Insurance - Atlas-Allied - 2002-05-24 Client# . 32903 ATLAALL
ACORD CERTIFICATE OF LIABILITY INSURANCE os%24%oz
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Armstrong/Robitaille Bus&Iris Sv ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
680 Langsdorf Drive Suite 100 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
g ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO Box 34009
Fullerton CA 92834-9409 INSURERS AFFORDING COVERAGE
INSURED INSURERA Royal Surplus Lines Insurance
Atlas Allied Inc INSURERB CNA/American Cas Co of Reading PA
1210 N Las Brisas INSURERC Constitution Insurance Co
Anaheim, CA 92806 INSURERD State Compensation Insurance Fund
I INSURERB CNA/Nat' l Fire Ins of Hartford
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.
INSR TYPE OF POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION I LIMITS
LTR DATE(MM/DD/YY) DATE(MWDDNY)
A GENERAL LIABILITY KZ13518549 11/01/01 11/01/02 EACHOCCURRENCE $1, 000 , 000
X COMMERCIAL GENERAL LIABILIN FIRE DAMAGE(Anyo he) $50 , 000
CLAIMS MADE []OCCUR MED EXP(My person) I$0
BI/PD Ded. 2 , 500 PERSONAL BADV INJURY $1, 000, 000
GENERAL AGGREGATE I$2 000, 000
GEN'L AGGREGATE LIM ITAPPLIES PER PRODUCTS -COMP/OP AGG $1 000, 000
7 POLICY I . 1 2 jEOT I LOC
B AUTOMOBILE LIABILITY BUA1010931884 11/01/01 11/01/02 COMBINED SINGLE LIMIT $1 000 000
X
ANY AUTO (Ea 'dent)
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Perpersan) $
X HIRED AUTOS
BODILY INJURY $
X NON-OWNED AUTOS (Pe dent)
PROPERTY DAMAGE $
(Pe 'dent)
GARAGE LIABILITY AUTO ONLY EA ACCIDENT I$
ANY AUTO
OTHER THAN
AUTO ONLY EAACC $AGG $
C EXCESSUABILITY
OCCUR
CUL41383 11/01/01 11/01/02 EACH OCCURRENCE I$4 , 000, 000
CLAIMS MADE AGGREGATE $4 , 000, 000
DEDUCTIBLE
RETENTION $ $
D WORKERS COMPENSATION AND 31972 11/01/01 11/01/02 X ORYLMITS I IOER
EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $1, 000, 000
E L.DISEASE EA EMPLOYEE $1 000, 000
EL.DISEASE POLICY LIMIT $1 , 000, 000
E OTHER Installation TCP1010931870 11/01/01 11/01/02
Floater $500 000 limit
$500 deductible
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
30 Day Notice of Cancellation Except for 10 Day Non-pay of Premium
Re project# 1112100-161 Water Services for Sewer Pump Station
Costa Mesa Sanitary District and its employees are added as additional
insured for the above project Waiver of subrogation for General Liability
(See Attached Descriptions)
CERTIFICATE HOLDER II I ADDmONALINSURED;INSURER LETTER. CANCELLATION
SHOULD ANYOFTH E ABOVE DESCRIBED POLICIESBE CANCELLED BEFORE THE EXPIRATION
Costa Mesa Sanitary District DATE THEREOF THE ISSUING INSURER WILL F/3Q%)OZgOQAAIL3-0—DAYS WRITTEN
Clerk of the District NOTICETOTHE CERTIFICATE HOLDER NAM ED TOTHE LEFT„@Mtg MOT32)A$OSZp¢D[){
PO Box 1200 KMERSEKOINWCIUMCDIERLIXIWKDOUNISXWAEXIMECKSIIDIERFCM510342FC
Costa Mesa CA 92660 1200 BERBESTEKNITEDESC
AUTHORIZED ESENTATIVE
ACORD 25-S(7/97)1 0 f 3 #5170325/M155179 CIK 0 ACORD CORPORATION 1988
DESCRIPTIONS (Continued from Page 1)
applies per attached endorsement Waiver of subrogation for Work Comp
applies endorsement to be issued by carrier This insurance is Primary &
non-contributory Admitted carrier/cut-thru endorsement to be issued by
carrier
AMS25.3(07/97) 3 of 3 #S170326/M155179
POLICY NUMBER: KZB518549 COMMERCIAL GENERAL LIABILITY
ATLAS-ALLIED INC.
THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
COSTA MESA SANITARY DISTRICT
Job Description: JOB# 1112100-161 WATER SERVICES FOR SEWER PUMP STATION
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
WHO IS AN INSURED (Section II) 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' for that insured by or for you.
Such insurance as is afforded by the General Liability policy is Primary Insurance and no other insurance of the
additional insured will be called upon to contribute to a loss as required by written contract.
CG 20 10 11 85 Copyright, Insurance Services Office, Inc. 1984 Page 1 of 1 ❑
ROYAL SURPLUS LINES INSURANCE COMPANY
Named Insured: ATLAS-ALLIED INC. Endorsement No:
Policy KZB518549 Effective Date: 11 1-01
COMMERCIAL GENERAL LIABILITY
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
OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
ANY PERSON OR ORGANIZATION AS REQUIRED BY WRITTEN CONTRACT
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHER TO US Condition 8. (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 payment we make for injury or damage arising out of your ongoing operations or 'your work done
under a written contract with that person or organization. This waiver applies only to the person or organization
shown in the Schedule above.
RSA1001 (11/99),
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
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State of California
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1 i Pla Notary Seal Abo Signatu of Notary Public $1
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le Though the information below is not required by law, it may prove valuable to persons relying on the document l
ii and could prevent fraudulent removal and reattachment of this form to another document. '0
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Ie Description of Attached current )
i Title or Type of Document 'ej t-{-t 16 'e-o a
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Ii Document Date 4 J` 2-4 -C�L 3 Number of Pages: �
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Signer(s) Other Than Named Above: '1
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It Signers Name: _ RIGHT THUfJEPRINT I
1% ❑ Individual Top of SIGN here Ol
;i ❑ Corporate Officer—Tltle(s):
ig ❑ Partner—❑ Limited ❑ General y
it ❑ Attorney in Fact
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®1999 Na al No ary Associate,,•9350 De Su PO Box 2402•Chatsworth CA 91 13 2402•www nalwrialn ary o Plod No Rcxde Call Toll Fr 13a)1376-6827
JUN-C^-2CO2 s• 1 CU I NE9:I Sri L ST 71- 432 143b P E C
RECEIVED
STATE P.O. BOX 420807 SAN FRANCISCO, CA 94142.0807 JUN ` 7 2002
CO AFP EN S AN CN
1`NSURANC6
COSTA MESA SA+.3i-.Y";^T",,T
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
JUNE 5, 2002 POLICY NUMBER' 3t9—01 UNIT 0030072
CERTIFICATE EXPIRES 1i_1_09
COSTA MESA SANITARY DISTRICT
CLERK OE THE DISTRICT•
PO BOX 1200
COSTA MESA CA 92686-1200 JOB: PROJECT 11112100-161
WATER SERVICES FOR SEWER
L P I? STATION
•
This is"t,i cartrTy thaitivE have iss(ied a Valid'✓nrorkeis Corrpensation insiror;e pa' ty Ire farm approved by the California
Insurance Commissioner to tnc employer named below for the policy period indica:ed.
Tnis policy is not subject to Cancellation by the Fund except upon ten days advance wr tte: notice tc the employer.
We will a5o give you TEN pays'advance notice should this poi Cy be canceled prior tb its normal expiration
This oervfl tte.ot insurance is not an insurance policy and does rot?mend, extend oralter ine roter£ne afforded by tire
policies hated herein. No:wltl' taridino any requirement, term, or conditon or any contract or otter document with
respect to which this certificate of insurance may i sueC or may pertain, the insurance affordec by the aolcies
descnoed herein is subject to all the terms ecluslons and conditIons of sucn policies
es' A,../esidetrietestnr
APs onIZeD'ntfnesE, TATIVE :FSMcN-
''3iPLDYER'S LIABILITY ,LIMIT INCUJDTNG DEFENSE CASTS. $1,000,000 PER OCGSIRRENCE.
ENDORSI281YI' 52570 ENTITLED'WAIVER OF SUBROGATION EFFECTIVE
06/06/02 IS ATTACHED TO AND FORMS A PART OF PHIS POLICY
THIRD PARTY NAME COSTA MESA SANITARY DISTRICT
'EMPLOYER
ATLAS—.ALLIISD INC
1210 N LAS-BRISAS
ANAHEIM CA 92806
TOME P 01