compen In Fund
Corporation INSURER QBE Specialty
DBA: Nikola Corporation -
16012 Cowani Suite 290 INSURER 0 un tad al In nee co
Irvine CA 91614
INSURER E.
COVERAGES
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 AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
IN H ADU L POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMBS
LTR NSRC TYPE OF INSURANCE DATE(MM/DD/YY) DATE(MM/DD/YY)
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A X X COMMERCIAL GENERAL LIABILITY VCGP013092 08/15/06 08/15/07 PRISES(EaEO«arena) $50,000
CLAIMS MADE X OCCUR MED EXP(Any o person) $5,000
X Blanket Addl Insd PERSONAL BADV INJURY $ 1,000,000
X Waiver of Subro GENERAL AGGREGATE $2,000,000
�GENT AGGREGATE LIMIT APPLIES PER PRODUCTS COMP/OP AGG $2,000,000
n l POLICY PRO- LOC
JECT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Pe accident) $
PROPERTY DAMAGE
(Pe acadent)
GARAGE LIABILITY AUTO ONLY EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $2,000,000
L: X OCCUR CLAIMSMADE FCX0004019 09/05/06 06/05/07 AGGREGATE $2,000,000
$
DEDUCTIBLE $
X RETENTION $10,000 $
Wf,SIAIU- OIH-
WORKERS COMPENSATION AND X TORY LIMITS) ER
EMPLOYERS'LIABILITY 046-12549-2005 12/24/06 12/24/07 E L.EACH ACCIDENT $ 1,000,000
ANY PROPRETORI RIEXECUTIVE
EXCLUDED?EXCLUDED? E.L.DISEASE EA EMPLOYEE $ 1,000,000
It SPECIAL PROVISIONS E.L.DISEASE POLICY LIMIT $ 1,000,000
SyeCIAL PROVISIONS below
OTHER
C Leased, Borrowed 2598480 07/10/06 07/10/07 Contrs EQ $100 000
Rented Equipment 2% ded $5,000 max
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Certificate holders and its officers agents and employees are named as
additional insured per the Blanket Additional Insured Endorsement VE0182 03
04 with respect to Costa Mesa Sanitary District Project #181 - Newport Blvd
Sewer at 19th St & Placentia Avenue Sewer at 18th Street Waiver of
Subrogation Endorsement applies *except 10 day notice for non payment
CERTIFICATE HOLDER CANCELLATION
COSTAME SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Costa Mesa Sanitary District DATE THEREOF THE ISSUING INSURER WILL XIWIQ tXMAIL 30* DAYS WRITTEN
Joan Revak, Board Secretary NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,KM KALORK0003EO0'QRNX
FAX 949-650-2253 113E t34TsLeio BRX4XLir$rd d416a01dtKiwlfixs atKxswxseisxBc
628 w 19th Street
Costa Mesa CA 92627
A ED REPR T, n
ACORD 25(2001/08) 4/ rS/ 0 ACORD CORPORATION 1988
Policy Number VCGPO11324
VE 0182 03 04
Insured Name:NIKOLA CONSTRUCTION CORP
DBA. NIKOLA CORPORATION Effective Date:08/15/2005
Number 32
TINS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLI
BLANKET ADDITIONAL INSURED ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
A. Section II —Who is An Insured is amended to include as an 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 but only with respect to liability caused by your ongoing operations
performed for that insured. A person s or organization s status as an insured under this
endorsement ends when your operations for that insured are completed. This insurance does
iAtaiplffir?alnlity'oalred by the sole negligence of any additional insured. fr
çWithtieflTth einurpe affo ed tp hese additional nsure s, the eollo ng additionaal
} F
e clusrons applies: s `'` „_ .
x..., ,
Thisurance does noLLappZy to:
1 The preparing, approving, or failing to prepare and approve, maps, shop drawings,
opinions, reports, surveys, field orders, change orders or drawings and specifications; and
2. Supervisory inspection, architectural or engineering activities.
VE 0182 03 04 Page 1 of 1
Policy Number VCGP013092 CG 24 04 10 93
Insured Name:NIKOLA CONSTRUCTION CORP DBA.NIKOLA CORPORATION
Number 33 Effective Date:08/15/2006
THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
AS REQUIRED BY WRITTEN CONTRACT
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable
to this endorsement)
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition(Section IV—COMMERCIAL GENERAL
LIABILITY CONDITIONS)is amended by the addition of the following.
We waive any right of recovery we may have against the person or organization shown in the Schedule above because of
payments we make for injury or damage arising out of your ongoing operations or 'Your work' done under a contract with
that person or organization and included in the products-completed operations hazard' This waiver applies only to the
person or organization shown in the Schedule above.
CG 24 04 10 93 Copyright. Insurance Services Office, Inc 1992 Page 1 of 1 ❑