2015/09/16 Bucknam Infrastructure Group, Inc. Certificate of Liability Insurance (3)A4CC>R" CERTIFICATE OF LIABILITY INSURANCE
DAT2112015 /2015
9/
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
WILLIS OF ILLINOIS, INC.
`` ��t
233 S WACKER DR,SUITE 2000 .. �% �Y1 % �� ( 1 � '
CONTACT
NAME:
PHONE ggg 780-5381 iFAX 877 737-8498
(AlC, NO_FXt): ( ) (AIC No): ( ) _
EMAILADDRESS: Certificate@hanover.com
INSURERS) AFFORDING COVERAGE _ ! NAIC d
CHICAGO, IL 60606
��� � � 2U15
INSURER A : Citizens Ins Co of America 31534
INSURED —
BUCKNAM INFRASTRUCTURE GROUP/^��
INC ��it
INSURERB: Hanover American Ins Co 36064
------
INSURERC_
—_
INSURER D :
3548 SEAGATE WAY SUITE 230
_
INSURER E :
INSURER F
OCEANSIDE, CA 92056
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.
INSR rAODL SiJBR POLICY EFF POLICY EXP
LTR I TYPE OF INSURANCE I I POLICY NUMBER MMlDDIYYYY MMIDDIYYYY LIMITS
A
GENERAL LIABILITY I
COMMERCIAL GENERAL LIABILITY � X
CLAIMS -MADE OX OCCUR
X
OBC A399956 01
I O9/16/2015
I
I I EACH OCCURRENCE
PREMISES (Ea occurrence)
PREMISES
MED EXP (Any one person)
09/16/2016 � �.--..---------
PERSONAL BAOVINJURY
j GENERAL AGGREGATE
i $1,000,000
$1,000,000
S 10,000 —
151,000,000
152,000,000
I PRODUCTS - COMP/OP AGG
�GEN*L AGGREGATE LIMIT AP(PLLIIE�S PER:
POLICY I ^ I E I (LOC
I S 2,000,000
i5
AUTOMOBILE LIABILITY i y
' y
COMBINED SINGLE LIMIT
I EEa acadeno
1 5 1 ,000,000
A
_ ANY AUTO
jj ALL (MTAEO SCHEDULED I
I AUTOS AUTOS
X HIRED AUTOS X NON-0`hNED
X AUTOS
I
I
OBC A399956 01
09/16/2015
( BODILY INJURY (Per person)
09/16/2016
+BODILY INJURY (Per accident)
— -- —
I PROPERTY DAMAGE
Per acddent)
I Ts
S
S
— ---
I S
X UMBRELLA LIAR X OCCUR
��
I EACH OCCURRENCE
15 9,000,000
A
EXCESS LIAR CLAIMS-MADEI
OBC A399956 01
09/16/2015
09/16/2016 AGGREGATE
S 9,000,000
I
DED I RETENTIONS
S
I
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY i
ANY PROPRIETORIPARTNEJEXECUTIVE YIN
OFFICEPd6MBER EXCLUDED? ❑ I N / A I)
(Mandatory in NH)
If des, describe under
qrRloT c F. I
I
^
WZC A399946 01
09/16/2015
I
)( `AOSTATU• �OTH•I
TOR IMIT L ER
EL_ EACH ACCIDENT I51,000,000
09/16/2016 --_--
E.L DISEASE - EA EMPLOYEE
_
.
E.L DISEASE- POLICY LIMIT
S 1,000,000
_,—--_
S 1,000,000
�F.F
f
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
RE: MGIS Services
City of Menifee, 29714 Haun Road, Menifee, CA 92586, and its officers, employees, agents, and authorized volunteers are additional Insured pursuant to the terms and
conditions of form: 3911586 (GENERAL LIABILITY SUPPLEMENTARY ENDORSEMENT). Additional Insured is primary to the extent provided by 391-1586. Waiver of
subrogation as provided by 391-1586 and WC040306 (California Form).Waiver of Subrogation in favor of additional insured only in the event of sole negligence on the part of
the named insured.
Cancellation notice will be provided to the Certificate Holder pursuant to endorsement: 4011235 (Notice of Cancellation). Such notice is solely for the purpose of informing the
Certificate Holder of the effective date of cancellation and does not grant, alter, or extend any rights or obligations under this policy.
Certificate emailed to:
City of Menifee
29714 Haun Road
Menifee, CA 92586
I+HIVI+CLLH 1 IUN
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
@ 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD