Insurance - Sancon - 2004-08-06 a is P0118 and ASSOC Fa 1-818-876-3322 Au, 6 2004 14 32 P 01
AQOORQ CERTIFICATE OF LIABILITY INSURANCE 08/06/20' -
PRODUCER (818)876-3336 FAX (818)876-3321 I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Poms & Associates I ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
24025 Park Sorrento Attn Mary H Pavlo HOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
Suite #110
Calabasas, CA 91302 1 INSURERS AFFORDING COVERAGE NAIC#
iwsuRED Sancon Engineering II Inc INSURER A: Virginia Surety Company, Inc -A/IIX
5841 Engineer Drive INSURERS: Liberty Insurance Underwriters A/XV
Huntington Beach CA 92649 INSURE C: American Int'1 . Specialty Lines JA+/XV
I INSURER E:
COVERAUS
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.
INSR MOO^r POLICY EPPk C IPDLICYEXP tt
Imo, Gpq TYPE OF INSURANCE I POLICY NUMBER y?v A,..n°rt .A-E rM '^%4, _ LIMITS
GENERAL LIABILITY I EACH CC..URRENC I 1,000,000
A COMMERCIAL GENERALLG:P "HI' 1CG53 1Dt 00 10/01/2003 10/0,/,004 CAV TO tiN- D
—„ 1s 50,000
CLAIMS MADE n OCC.R ME EXP(Any P apes n) 5,000
A 1 PERSONAL A ADV INJURY Is 1,000,000
I GENERALAGGFLGATE I5 2.000,000
GENL AGGREGATE LIMIT APPUV'PER PRC^DUCTS COMPIOP recur I $ 2,000.000
n POUCYn jr:CT it n I LOC I
I AUTOMO E uASIUTY i I COMBINED SING =LIMIT
X ANY AIM 11 (Ea=Pent) 1,000,000
AL_CANSO AUTOS I I I I e9DILY JURY
I
A SCHE_U EDAUTOS 1CA5011-3300 10/01/20^u3 10/01/2004 1 (Pe'Pe n1
X HIRE AUTOS I BODILY INJURY $
X NON-CWNED Ads i (P 'ticAnf)
PROFP;TY DAMAGE
!!!
(Pr et:bent) IS I
CARACE LIABILITY _ II`AUTO ONLY AAL .'_. . >
ANY ALTO OTHER THAN EA ACC a
• ALRO ONLY: AuG I a
—EXD�{ESSAIMGRELLA LIABILITY I EACH DC..URRENC_ S 4,000 1000
CC'UR ECLAIMS MAC AGGREGATE S 4,000,000
B L01-671181325013 10/01/2003 10/01/2004 IS
~
DEDUCTiEL_ S
_
RETENTION 5 I I IS
I
X I wC STATU. TH•
WORICSRS COMPENSATIONAND T�—°'IL4ET;, CR.
EMPLOYERS'UAEILITY E_.EACH ACCIDENT IS 1,000,000
A OffICERIMEMB.71P°_XR-UOEO?i DJrn� 1CW50113100 10/01/2003 10/01/2004 E.L-DISEASE EA EMPLOYS-6 -1,000,000
N yea.deer e under
SPECIAL POLICY LIMIT I 1,000,000
SPECIAL PROVISION'S belay
I CLAIMS MADE POLICY
Hniactor s Pollution CPL1176136 10/01/2003 10/01/2004 51,000,000 Each Claim/Agg
C Liability (CPL)
DESCRIPTION OF OPERM ONS ILQCIATIDNS/YFMICLe- IEXCLL'SIO SASDEDB NDqORS'MENTISP'-.A PROVISION!
e• Costa Mesa Sanitary Distrisct Project 11.2100-166-ManLOle and Pump Station Rehabilitation
-_-_ t_is agreed that Costa Mesa Sanitary District is named as Additional Insured per the attached
ndorsement
1
10 Days Notice of Cancellation Shall Apply for Non-Payment of Premium
CERTIFICATE HOLDER 1 C'NCELLA ION
SHOULD ANY OF THE ABOVE DESCRIES°POLICIES BE CANCELLED BEFORE THE
I EXPIRATION DATE THEREOF THE ISSUING INSURER WILL ENDEAVOR TO MAIL
I
Costa Mesa Sarti Lary District 30* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TOTHE LEFT,
Attn Joan Revak BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
P.0 Sox 12001 OF AN I UPON THEIMBURER.ITSACENTS OR REPRESENTATIVES.
Costa Mesa, CA 93628 AUTHORIZED ENTATIVE n
/1 Ari ACORD 25(2001106) , ®ACORD CORPORATION 1988
POMS and ASSOC Fa 1-818-876-3^22 Aug 6 2004 14 32 P 02
Costa Mesa Sanitary District
Certificate issued to Costa Mesa Sanitary District 08/06/2004
Pools & Associates
08/06/2004
Virginia Surety Company Inc Admitted A/IX
Policy No 1CG50113200'
Additional Insured Owners Lessees or Contractors (FORM B)
This endorsement modifies nsurance provided under the following
COMMERCIAL GENERAL LIABILITY PART
SCHEDULE
Name of Person or Organization r^^ n Mesa Sanitary District
(If no entry appears above information required to complete this endorsement will be shown in the
Declarations as applitable to this endorsement )
WHO IS AN INSURED (Section II) is amended to nclude as an nsured the person or organization shown in
the Schedule, but only with -espect to 1 cab' :y ari n^ out of your work' for that insured by or r
You
ISO ENDORSEMENT ECC 20 10 11 85