2018/01/24 Innovative Document Solutions Certificate of Liability Insurance (5)CERTIFICATE OF LIABILITY INSURANCE
DATE(MMfDDIYYYY)
11 /30/2018
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
c NTa T NAME: Anna Liera
R. David Bulen Insurance Agency
(HONE . Exit: (951) 674-0675 AX (951) 674-2375
(AiC, Not:
P.O. Box 115
At-MAILDDRESS: anna@bulen.com
INSURER(S) AFFORDING COVERAGE
NAIC #
Lake Elsinore CA 92531-0115
INSURER A: AMCO Insurance Company
19100
INSURED
INSURER B : Preferred Employers Ins. Co.
10900
Heitritter, Kevin, DBA: Innovative Document Solutions
INSURER C: Nationwide Mutual Insurance Company
23 887
26855 Jefferson Ave
INSURER D
Suite F
INSURER E:
Murrieta CA 92562
INSURER F:
--'----- --- n G YIJIVIY 114unnor-M.
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
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS
TO WHICH THIS
SUBJECT
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TO ALL THE TERMS,
IN fl D
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMMI�OIYYYY) MMIDDCY EFF IYYYY)
LIMITS
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
S 1,000,000
CLAIMS -MADE OCCUR
300,000
PREMISES IEa occur>nce)
$
A
MED EXP (Any one oerson)
$ 5,000
Y ACP7841746108 01/24/2018 01/24/2019
PERSONAL & ADV INJURY
S 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
X PR
POLICY❑
❑
GENERAL AGGREGATE
S 2,000,000
JECTO•
LOC
PRODUCTS -COMP/OP AGG
3 2,000,000
OTHER:
$
AUTOMOBILE
LIABILITY
COMBINED SINGLELIMlr
fEn accidam
$ 1,000,000
X
ANY AUTO
BODILY INJURY (Per person)
$
C
OWNED SCHEDULED
AUTOS ONLY AUTOS
BA7841746108
01/24/2018
01/24/2019
BODILY INJURYIPoraccident)
S
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
NROFERTY DAI:.AGE
INer accidan1l
S
UMBRELLA LIAB
OCCUR
L
EACH OCCURRENCE
$
EXCESS LIAB
CLAIMS -MADE
AGGREGATE
$
DED I I RETENTION S
WORKERS COMPENSATION
AND EMPLOYERS'
X I
LIABILITY YIN
STATUTE ER
B
ANY CER/MEMBERIPACLUDED XECUTIVE
ER EXCLUDED? a
NIA
WKN146463-7
04l0112018
04/0112019
EL. EACH ACCIDENT
$ 1,000,000
(MandatoryIn N
(f yes, d ary in and
If yes, describe under
E.L. DISEASE - EA EMPLOYEE
S 1,000, 000
E.L. DISEASE -POLICY LIMIT
$ 1,000,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
City of Menifee and its officers, employees, agents, and authorized volunteers are named as Additional Insured in regards to General
Liability per the
attached PB0447 11114. Insurance is Primary and Non Contributory. '30-day notice of cancellation, except for 10-day notice of cancellation for
nonpayment of premium.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Menifee ACCORDANCE WITH THE POLICY PROVISIONS.
29714 Haun Road
AUTHORIZED REPRESENTATIVE
Menifee CA 92586
u lUbti-21115 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
BUSINESSOWNERS
PB 04 47 1114
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
A "'T10N�L C VISU�Eu" - VEN®0.,S
This endorsement modifies insurance provided under the following:
PREMIER BUSINESSOWNERS LIABILITY COVERAGE FORM
A. The following is added to Section 11. WHO 1S AN
INSURED:
Any person or organization (referred to
throughout this endorsement as vendor) shown in
the Schedule of this endorsement is also an
insured, but only with respect to "bodily injury" or
"property damage" arising out of "your products"
shown in the Schedule of this endorsement which
are distributed or sold in the regular course of the
vendor's business, subject to the following
additional exclusions:
However:
1. The insurance afforded to such vendor only
applies to the extent permitted by law; and
2. If coverage provided to the vendor is
required by a contract or agreement, the
insurance afforded to such vendor will not
be broader than that which you are required
by the contract or agreement to provide for
such vendor.
B. With respect to the insurance afforded to these
vendors, the following additional exclusions
apply:
1. The insurance afforded the vendor, including
any duty we have to defend "suits", does not
apply to:
a. "Bodily injury" or "property damage" for
which the vendor is obligated to pay
damages by reason of the assumption
of liability in a contractor agreement.
This exclusion does not apply to liability
for damages that the vendor would have
in the absence of the contract or
agreement;
b. Any express warranty unauthorized by
you;
c. Any physical or chemical change in the
product made intentionally by the
vendor;
d. Repackaging, unless unpacked solely
for the purpose of inspection,
demonstration, testing or the
substitution of parts under instructions
from the manufacturer, and then
repackaged in the original container;
PB 04 4711 14
ACP BPR 7831746108
e. Any failure to make such inspections,
adjustments, tests or servicing as the
vendor has agreed to make or normally
undertakes to make in the usual course
of business, in connection with the
distribution or sale of the products;
f. Demonstration, installation, servicing or
repair operations, except such
operations performed at the vendor's
premises in connection with the sale of
the product; or
g. Products which, after distribution or sale
by you, have been labeled or relabeled
or used as a container, part or
ingredient of any other thing or
substance by or for the vendor.
h. "Bodily injury" or "property damage"
arising out of the sole negligence of the
vendor for its own acts or omissions or
those of its employees or anyone else
acting on its behalf.
HOWEVER, this exclusion does not
apply to:
(1) The exceptions contained in Sub -
Paragraphs d. or f.; or
(2) Such inspections, adjustments, tests
or servicing as the vendor has
agreed to make or normally
undertakes to make in the usual
course of business, in connection
with the distribution or sale of the
products.
2. This insurance, including any duty we have to
defend "suits", does not apply to any insured
person or organization from whom you have
acquired such products, or any ingredient,
part or container entering into, accompanying
or containing such products.
C. With respect to the insurance afforded to these
additional insureds, the following is added to
Section III. LIMITS OF INSURANCE AND
DEDUCTIBLE:
If coverage provided to the vendor is
required by a contract or agreement, the most we
will pay on behalf of the vendor is the
amount of insurance:
Includes copyrighted material of Insurance Services Office, Inc., with its permission
AGENT COPY
Page 1 of 2
47 05300
PR 04 47 1114
1. Required by the contract or agreement; or This endorsement shall not increase the
2. Available under the applicable Limits Of applicable Limits Of Insurance shown in the
Insurance shown in the Declarations; Declarations.
whichever is less.
All terms and conditions of this Policy apply unless modified by this endorsement.
Your Products:
COPIERS
SCHEDULE
Name Of Person Or Organization (Vendor):
City of Menifee and its officers, employees, agents, and authorized volunteers
29714 Haun Road, Menifee CA 92586.
Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission. PB 04 47 111114
ACP BPR 7831746108 AGENT COPY
47 05301