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Insurance - GCI Construction - 2013-04-10 _, OP ID: BS A CCDR 12r CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DO/YYYY) 1....-------- 04/10/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE.HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Phone:855403-9800 NAOrNnEACT Jeremy Seltzer 13681 Newport Ave.,Ste 8 Inc.#622 _lau_ci EA:714-665-9800 FAX :714-665-9801 Fax:714-665-9801 Tustin,CA 92780 Ao aESS:Jeremy(?cdisi-com Compass Direct Ins.Serv.Inc. 'PRODUCER' — D R;GCIC0-1 INSURER(SI AFFORDING COVERAGE NAIC F INSURED GCI Construction Inc INSURER A:Great American Assurance Co. 126344 245 Fischer Ave.,Ste B3 esco nsura• INSURER a:W Insurance Co. 125011 Costa Mesa,CA 92626 INSURER c:Security National Ins Co. 19879 INSURER 0:American Zurich Insurance Co. INSURER E _INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSfi( A 5C SUBR I POLICY EFF-1 POLICY EXP l LTR, TYPE OF INSURANCE I INSR,my POUCY NUMBER IMM/DO/YYYYI i(MMIDD/YYYYI l LIMITS GENERAL LIABILITY I I ! I , 'EACH OCCURRENCE I S 1,000,000 A i X l COMMERCIAL GENERAL X X IGLP4647859 1 04101l2013 04/01/2014 I PR�SES(E �pnce) I s 50,0001 I i 1 I CLAIMS•MADE X I OCCUR 1 I I MED EXP(Any one person) 1 S Excluded 7( I Owners/Copt Pro I Pro ( I 1 PERSONAL&ADV INJURY !.5 1,000,000 I X XCU/Deductible 155,000 I 1 I_GENERAL AGGREGATE i$ 2,000,000 .I Gm.AGGREGATE LIMIT APPLIES PER I I I i PRODUCTS-COMP/OP.AGG I S 2,000,000 I PoucY X 7P-i: 71 LOG I I 1 IEmp.Ben. I s '1,000,000 `AUTOMOeILE LIABILITY I X X I I 15 a COMBINED!SINGLE LIMIT j s 1,000,000 B 1 X I ANY.AUTO IWPP1055077 01 1 04/01/2013 1 04/01/2014 ( person) !S �� I I BODILY INJURY Per ALL OWNED AUTOS I I ' �� I BODILY INJURY(Per arxldengl S I SCHEDULED AUTOS I 1 NO LIABILITY DEDUCTIBLE i 1 PROPERTY DAMAGE S I I - I (Per accident} X i HIRED AUTOS I ri NO NOVJNEOAUTOS I I S II Comp/Coll Ded I !$1000 ! I I S j x UMBRELLA LIAa i X I OCCUR 1 I I II EACH OCCURRENCE .S 4,000,000 1 EXCESS UAB I CLAIMS-MADE I i i I 1 AGGREGATE S 4,000,0001 • A 1 I X X %UMB4647862 1 04/01/20131 04/01/2014 iI DEDUCTIBLE j g.�_ -- WORKERS 1-1 RETENTION S ! I I I I S WORKERS COMPENSATION I I I WC STATL• 0TH- AND EMPLOYERS'UABIUTY YIN H I `x TORY L1MLT;i. I FR C ANY PROPRIETOR/PARTNER/EXECUTIVE ;SWC1020466 ( 03/17/2013 03/17/2014 1 E.L.EACH ACCIDENT S 1,000,000 OFFICER/MEMBER EXCLUDED? ( N I A! X (Mandatory in NM) I E.L DISEASE-EA EMPLOYEE,S 1,000,000 U es,desa ba under DESCRIPTION OF OPERATIONS below , I `,E.L.DISEASE•POLICY LIMIT S 1,000,000 B IIM-Egp./Lesd-Hrd-R ;WPP1055077 01 i 04/01/2013 1 04/01/2014 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD NM,Additional Remarks Schedule,If more apace In required) The District, its directors, officers, engineers, employees, and authorized . agents are named as additional insured as per attached endorsements, with respects to the work performed by the insured as per contract. CERTIFICATE HOLDER CANCELLATION ir SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Costa Mesa Sanitary District 6 ACCORDANCE WITH THE POLICY PROVISIONS. 628 W.19th Street �`116 t J Costa Mesa,CA 92627 A\t(?) AUTHORIZED REPRESENTATIVE Compass Direct Ins.Serv. Inc. ©1988-2 A RD C OR TION. All righ erved. ACORD 25(2009/09) The ACORD name and logo are registered marks off ACORD 9 q� • • • Great American Assurance Company GC! Construction, Inc. # GLP4647859 CG 20 33 Policy (Ed. 07 04) Effective: 04/01/13 - 04/01/14 THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following. COMMERCIAL GENERAL LIABILITY COVERAGE PART • A. SECTION II - WHO IS AN INSURED is This insurance does not apply to: amended to include as an Additional Insured any person or organization for whom you are 1. "Bodily injury," "property damage" or"per- performing operations when you and such sonal and advertising injury" arising out of person or organization have agreed in writing the rendering of, or the failure to render, in a contract or agreement that such person any professional architectural, engineering or organization be added as an Additional In- or surveying services, including: sured on your policy. Such person or or- ganization is an Additional Insured only with a, the preparing, approving, or failing to respect to liability for "bodily injury," "prop- prepare or approve, maps, shop erty damage" or "personal and advertising in- drawings, opinions, reports, surveys, jury" caused, in whole or in part, by: field orders, change orders or draw- ings and specifications; or b. supervisory, inspection, architectural 1. your acts or omissions; or or engineering activities. • 2. "Bodily injury," or "propertyy damage" oc- 2. the acts or omissions of those acting on curring after: your behalf; a. all work, including materials, parts or equipment furnished in connection in the performance of your ongoing oper- with such work, on the project (other ations for the Additional Insured. than service, maintenance or repairs) to be performed by or on behalf of the Additional Insured(s) at the location of the covered operations has been A.person's or organization's status as an Ad- ditional Insured under this endorsement ends completed; or when your operations for that Additional In- b. that portion of "your work" out of sured are completed. which the injury or damage arises has been put to its intended use by any person or organization other than an- B. With respect to the insurance afforded to other contractor or subcontractor en- these Additional Insureds, the following addi- gaged in performing operations for a tional exclusions apply: principal as a part of the same project Copyright, ISO Properties, Inc., 2004 CG 20 33 (Ed. 07/04) XS • Insured: GCI Construction, Inc. CG 20 37 Policy#GLP4647859 (Ed 07 04) Policy Period: 04/01/2013-04/01/2014 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Schedule Name of Additional Insured Person(s) or Organization(s): Location and Description of Completed Operations: Any person or organization that Per Certificate ( s ) of Insurance "you" and such person or organiza- tion have agreed in writing in a contract or agreement that such Your work" performed during this policy person or organization be added as period . an additional insured on "your policy , but only for "your work " performed during this policy period . Additional Premium: Included Information required to complete this Schedule, if not shown above, will be shown in the Declarations. SECTION II - WHO IS AN INSURED is amended to include as an Additional Insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for 'bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that Additional Insured and included in the "products—completed operations hazard" Copyright, ISO Properties. Inc., 2004 CG 20 37 (Ed. 07/04) PRO (Page 1 of 1) Insured:GCI Construction, Inc. GAC 3649CG Policy#GLP4647859 (Ed. 11 06) Policy Period: 04/01/2013-04/01/2014 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY NON-CONTRIBUTORY INSURANCE ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE FORM This insurance is primary to any other insurance held by third parties with respect to work performed by you under written contractual agreements with such third parties and any other insurance which may be available to such third parties shall be non—contributory. GAC 3649CG (Ed. 11/061 XS Insured: GCI Construction, Inc. CG 24 04 Policy#GLP4647859 (Ed. 05 09) Policy Period: 04/01/2013-04/01/2014 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 PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART Schedule Name of Person or Organization: Any person or organization for whom or on whose behalf ' you" are performing operations when "you" and such person or organization have agreed in writing in a contract or agreement t.o waive any right of recovery "we' may have against such person or organization . Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to paragraph 8. Transfer of Rights of Recovery Against Others to Us of SECTION IV - CONDITIONS: 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. • Copyright, ISO Properties, Inc., 2008 CG 24 04 (Ed. 05/091•PRO (Page 1 of 11 • Insured: GCI Construction, Inc. CG 25 03 Policy#GLP4647859 (Ed. 03 97) Policy Period: 04/01/2013-04/01/2014 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECTISI GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Projects: Any construction project where "you" are performing operations when "you" have agreed in writing in a contract or agreement that a separate General Aggregate Limit shall apply to such construction project , but only if "your work" on or at the construction project is performed during the period of this policy . (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. For all sums which the Insured becomes legally obligated to pay as damages caused by "occurrences" under COVERAGE A. (SECTION I), and for all medical expenses caused by accidents under COVERAGE C. (SECTION I}, which can be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. A separate Designated Construction Project General Aggregate Limit applies to each designated construction project, and that limit is.equal to the amount of the General Aggregate Limit shown in the Declarations. 2. The Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all damages 'under Coverage A. except damages because of "bodily injury" or "property damage" included in the "products—completed operations hazard,' and for medical expenses under Coverage C. regardless of the number of: a. Insureds; b. claims made or "suits" brought; or c. persons or organizations making claims or bringing "suits." Copyright. Insurance Services Office. Inc., 1996 CG 25 03 (Ed. 03/97) PRO (Page 1 of 21 • 3. Any payments made under Coverage A. for damages or under Coverage C. for medical expenses shall reduce the Designated Construction Project General Aggregate Limit for that designated construction project. Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Designated Construction Project General Aggregate Limit for any other designated construction project shown in the Schedule above. 4. The limits shown in the Declarations for Each Occurrence, Fire Damage and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Designated Construction Project General Aggregate Limit. B. For all sums which the Insured 'becomes legally obligated to pay as damages caused by "occurrences" under COVERAGE A. (SECTION I), and for all medical expenses caused by accidents under COVERAGE C. (SECTION I), which cannot be attributed only to ongoing operations at a single designated construction project shown in the Schedule.above: 1. any payments made under Coverage A. for damages or under Coverage C. for medical expenses shall reduce the amount available under the General Aggregate Limit or the Products-Completed Operations Aggregate Limit, whichever is applicable; and 2. such payments shall not reduce any Designated Construction Project General Aggregate Limit. C. When coverage for liability arising out of the "products-completed operations hazard" is provided, any payments for damages because of "bodily injury" or "property damage" included in the "products-completed operations hazard" will reduce the Products-Completed Operations Aggregate.Limit,. and not reduce the General Aggregate Limit nor the Designated Construction Project General Aggregate Limit D. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restarted, or'if the authorized contracting parties deviate from plans, blueprints, designs, specifications or timetables, the project will still be deemed to be the same construction project E. The provisions of LIMITS OF INSURANCE (SECTION III) not otherwise modified by this endorsement shall continue to apply as stipulated. Copyright. Insurance Services Office, Inc.. 1 996 CG 25 03 (Ed. 03/97) PRO (Page 2 of 2) • POLICY NUMBER: WPP1055077 00 COMMERCIAL AUTO CA 20 48 02 99 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless mod- ified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provi- sion of the Coverage Form. This endorsement does not-alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective: 4/01/2013 Countersigned By: /(1L✓,: Named Insured: GCI Construction, Inc. (Authorized Representative) SCHEDULE • Name of.Person(s)or,Organization(s): Blanket 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 the endorsement.) Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section 11 of the Coverage Form. • CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 Cl • POLICY NUMBER:WPP1055077 01 COMMERCIAL AUTO CA 0444 03 10 • THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: GC! Construction, Inc. Endorsement Effective Date: 04/01/2013 SCHEDULE Name(s)Of Person(s)Or Organization(s): Blanket as required by written contract Information required to complete this Schedule, if not shown above,will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Oth- ers To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "ac- cident"or the"loss" under a contract with that person or organization. CA 04 44 0310 ©Insurance Services Office, Inc., 2009 Page 1 of 1 ❑ 'WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06! (Ed.4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy.We will not enforce our right against the person or organization named in the Schedule.(This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. • The additional premium for this endorsement shall be 2.00%of the California workers'compensation premium otherwise due on such remuneration. • Schedule Person or Organization Job Description Any person or organization as required by written contract Blanket as required by written contract This endorsement changes the policy to which it is attached and is.effective on the date issued unless otherwise stated. Endorsement Effective 3/1712013 Policy No. SWC1020466 Endorsement No. WC 04 03 06 Insured GCI Construction, Inc. Premium S Insurance Company Security National Insurance Company Countersigned by 1