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Insurance - Michael Balliet Consulting LLC - 2012 I I DATE(MM/DD/YY) _A�� • CERTIFICATE OF LIABILITY INSURANCI _ 03/04/13 PRODUCER Ability Insurance Agency Inc. ' THIS CERTIFICATE IS ISSUED AS MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS r ON THE CERTIFICATE P.0.Box 540 HOLDER.THIS CERTIFICATE DOE•i NOT AMEND,EXTEND OR Rancho Cucamonga,CA 91739 ALTER THE COVERAGE AFFORDE II BY THE POLICIES BELOW. Phone (714)968-9600 Fax (714)968-8001 INSURERS AFFORDING COVERAGE NAIC# INSURER A: Hartford Casualty Insura' ce Co. INSURED Mike Balliet INSURER B: Hartford Casualty Insural ce Co. 26351 Tarrasa Lane I INSURER C: I Mission Viejo, CA 92691- !INSURER D: I —. (949)837-3618 I INSURER E: _ I I COVERAGES I THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDIC TED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CE-, IFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUS•NS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFFECTIVE !POLICY EXPIRATION I INSR ADD'L LIMITS _iR IN (• TYPE OF INSURANCE POLICY NUMBER DATE(MM/DDIYYYY!DATE(MM/DDIYYYY)! GENERAL LIABILITY I EACH Oa CURRENCE $1,000,000 '16 COMMERCIAL GENERAL LIABILITY DAMAG TO RENTED $300,000 72SBAZB1092SC 10/26/2012 10/26/2013 PREMIS=_JEa occurrence) ! MED EX (Any one person) $10,000 A ' ❑❑ CLAIMS MADE d OCCUR• 21 ❑ PERSO I.L&ADV INJURY $1,000,000 ❑ _ GENERPi AGGREGATE $2,000,000 PRODU p S-COMP/OP AGG $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: i POLICY ❑PROJECT ❑ LOC __T r� AUTOMOBILE LIABILITY I COMBINI D SINGLE LIMIT $1,000,000 ❑ ANY AUTO 72SBAZB1092SC 10/26/2012 10/26/2013 (Ea acci.,-nt) I ❑ ALL OWNED AUTOS I BODILY NJURY B iV ❑ SCHEDULED AUTOS (Per per.on) 1✓J HIRED AUTOS BODILY!NJURY JI NON OWNED AUTOS (Per acc'.ent) ❑ PROPE-TY DAMAGE — (Per acc!.ent) - GARAGE LIABILITY AUTO• LY-EA ACCIDENT ❑ ❑ ANY AUTO OTHER HAN EA ACC ❑ - I --- ----- I — - -- ---I-AUTO CI LY: AGG i ! I EXCESS/UMBRELLA LIABILITY EACH 0, CURRENCE III ❑ OCCUR [1] CLAIMS MADE j AGGREGATE ❑ DEDUCTIBLE I ❑ RETENTION $ i I WORKERS COMPENSATION AND ❑ Wo STATU- ❑ OTH-� I EMPLOYERS'LIABILITY TO-Y LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EAoH ACCIDENT OFFICER/MEMBER EXCLUDED? i (Mandatory in NH) .DIS: ■SE-EA EMPLOYEE E E.L If yes,describe under E.L.DIS;ASE-POLICY LIMIT SPECIAL PROVISIONS below OTHER 1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION ,I SHOULD ANY OF THE ABOVE DESCRIBED P,.LICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING' SURER WILL ENDEAVOR TO MAIL Costa Mesa Sanitary District DAYS WRITTEN NOTICE TO THE uERTIFICATE HOLDER NAMED TO 628 West 19th Street <r) E LT, O SH l TIN IABILITY ?n\ OF TH ANY EF KIND BUT UPON FAILURE THE INSUTO D SRO,ITS ALL AGE! POSE S OR REPRESENTATIVES NO OBLIGA OOR L Costa Mesa, CA 92627 V) AUTHORIZED REPRESENTATIVE ;: ACORD 25(2009/01)QF ©1988-2009 ACORII CORPORATION.All rights reserved. The ACORD name an logo are registered marks of ACORD POLICY NUMBER: 72 SBA ZB1092 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PERSON-ORGANIZATION THE CITY OF HUNTINGTON BEACH, ITS OFFICERS, ELECTED OR APPOINTED 'OFFICIALS, EMPLOYEES, AGENTS AND VOLUNTEERS 2000 MAIN ST HUNTINGTON BEACH, CA 92648 ATTN: RISK MANAGEMENT THE CITY OF NEWPORT BEACH, THE CITY, ITS ELECTED OR APPOINTED THE CITY OF NEWPORT BEACH, THE CITY, ITS ELECTED OR APPOINTED OFFICERS, OFFICIALS, EMPLOYEES, AGENTS AND VOLUNTEERS ARE TO BE COVERED AS ADDITIONAL INSUREDS WITH RESPECT TO LIABILITY OUT OF WORKPERFORMED BY OR ON BEHALF OF THE CONSULTANT THE CITY OF COSTA MESA AND ITS ELECTED AND APPOINTED BOARDS,. OFFICERS, AGENTS, AND EMPLOYEES 77 FAIR DRIVE COSTA MESA, CA 92626 "`— COSTA MESA SANITARY DISTRICT 628 W 19TH ST. �1 (\ COSTA MESA, CA 92627 1 Form IH 12 00 11 85 T SEQ. NO. 002 Printed in U.S.A. Page 001 Process Date: 03/01/13 Expiration Date: 10/26/13 i `4s THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT AREFULLY. POLICY CHANGE This endorsement changes the policy effective on the Inception Date of the policy unless another date is indicated below: Policy Number: 72 SBA ZB1092 DX Named Insured and Mailing Address; MIKE BALLIET 26351 TARRASA LN MISSION VIEJO CA 92691 Policy Change Effective Date: 03/01/13 Effective hour is the same as stated in the Declarations Page of the Policy. Policy Change Number: 001 Agent Name: SUPERIOR ACCESS INS SRVC INC/PHS Code: 181840 POLICY CHANGES: SENTINEL INSURANCE COMPANY, LIMITED ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLIN STATEMENT.IF YOU ARE ENROLLED IN REPETITIVE EFT FROM YOUR B .NK ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A BILL. ADDITIONAL PREMIUM DUE AT POLICY CHANGE EFFECTIVE DATE: $E9.00 *INCLUDES ADDITIONAL TERRORISM PREMIUM OF: 2.00 RATES AND PREMIUMS ARE CHANGED. BUSINESS LIABILITY OPTIONAL COVERAGES ARE REVISED HIRED/NON-OWNED AUTO LIABILITY IS ADDED: FORM SS 04 38 LIMIT OF INSURANCE: $1, 000, 000 �_- PRO RATA FACTOR: 0.655 THIS ENDORSEMENT DOES NOT CHANGE THE POLICY EXCEPT AS SHOWN. Form SS 12 11 04 05 T Page 001 (CONTINUED ON NEXT PAGE) Process Date: 03/01/13 Policy Effective Dote: 10/26/12 Policy Expiration Date: 10/26/13 • --w., CERTIFICATE OF LIABILITY INSURANCE DATE 2i2812YY) • PRODUCER Ability Insurance Agency Inc. THIS CERTIFICATE IS ISSUED-AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.0.Box 540 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR .•• . (714)968-8001 - -- ---- _....RDI---O E — Phone (R714)968-9600 Cucamonga,CA 91730 Fax (7ta)968-8001 INSURERS AFFORDING THE POLICIES BECOW. —;I . i INSURED Michael Baliiet Consulting INSURER A. Lloyds of London ; i INSURER B. 26351 Tarrasa Lane l_...-- -- --------- --- ----- ..__... . :---- ---____...—.. I INSURER C: • Mission Viejo, CA 92691- INSURER D: . - . . ___ :(949)837-3618 INSURER E: _i • COVERAGES • THE POLICIES OF INSURANCE LISTED 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. _ • ■IINSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE ;POLICY EXPIRATION; LIMITS {-rR:INSRD._....- ...__. —._.____� _..__...-...._.__ !DATE(MMIDDNYYY_DATEfMWDD/YYYY� .__. i i ; GENERAL LIABILITY : • I EACH OCCURRENCE 1 $1,000,000 DAMAGE TO RENTED . COMMERCIAL GENERAL LIABILITY ,lMPL(068477.12 • 07/19/2012 07/19/2013 ;PREMISES(Ea occurrence) .._-._. • MED EXP(A ) (Any one person —�." CLAIMS MADE ;-., OCCUR A ! I PERSONAL 8 ADV INJURY $1,000,000, v Professional Liability ----- .-- --GENERAL AGGREGATE S . i GEN'L AGGREGATE LIMIT APPLIES PER ;PRODUCTS-COMP/OP AGG • ___, POLICY ;_;PROJECT LI LOC , • • AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT •• ANY AUTO (Ea accident) -- __ •ALL OWNED AUTOS - BODILY INJURY• :J _.. SCHEDULED AUTOS - (Per person) HIRED AUTOS INJURY . ' NON OWNED AUTOS (Per accident) • ...___. - . PROPERTY DAMAGE (Per axideN) _....... I , GARAGE LIABILITY • AUTO ONLY-EA ACCIDENT ANY AUTO OTHER THAN E A ACC .--__ • • . ;AUTO ONLY: AGG j I EACH OCCURRENCE ! I EXOESS/UMBRELLA LIABILITY E--.. OCCUR CLAIMS MADE AGGREGATE _ _ — a • . i DEDUCTIBLE — 1 i RETENTION $ I WORKERS COMPENSATION AND TORY LIMIT IMITS 0TH_ _--..._— • . ;EMPLOYERS'LIABILITY YIN• ANY PROPRIETOR/PARTNER/EXECUTIVE E L.EACH ACCIDENT OFFICER I MEMBER EXCLUDED? -- —'" '"'"''— — • (Mandatory in NH) i :E.L.DISEASE-EA EMPLOYEE; If yes,describe under i E.L.DISEASE-POLICY LIMIT SPECIAL PROVISIONS below OTHER . DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION j SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE • EXPIRATION DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL PROOF ONLY DAYS WRITTEN NOTICE TO THE CERTIFICATE-HOLDER NAMED TO i THE LEFT.BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY . OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2009101)OF I€1989-2009 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered-marks of.ACORD • • Javier Ochiqui From: Mike Balliet <mikeballietl @yahoo.com> Sent: Tuesday, March 05, 2013 9:09 AM To: Javier Ochiqui Subject: Re:Independent Contractor or a sole proprietorship? Hi Javier: Michael Balliet Consulting is a limited liability corporation formed in California last year. I am the owner. I do not carry workers' comp coverage on myself as I am the owner. If it is preferable I can re-sign the contract as "owner". Regarding Anna's question yesterday regarding auto insurance. I carry personal coverage at $300K limits. The car is my personal asset and not an asset of Michael Balliet Consulting, LLC. Therefore the $1 million coverage for "non-owned" auto on the GL policy protects you on my contracted work as Michael Balliet Consulting. I apologize that the professional liability wasn't included in the paperwork provided yesterday. I believe it was included in my proposal packet but can have my insurance agent send another copy if needed. Please let me know if this resolves all questions/issues and if there is anything else you require. Thanks, Mike From: Javier Ochiqui <jochiqui(a�crosdca.gov> . To: Mike Balliet<mikeballiet1(a�yahoo.com> Sent: Tuesday, March 5, 2013 7:36 AM Subject: Independent Contractor or a sole proprietorship? Mike, For clarification, are you an independent contractor or a sole proprietorship? Also, we need proof of professional liability and workers comp since you signed as "President" and not "owner."Thanks. Javier Ochiqui Management Analyst l Costa Mesa Sanitary District 1 Website: www.cmsdca.gov phone:949.645.84001 email: iochiqui@a crosdca.Qov 1 628 W. 19`h St,Costa Mesa CA 92627 S Ry �C 71JW6 Jl; J�0� i a . J ,., „:„ s„,,:,,,, RhIt . 1 92 This Spectrum Policy consists of the Declarations, Coverage Forms,Common Po li y Conditions and any 10 other Forms and Endorsements issued to be a part of the Policy.This insurance is p ovided by the stock ZB insurance company of The Hartford Insurance Group shown below. SBA RECE1 ' ED INSURER: SENTINEL INSURANCE COMPANY, LIMITED MAR 0 4 201 �. HARTFORD PLAZA, HARTFORD, CT 06115 ) • COMPANY CODE: A USIA IVIbbA SAM('.'Y DISIRICI x:? Policy Number: 72 SBA ZB1092 DX ITHE ,�°.:); ARTFORD SPECTRUM POLICY DECLARATIONS Named Insured and Mailing Address: MIKE BALLIET (No., Street,Town, State,Zip Code) 26351 TARRASA LN MISSION VIEJO CA 92691 Policy Period: From 10/26/12 To 10/26/13 1 YEAR 12:01 a.m., Standard time at your mailing address shown above. Exception: 12 noon in Ne Hampshire. Name of Agent/Broker: SUPERIOR ACCESS INS SR VC INC/PHS Code: 181840 Previous Policy Number: 72 SBA ZB1092 Named insured is: INDIVIDUAL Audit Period: NON-AUD I TABLE Type of Property Coverage: SPECIAL Insurance Provided: In return for the payment of the premium and subject to all of the terms of this policy,we agree with you to provide insurance as stated in this policy. TOTAL ANNUAL PREMIUM IS: $500 MP Countersigned by 08/08/12 Authorized Representative Date I. Form SS 00 02 12 06 Page 001 (CONTINUED ON EXT PAGE) Process Date'. 08/08/12 Policy.Expiratio Date: 10/26/13 SPECTRUM POLICY DECLARATIONS (Continued) POLICY NUMBER: 72 SBA ZB1092 Location(s), Building(s), Business of Named Insured and Schedule of Coverages for Premis-.s as designated by Number below. Location: 001 Building: 001 26351 TARRASA LN MISSION VIEJO CA 92691 Description of Business: Consultant - NOC Deductible: $ 500 PER OCCURRENCE • BUILDING AND BUSINESS PERSONAL PROPERTY LIMITS OF INSURANCE BUILDING NO COVERAGE' BUSINESS PERSONAL PROPERTY REPLACEMENT COST $ 6,500 PERSONAL.PROPERTY OF OTHERS REPLACEMENT COST NO COVERAGE MONEY AND SECURITIES INSIDE THE PREMISES $ 10,000. OUTSIDE THE. PREMISES $ 5,000 Form SS 00 02 12 06 Page 002 (CONTINUED ON NEXT PAGE) Process Date: 08/08/12 Policy Expiration Date: 10/26/13 SPECTRUM.POLICY DECLARATIONS (Continued) POLICY NUMBER: 72 SBA ZB1092 Location(s), Building(s), Business of Named Insured and Schedule of Coverages for Premisl-s as designated by Number below. Location: 001 Building: 001 �. PROPERTY OPTIONAL COVERAGES APPLICABLE LIMITS OF INSURANCE TO THIS LOCATION STRETCH COVERAGES FORM: SS: 04 08 THIS FORM INCLUDES MANY ADDITIONAL COVERAGES. AND EXTENSIONS OF COVERAGES. A SUMMARY OF THE COVERAGE LIMITS IS ATTACHED.. LIMITED FUNGI, BACTERIA OR VIRUS $ 50, 000 COVERAGE: FORM SS 40 93 THIS IS THE MAXIMUM AMOUNT OF INSURANCE FOR THIS. COVERAGE', SUBJECT TO. ALL PROPERTY LIMITS FOUND ELSEWHERE ON THIS DECLARATION. INCLUDING BUSINESS INCOME AND EXTRA EXPENSE COVERAGE FOR: 30 DAYS • Form SS 0002 1206 Page 003 (CONTINUED ON EXT PAGE) Process Date: 08/08/12 Policy Expiratio Date: 10/26/13 SPECTRUM POLICY DECLARATIONS (Continued) POLICY NUMBER: 72 SBA Z31092 Location(s), Building(s), Business of Named Insured and Schedule of Coverages for Premiss as designated by Number below. Location: 002 Building: 001 18391 GOLDENWEST ST HUNTINGTON BEACH CA 92648 Description of Business: Consultant - NOC Deductible: $ 500 PER OCCURRENCE BUILDING AND BUSINESS PERSONAL PROPERTY LIMITS OF INSURANCE BUILDING NO COVERAGE { BUSINESS PERSONAL PROPERTY REPLACEMENT COST $ 6,500 PERSONAL PROPERTY OF OTHERS REPLACEMENT COST NO COVERAGE MONEY AND SECURITIES INSIDE THE PREMISES $ 10, 000 OUTSIDE THE PREMISES $ 5,000 l. i Form SS 0002 12 06 page 004 (CONTINUED 0: NEXT PAGE) Process Date: 08/08/12 Policy Expiration' ate: 10/26/13 SPECTRUM POLICY DECLARATIONS (Continued) i POLICY NUMBER: 72 SBA ZB1092 Location(s), Building(s), Business of Named Insured and Schedule of Coverages for Premis,-s as designated by Number below. Location: 002 Building: 001 PROPERTY OPTIONAL COVERAGES APPLICABLE LIMITS OF INSURANCE TO THIS LOCATION STRETCH COVERAGES FORM:. SS 04 08 THIS FORM INCLUDES MANY ADDITIONAL COVERAGES AND EXTENSIONS OF �. COVERAGES. A SUMMARY OF THE COVERAGE LIMITS IS ATTACHED. LIMITED FUNGI, BACTERIA OR VIRUS $ 50,000 COVERAGE: FORM SS 40 93 +( THIS IS THE MAXIMUM AMOUNT OF INSURANCE FOR THIS COVERAGE, SUBJECT TO ALL PROPERTY LIMITS FOUND ELSEWHERE ON THIS DECLARATION. INCLUDING BUSINESS INCOME AND EXTRA EXPENSE COVERAGE FOR: • 30 DAYS Form SS 00 02 1206 Page 005 (CONTINUED ON li EXT PAGE) Process Date: 08/08/12 Policy Expiratio' Date: 10/26/13 SPECTRUM POLICY DECLARATIONS (Continued) POLICY NUMBER: 72 SBA ZB1092 PROPERTY OPTIONAL COVERAGES APPLICABLE LIMITS OF INSURANCE TO ALL LOCATIONS BUSINESS INCOME AND EXTRA EXPENSE �. COVERAGE 12 MONTHS ACTUAL LOSS SU°TAINED COVERAGE INCLUDES THE FOLLOWING COVERAGE EXTENSIONS: ACTION OF CIVIL AUTHORITY: 30 DAYS I. { { SPECTRUM POLICY DECLARATIONS (Continued) POLICY NUMBER: 72 SBA ZB1092 BUSINESS LIABILITY LIMITS OF INSURANCE ;. LIABILITY AND MEDICAL EXPENSES $1,000,000 MEDICAL EXPENSES -ANY ONE PERSON $ 10,000 PERSONAL AND ADVERTISING INJURY $1,000,000 DAMAGES TO PREMISES RENTED TO YOU $1,000,000 ANY ONE PREMISES AGGREGATE LIMITS PRODUCTS-COMPLETED OPERATIONS $2,000,0.00 FORM SS 05 09 GENERAL AGGREGATE $2,000,000 {{i Form SS 00 02 12 06 Page 007 (CONTINUED ON NEXT PAGE) Process:Date: 08/08/12 Policy Expirati•n Date: 10/26/13 3 � THIS ENDORSEMENT-CHANGES THE POLICY. PLEASE READ IT AREFULLY. POLICY CHANGE This endorsement changes the policy effective on the Inception Date of the policy Unless: other date is indicated below: Policy Number: 72 SBA ZB1092 DX Named Insured and Mailing Address; MIKE BALLIET 26351 TARRASA LN MISSION VIEJO CA •92691 Policy Change Effective.Date: 03/01/13 Effective hour is the same as stated in the Declarations Page of the Poll y. Policy Change Number:. 001 I .Agent Name: SUPERIOR ACCESS INS •SRVC INC/PHS Code: 181840 POLICY CHANGES: SENTINEL INSURANCE COMPANY, LIMITED ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLINe STATEMENT.IF YOU ARE. ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR B' K ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A. BILL. ADDITIONAL PREMIUM DUE AT POLICY CHANGE EFFECTIVE DATE: $,;9.00 *INCLUDES ADDITIONAL TERRORISM PREMIUM OF: ;2.0O RATES AND PREMIUMS ARE CHANGED. BUSINESS LIABILITY OPTIONAL COVERAGES ARE REVISED -....,,,,„,.' € HIRED/NON-OWNED AUTO LIABILITY IS ADDED: FORM SS 0,4 38 • LIMIT OF 'INSURANCE: $1,000,000 f,,---''''''' ,r f PRO RATA FACTOR:: µ0:675-5- -------------r----------' -°.,, . 'F THIS ENDORSEMENT DOES NOT CHANGE THE POLICY EXCEPT AS SHOWN. I Form SS 12 11 04 05 T Page 001 (CONTINUED ON EXT PAGE) Process Date: 03/01/13 Policy Effective Dal e: 1.0/26/12 Policy.Expiration late: 10/26/.13 • POLICY NUMBER: 72 SBA ZB1092 ` THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PERSON-ORGANIZATION r THE CITY OF HUNTINGTON BEACH, ITS OFFICERS, ELECTED OR APPOINTED OFFICIALS, EMPLOYEES, AGENTS AND VOLUNTEERS 2000 MAIN ST HUNTINGTON BEACH, CA 92648 ATTN: RISK MANAGEMENT THE CITY OF NEWPORT BEACH, THE CITY, ITS ELECTED OR APPOINTED • THE CITY OF NEWPORT BEACH, THE CITY, ITS ELECTED OR APPOINTED OFFICERS, OFFICIALS, EMPLOYEES., AGENTS AND VOLUNTEERS ARE TO BE COVERED AS- ADDITIONAL. INSUREDS WITH. RESPECT TO LIABILITY OUT OF ,4 WORKPERFORMED BY OR ON BEHALF OF THE CONSULTANT f THE CITY OF COSTA MESA AND ..ITS ELECTED AND APPOINTED BOARDS, OFFICERS, AGENTS, AND EMPLOYEES 77 FAIR DRIVE COSTA MESA, 92626 COSTA MESA SANITARY DISTRICT 628 W 19TH ST. .„, COSTA MESA, CA 92627 Form IH 12 00 11 85 T SEQ.NO. 002 Printed in U.S.A. Page 001 Process Date: 03/01/13. Expiration Date: 10/261 13