Loading...
2013/08/28 Dudek Certificate of Liability Insurance-a A Ro° CERTIFICATE OF LIABILITY INSURANCE DATE (6 09/0/20 YYYY) /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: (360) 598-3700 Fax: (360) 598-3703 MICHAEL J. HALL & COMPANY f� A/E INSURANCE SERVICES� (; � 19660 10TH AVENUE N.E. !i POULSBO WA 98370, 2p�3 CONTACT MICHAEL J. HALL 8r COMPANY NAME: PHONE (360) 598-3700 FAX, (360) 598-3703 aC "° Ext: AIC N°: E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER American Automobile Insurance Co. 21849 3 Agency Lic#: 0792445 INSURED Dudek ���. INSURER B Greenwich Insurance Company p Y 22322 � 605 3Rd Streetryp��� Encinitas, CA 92024-3513 INSURER INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 186668 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 LTR TYPE OF INSURANCE ADD'L INSR SUBR WVD POLICY NUMBER POLICY EFF IMMIDDIYYYYI POLICY EXP (MMIDDfYYYYILIMITS A GENERAL LIABILITY MZG80950804 08/28/13 08/28/14 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES (Ea occurence) $ 100,000 CLAIMS -MADE OCCUR MED. EXP (Any one person) $ 10,000 X OCP, XCU, BFPD PERSONAL & ADV INJURY $ 1,000,000 X Separation of Insureds GENERAL AGGREGATE $ 21000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 21000,000 JECTRO POLICY X PLOC $ A AUTOMOBILE LIABILITY MZG80950804 08/28/13 08/28/14 COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident ( ) $ AUTOS AUTOS X HIREDAUTOS X NON -OWNED PROPERTYDAMAGE $ AUTOS (per accident) X Dad: Comp - X Dad: Coll - $1,000 $ S7 000 A X UMBRELLA LIAR X OCCUR CGU32044109 08128/13 08/28/14 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 EXCESS LIAB CLAIMS -MADE DED I X IRETENTION $ $ A WORKERS COMPENSATION WZC81014322 08/28/13 08/28/14 X I WC STATU'M TS OTH ER $ AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN E.L. EACH ACCIDENT $ 1,000,000 O 'Mandatory NH R EXCLUDED? (Mandatory in NH) NIA E.L. DISEASE -EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,UDO B Professional Liability: Claims Made Form PEC002403106 08/28/13 08/28/14 $1,000,000 Per Claim Retro Date: Pollution Liability: Occurrence Form $2,000,000 Aggregate Jan. 01, 1970 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Project: Newport Road Widening (Antelope and Menifee) CIP #01-13. City of Menifee and its officers, officials, employees, and authorized volunteers are an Additional Insured on the Commercial General Liability and Auto Liability when required by written contract or agreement regarding activities by or on behalf of the Named Insured. The Commercial General Liability insurance is primary insurance and any other insurance maintained by the Additional Insured shall be excess only and non-contributing with this insurance. A waiver of subrogation applies to the Commercial General Liability, Auto Liability, Umbrella / Excess Liability and Workers Compensation / Employers Liability in favor of the Additional Insured CERTIFICATE HOLDER CANCELLATION City of Menifee 29714 Haun Road Menifee, CA 92586 Attention: 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 7 Q ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Ashley L. Hurd Courtesy Notice of Cancellation for Other Than Nonpayment of Premium to Designated Entities .145977 0111 Policy Amendment Schedule Name and Address of Person(s) or Organizations Number of Days Notice if other than 10 days: 30 City of Menifee 29714 Haun Road Menifee, CA 92586 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. This policy is amended as follows: A. If We cancel this policy prior to expiration for any reason other than non payment of premium or at Your request, and we have been notified that You are required under a current contractual obligation to notify a certificate of insurance holder or holders when this policy is canceled, then We will endeavor to mail or deliver a copy of such written notice of cancellation to the certificate holder(s) shown in the Schedule above, as follows: 1 To the name and address corresponding to each certificate of insurance holder indicated in the Schedule above; and 2. At least 10 days prior to the effective date of the cancellation, as shown in our notice to the first Named Insured, or, if indicated, the longer number of days notice shown in the Schedule above Notwithstanding the foregoing, such notice of cancellation is provided on an informational basis and solely to assist You in informing the certificate of insurance holder(s) in advance of pending cancellation in coverage to assist you in meeting Your contractual notice requirements to such parties. Our failure to provide such advance notification to the certificate of insurance holder(s) shown in the Schedule of this endorsement will not extend any policy cancellation date, negate any cancellation of the policy, or grant, alter or extend any rights or obligations under this policy and we shall have no liability for any failure to provide the notice(s) as provided herein. All other terms and conditions of this policy remain unchanged. Dudek MZG80950804 AUG 28 2013 to AUG 28 2014 This Form must be attached to Change Endorsement when issued after the policy is written. One of the Fireman's Fund Insurance Companiesas named in the policy 1459771-11 © 2010 Fireman's Fund Insurance company, Novato, CA. All rights reserved. Workers' Compensation and Employers' Liability Insurance Policy Waiver of Our Right to Recover From Others Endorsement California WC 04 03 06 If the following is not complete, refer to the appropriate Schedule attached to the policy. Insured Dudek Producer Michael J. Hall & Company Schedule Person or Organization City of Menifee 29714 Hann Road Menifee, CA 92586 Additional Premium % Policy WZC81014322 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.) Effective Date AUG 28 2013 Job Description 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 the percentage, as shown in the Schedule applicable to this endorsement, of the California workers' compensation premium otherwise due on such remuneration. This Form must be attached to Change Endorsement when issued after the policy is written. One of the Fireman's Fund Insurance Companies as named in the policy. Secretary WC040306 4.84 President Amendmentto Condition 4. Other Insurance - CG 72 53 09 05 Policy Amendment(s) Commercial General Liability The following is added as a second paragraph to Sec- tion IV Conditions, Condition 4. Other Insurance, fol- lowing paragraph b.(2).- However, if you have added any person, organization or vendor of yours as an additional insured to this policy by way of a MultiCoverO endorsement and have agreed in a written insured contract that this insurance is primary and non-contributory with other insurance available to that additional insured, this insurance is primary and we will not seek contribution from such additional insured's other insurance. This provision does not apply to other insurance to which such addi- tional insured has been added as an additional insured - This Form must be attached to Change Endorsement when issued after the policy is written. One of the Fireman's Fund Insurance Compaufes as named in the policy President CG7353 9-05 F1eetCovem Endorsement- CA 70 18 10 01 Policy Amendmeni(s) Commercial Business Auto Coverage Form - Truckers Coverage Form A. Broadened Named Insured as an insured under any other automobile li- ability insurance policy whose limits of insur- SECTION II -LIABILITY COVERAGE, A Coverage, 1. Who Is An Insured, the following is has have been exhausted or whose insurer become insolvent. added: has Any organization you own on the inception of this policy, or newly acquire or form during the policy period, and over which you maintain during the policy period, majority ownership or majority in- terest will qualify as a Named Insured if (1) There is no other similar insurance available to that organization; and (2) The first Named Insured shown in the Dec- larations of this policy has the responsibility of placing insurance for that organization; and (3) The organization is incorporated or organized under the laws of the United States of Amer- ica. However: (a) Coverage under this provision is afforded only until the next occurring 12 month anniversary of the beginning of the policy period shown in the Declarations, or the end of the policy period, whichever is earlier, and (b) Coverage under this provision does not apply to bodily injury or property damage that re- sults from an accident that occurred before you acquired or formed the organization; and (c) No person or organization is an insured with respect to any current or past partnership, or joint venture that is not shown as a Named Insured in the Declarations; and (d) Coverage under A.(1), (2) and (3).above does not apply to any organization that is covered B. Broadened Who Is An Insured 1. Form CA0001 (if attached to this policy), SECTION H - LIABILITY COVERAGE, L Who Is An. Insured, item b..(2) is deleted, and d. is added as follows: d. Your employee while using his owned auto, or an auto owned by a member of his or her household, in your business or your personal affairs, provided you do not own, hire or borrow that auto. 2. Form CA0012 (if attached to this policy), SECTION 11 - LIABILITY COVERAGE, 1 Who Is An Insured, item b.(2) is deleted, and £ is added as follows: f. Your employee or agent while using his owned private. passenger type auto, or a private passenger type auto owned by a member of his or her household, in your business or personal affairs, provided you do not own, hire, or borrow that auto. C. Additional Insured Coverage and Waiver of Subrogation Form CA0001 (if attached to this policy), SECTION 11 - LIABILITY COVERAGE, 1. Who Is An Insured, the following is added as item e.; and form CA0012 (if attached to this policy), SECTION II - LIABILITY COVERAGE, 1. Who Is An Insured; the following is added as item g.: This Form must be attached to Change Endorsement when issued after the policy is written. One of the F➢reman's Fund Insurance Companies as named in the policy 4XA"w_' X01VII Se retary President CA7018 10.OI S Any person or organization with respect to the operation, maintenance, or use, of a cov- ered auto, provided that you and such person or organization have agreed under an ex- pressed provision in a written insured contract or written agreement, or a written permit is- sued to you by a governmental or public au- thority, to add such person, organization, or governmental or public authority to this poI- icy as an insured However, such person or organization is an insured: (1) Only with respect to the operation, maintenance, or use, of a covered auto; and (2) Only for bodily injury or property dam- age caused by an accident which takes place after: (a) You executed the insured contract or written agreement; or (b) The permit has been issued to you. Form CA0001 (if attached to this policy), SECTION IV - BUSINESS AUTO CON- DITIONS, A. Loss Conditions, item 5.; and form CA0012 (if attached to this policy), SECTION V - TRUCKERS CONDI- TIONS, A- Loss Conditions, item 5.; the fol- lowing is added: Waiver of Subrogation If required by a: a. Written insured contract or written agreement executed prior to the accident; or b. Written permit issued to you by a gov- ernmental or public authority prior to the accident; we waive any right of recovery we may have against any person or organization named in such contract, agreement or permit, because of payments we make for injury or damage arising out of a covered auto. D. Auto Medical Payments - Increased Limit For each covered auto described in the DecIara- tions or shown in the . Schedule as having Auto CA7018 10-0I S Medical Payments Coverage, the Medical Pay- ments Limit of Insurance for those autos is revised to the greater of: 1. $5,000; or 2 The limit shown in the Declarations E. Hired Auto Physical Damage Coverage If PHYSICAL DAMAGE COVERAGE is pro- vided by this policy on your owned covered autos, the following applies: Any auto that you lease, hire, rent or borrow without a driver, will be covered under this policy for PHYSICAL DAMAGE COVERAGE.. However any such auto: Will be covered only for the same PHYS- ICAL DAMAGE COVERAGE that applies to your owned covered autos; 2. Will be subject to the same applicable deductible shown in the Declarations that applies to your most similar owned covered auto, except any Comprehensive Coverage deductible does not apply to loss caused by fire or lightning; and 3. The most we will pay for any one loss in any one accident is the lesser of the following: a Actual Cash Value of the damaged or stolen property as of the time of the loss as determined by us; or b. The cost of repairing or replacing the damaged or stolen property with other property of like kind and quality. In addition, we will pay costs and fees associated with such covered loss only for a maximum time period of seven days beginning with the date of loss, subject to a maximum of $500. However. I. If form CA0001 is attached to this policy, this coverage does not apply to autos you lease, hire, rent or borrow from any of your employees, partners (if you are a partnership), members (if you are a limited liability com- pany) or members of their households; and 2. If form CA0012 is attached to this policy, this coverage does not apply to any private POLICY NUMBER: MZG80950804 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 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 Organ izations : Location And Description Of Completed Operations City of Menifee 29714 Haun Road Menifee, CA 92586 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section If — 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 dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sche- dule of this endorsement performed for that addi- tional insured and included in the "products - completed operations hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ POLICY NUMBER: MZG80950804 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS This endorsement modifies insurance provided under the following. COMMERCIAL GENERAL LIABILITY COVERAGE PART. OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) We waive any right of recovery we may have against the person or organization shown in the Schedule because of payments we make for injury or damage arising out of "your work" done under a contract with that person or organization. The waiver applies only to the person or organization shown in the Schedule. CG 24 0411 86 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 0 POLICY NUMBER: MZG80950804 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location(s) Of Covered Operations City of Menifee 29714 Haun Road Menifee, CA 92586 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. 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", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; In the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 11