Loading...
2018/08/01 All American Asphalt Certificate of Liability Insurance - Bradley Rd & Encanto Rd Rehabilitation7 ® AC40 o CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 7/18/2018 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 have ADDITIONAL INSURED provisions or 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 Ed ewood Partners Insurance Center P.O. Box 5003 San Ramon, CA 94583 www.epicbrokers.com CA LICENSE #OB29370 CONTACT NAME: Certificates Department PHONE AIC No Ext : 925-244-7700 Fvc No): 925-901-0671 -M E AIL ADDRESS: EPICCertS a icbrokers.com INSURERS AFFORDING COVERAGE NAIC# INSURERA: Arch Specialty Insurance Company 21199 INSURED All American Asphalt P.O. Box 2229 Corona CA 92878 INSURER B: Zurich American Insurance Company 16535 INSURERC: American Guarantee and Liability Ins Co 26247 INSURERD: INSURER E : INSURER F : 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. INSR LTR TEXP YPE OF INSURANCE ADDL SUER NUMBER POLPOLICY MM DIDfYYYY MMIDDEFF POLICY /YYYY LIMITS A �/ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR DPC1005856-02 8/1/2018 8/1/2019 EACHOCCURRENCE S1,000,000 PREMISES Ea occu ante $100,000 MED EXP (Any one person) S Cky Me ifee PERSONAL & ADV INJURY $1,000,000 }oaf City Cie GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 PRODUCTS - COMPIOP AGG S 2,000,000 POLICY PRO LOG JECT 'JUL 2 3 2 18 s B OTHER: AUTOMOBILE LIABILITY ✓ I ANY AUTO BAP5571088-06 � Receive 8/1/2018 8/1/2019 (EaaccidentSINGLELIMIT IS 2,000,000 BODILY INJURY (Per person) S BODILY INJURY (Per accident) S OWNED SCHEDULED AUTOS ONLY AUTOS HIRED ✓ AUTOS ONLY ✓ AUTOS ONEDY q . PROPERTY DAMAGE Per accident $ S C UMBRELLA LIAB �/ OCCUR SXS019797002 8/1/2018 8/1/2019 EACH OCCURRENCE 55,000,000 AGGREGATE S 5,000,000 EXCESS LIAB CLAIMS -MADE DED I ✓ I RETENTION 51 O,000 WORKERS COMPENSATION Following -Form ,/ STATUTE EORH S B WC593205705 8/1/2018 8/1/2019 E.L. EACH ACCIDENT S 1,000,000 AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) NIA E.L. DISEASE - EA EMPLOYEE S 1 0 0 E.L. DISEASE - POLICY LIMIT $1 ,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) RE: Bradley Road and Encanto Road Street Rehabilitation Certificate Holder is Additional Insured if Required by Written Contract Excluding Workers Compensation I-IL:A It NUL.UtK Cityy 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 Certificates Department �noo )nor Af rwr) r1r1RPr1RATIr1N All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 43186493 1 18 101) Standard with $5m X.S I Kris Stubbs 1 7/18/2018 9:56:47 AM (PDT) I Page 1 of 8 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OTHER INSURANCE - BROAD FORM, CGL POLICY ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM COMMERCIAL GENERAL LIABILITY SELF -INSURED RETENTION COVERAGE FORM Under SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, the following paragraph is added to Condition 4. Other Insurance: Where the Named Insured is required by a written contract to provide insurance that is primary and non-contributory, and the written contract so requiring is executed by the Named Insured before any "occurrence" or offense, this insurance will be primary, but only if and to the extent required by that written contract. All other terms and conditions of this Policy remain unchanged. REFERENCE: SCHEDULE: City of Menifee RE: Bradley Road and Encanto Road Street Rehabilitation Endorsement Number: This endorsement is effective on the inception date of this policy unless otherwise stated herein. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Policy Number: DPC1005856-02 Named Insured: All American Asphalt Endorsement Effective Date: 08/01/2018 00 CGLO130 00 09 06 Page 1 of 1 43166493 1 18 (01] Standard with $5= XS I Kris Stubbs 1 7/18/2018 9:56:47 AM (PDT) I Page 4 of 8 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF SUBROGATION ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM COMMERCIAL GENERAL LIABILITY SELF -INSURED RETENTION COVERAGE FORM SCHEDULE Name of Person or Organization: Where required by written contract. Under SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, Condition 8. Transfer Of Rights Of Recovery Against Others To Us is amended by the addition of the following provision: We waive any right of recovery we may have against the person or organization shown in the SCHED- ULE above because of payments we make for injury or damage arising out of your operations or "your work" done under a written contract with that person or organization. All other terms and conditions of this Policy remain unchanged. REFERENCE: SCHEDULE: City of Menifee RE: Bradley Road and Encanto Road Street Rehabilitation Endorsement Number: This endorsement is effective on the inception date of this policy unless otherwise stated herein. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Policy Number: DPC1005856-02 Named Insured: All American Asphalt Endorsement Effective Date: 08/01/2018 00 C61_0121 00 09 06 Includes copyrighted material of Insurance Services Office, Inc. Page 1 of 1 43186493 1 18 [01] Standard with $5— XS I Kris Stubbs 1 7/18/2018 9:56:47 AM (PDT) I Page 5 of 8 POLICY NUMBER: BAP5571088-06 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 modified 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 indi- cated below. Endorsement Effective: 08/01/2018 Named Insured: All American Asphalt SCHEDULE Name of Person(s) or Organization(s): ANY PERSON OR ORGANIZATION TO WHOM OR WHICH YOU ARE REQUIRED TO PROVIDE ADDITIONAL INSURED STATUS OR ADDITIONAL INSURED STATUS ON A PRIMARY, NON-CONTRIBUTORY BASIS, IN A WRITTEN CONTRACT OR WRITTEN AGREEMENT EXECUTED PRIOR TO LOSS, EXCEPT WHERE SUCH CONTRACT OR AGREEMENT IS PROHIBITED BY LAW. REFERENCE: SCHEDULE: City of Menifee RE: Bradley Road and Encanto Road Street Rehabilitation (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 II of the Coverage Form. CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 ❑ 43186493 1 18 101] Standard with $5m XS I Kris Stubbs 1 7/18/2016 9:56:47 AM (PDT) I Page 6 of 8 POLICY NUMBER: BAP5571088-06 COMMERCIAL AUTOMOBILE CA 04 44 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: All American Asphalt Endorsement Effective Date: 08/01/2018 SCHEDULE Name(s) Of Person(s) Or Organization(s): ALL PERSONS AND/OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTIED PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY REFERENCE: SCHEDULE: City of Menifee RE: Bradley Road and Encanto Road Street Rehabilitation Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others 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 "accident" or the 'loss" under a contract with that person or organization. CA 04 44 03 10 © Insurance Services Office, Inc., 2009 Page 1 of 1 ❑ 43186493 1 1S (01] Standard with $5m, XS I Kris Stubbs 1 7/18/2018 9:56:47 AM (PDT) I Page 7 of 8 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 0.00 % of the California workers' compensation pre- mium otherwise due on such remuneration. Schedule Person or Organization ALL PERSONS AND/OR ORGANIZATIONS THAT ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY FOR WORK PERFORMED BY YOU FOR THAT PERSON AND/OR ORGANIZATION SCHEDULE: City of Menifee Policy Number: WC593205705 Named Insured: All American Asphalt Endorsement Effective Date: 08/01/2018 WC 252 (4-84) WC 04 03 06 (Ed. 4-84) Job Description ALL CALIFORNIA OPERATIONS REFERENCE: RE: Bradley Road and Encanto Road Street Rehabilitation Page 1 of 1 43186493 1 18 [01] Standard with $5mm XS I Kris Stubbs 1 7/18/2018 9:56:47 AM (PDT) I Page 8 of 8 [919HIN PO Box 5003 San Ramon, CA 94583 Phone: 925.244.7700 Fax: 925.901-0244 Email: EPICcerts@epicbrokers.com CERTIFICATE HOLDER: City of Menifee 29y14 Haun Road Menifee CA 92586 To: Whom it may concern Regarding: Notice of Cancellation Date Issued: 7/18/2018 Named Insured(s): All American Asphalt Policy Number(s): DPC1005856-02 BAP5571088-06 WC593205705 SXS019797002 Should the above described policy be cancelled before the expiration date thereof, we will mail 30 days written notice to the above referenced Certificate Holder; except, 10 days notice for non-payment of premium. Sincerely, .4) 4--, Dan Ryan, Managing Principal epicbrokers.com edgewood partners insurance center ca license OB29370 43186493 1 18 [01] Standard with $5= XS I Kris Stubbs 1 7/18/2018 9:56:47 AM (PDT) I Page 2 of 8 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM COMMERCIAL GENERAL LIABILITY SELF -INSURED RETENTION COVERAGE FORM SECTION II — WHO IS AN INSURED is amended to include as an additional insured those persons or organizations who are required under a written contract with you to be named as an additional insured, but only with respect to liability for "bodily injury", "property damage", or "personal and advertising injury' caused, in whole or in part, by your acts or omissions or the acts or omissions of your subcontractors: A. In the performance of your ongoing operations or "your work", including "your work" that has been completed; or B. In connection with your premises owned by or rented to you. As used in this endorsement, the words "you" and "your" refer to the Named Insured. All other terms and conditions of this Policy remain unchanged. REFERENCE: SCHEDULE: City of Menifee RE: Bradley Road and Encanto Road Street Rehabilitation Endorsement Number: This endorsement is effective on the inception date of this policy unless otherwise stated herein. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Policy Number: DPC1005856-02 Named Insured: All American Asphalt Endorsement Effective Date: 08/01/2018 00 CGL0006 00 05 07 Page 1 of 1 43186493 1 18 (011 Standard with $5mm XS I Kiis Stubbs 1 7/16/2018 9:56:47 AM (PDT) I Page 3 of 8 Edgewood Partners Insurance Center P.O. Box 5003 San Ramon, CA 94583 City of Menifee 29714 Haun Road Menifee CA 92586 MAIL DOCUMENT Certificate of Insurance Delivery by ecertsonlineT11 Sender: Kris Stubbs Phone: 925-244-7704 Subject: 43186493 - All American Asphalt - . CerrttiNo. c ate Date: 7/18/2018 No. of Pages: 9 URL: www.epicbrokers.com This document has been brought to you by ecertsonline on behalf of Edgewood Partners Insurance Center. For new certificate requests, changes to an existing certificate, or if you have any other questions, please forward the current certificate issued with requested changes via E-Mail: EPICcerts@epicbrokers.com or Facsimile: (925) 901-0671 PLEASE NOTE: Requests must be submitted or approved by the Named Insured. FREQUENTLY ASKED QUESTIONS: Q: What is a Certificate of Insurance? A: A written document verifying insurance coverage of the Named Insured listed in the top left corner. Q: Why am I receiving this? A: The Named Insured listed in the top left corner is performing or has performed operations for you where they have been required to show you evidence of their insurance. Q: What is this costing me? A: Certificates are issued as a service to our Named Insured. We will not be sending you an invoice for having received this document. This document has been brought to you by ecertsonline on behalf of Edgewood Partners Insurance Center. For new certificate requests, changes to an existing certificate, or if you have any other questions, 9please forward the current certificate issued with requested changes via E-Mail: PICcerts@epicbrokers.com or Facsimile: (925) 901-0671 PLEASE NOTE: Requests must be submitted or approved by the Named Insured. FREQUENTLY ASKED QUESTIONS: Q: What is a Certificate of Insurance? A: A written document verifying insurance coverage of the Named Insured listed in the top left corner. Q: Why am I receiving this? A: The Named Insured listed in the top left corner is performing or has performed operations for you where they have been required to show you evidence of their insurance. Q: What is this costing me? A: Certificates are issued as a service to our Named Insured. We will not be sending you an invoice THIS MESSMI! IhIaTWIy) ri V�(�Ft t �i {`tl t�tN TO WHICH IT IS ADDRESSED AND MAY CONTAIN INFORMATION THAT IS PRIVILEGED, CONFIDENTIAL AND EXEMPT FROM DISCLOSURE UNDER APPLICABLE LAW. IF THE READER OF T MES AGE IS NOT THE INTENDED RECIPIENT, OR THE EMPLOYEE OR AGENT RESPONSIBLE FOR DELIVERING THE MESSAGE TO THE INTENDED RECIPIENT, YOU ARE HEREBYNOTIFIED THAT ANY DISSEMINATION, DISTRIBUTION OR COPYING OF THIS COMMUNICATION Is STRICTLY PROHIBITED. IF YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR, PLEASE NOTIFY US IMEDIATELY BYTELEPHONE, AND RETURN THE ORIGINAL MESSAGE TO US AT THE ABOVE ADDRESS VIA REGULAR POSTAL SERVICE. - - - Certificate of Insurance Delivered by ecertsonlineTI Insurance Visions, Inc. All rights reserved.