2018/09/18 Superior Pavement Markings, Inc. Certficiate of Liability InsuranceRor CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDD/YYYY)
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 pollcy(les) must have ADDITIONAL INSURED provisions or bo 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 ri hts to the certificate holder In Ileu of such endorsements .
PRODUCER Patriot Risk & Insurance Services NAfAEA
2415 Campus Drive, Suite #200 PHONE FAx
�949) 486 7900 sas a$
Irvine, CA 92612 .101611 v.Xtj: No : �79�a
NAIC 4
www.patdsk.com
OK07568
INSURED
Superior Pavement Markings, Inc.
5312 Cypress St.
Cypress CA 90630
INSURER D :
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: 50620308 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.
NSR TYPE OF INSURANCEADDL POLICY EFF POLIC EXP
LTR POLICY NUMBER M D LIMITS
A
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE F,/_1 OCCUR
�/
WPP158316101
9/18/2018
9/18/2019
EACH OCCURRENCE
$1 000 000
IJAMAG E TO RENTED
PREMISES JEa occurmnce}
$ 300 000
MED EXP Any one person)
$ 5 000
PERSONAL & ADV INJURY
$1 000 000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY ✓� JET LOC
GENERAL AGGREGATE
$2,000,000
PRODUCTS - COMP/OP AGG
$ 2 00O 000
J
$
OTHER:
A
AUTOMOBILE
LIABILITY
WPP158316101
9/18/2018
9/18/2019
Ee p SINGLE LIMIT
$1 000 000
BODILY INJURY (Per person)
$
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY f AUTOS
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
tid P BODILY INJURY (Per accident)
( )
$
PR RTYDA E
Per aobdent
$
B
/
UMBRELLA LIAR
�/
OCCUR
TUE 2191316 01
9/18/2018
9/18/2019
EACH OCCURRENCE
$ 9 000 000
AGGREGATE
$ 9 000 000
EXCESS LIAR
CLAIMS -MADE
DEp RETENTION
$
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y I N
ANYPROPRiETOR/PARTNERIEXECUTIVE
EREXOLUDED9
NIA
SUWC033321
6/1/2019
6/1/2020
/ STATUTE
E.L. EACH ACCIDENT
$1 000,000
E.L. DISEASE - EA EMPLOYEE
$ �(�Q
(Mal-sturyInOFF
(Mandatory In NH)
I} s, doscrEbe under
E.L. DISEASE - POLICY LIMIT
$1 000 000
DESCRIPTION OF OPERATIONS 00, ow
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
Re: Menifee, CA - On -Call Asphalt Striping Services, Project No: PW19.01
City of Menifee, its officers, agents and employees are named as Additional Insured as respects to General Liability per endorsement attached
where required by written contract.
Walver of Subrogation applies to General Liability and WC and in favor of the additional insured per attached endorsement.
"30-lay notice of cancellation 110-days for non-payment of premium.
►.ee% I trno#Ar a rIULaJCK L:ANL:CLL.A I IUN
City of Menifee
29714 Haun Road
Menifee CA 92586
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Dave Jacobson
9)1988.2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
50620308 1 18/19 GL/AU/UMB - 19/20 WC I Rachael Burnham 1 8/16/2019 11:03:20 AM (PDT) I Page 1 of 11
This certificate cancels and supersedes ALL previously issued certificates.