2021/02/18 L.C. Paving & Sealing, Inc. (5)��oRok CERTIFICATE OF LIABILITY INSURANCE
DATE(M02/19//2021 Y)
021
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
CONTACT JANA CLARK
NAME:
HARTLEY CYLKE PACIFIC-#0574253
PAHONN Ext (619) 295-5155 ACNo (619) 291-0912
Ao!Ail_ Jana@hcpacinsurance.com
DRE2747
INSURANCE SERVICES, INC.
INSURER(S) AFFORDING COVERAGE
NAIC#
UNIVERSITYAVENUE
SAN DIEGO CA 92104-4068
INSURER A : TRAVELERS PROPERTY & CASUALTY CO OF
25674
INSURED
INSURER B : CLEAR SPRING PROPERTY & CASUALTY CO
INSURER C: PALOMAR SPECIALTY INSURANCE CO
L,C. Paving & Sealing, Inc.
INSURER D:
620 Alpine Way
INSURER E:
INSURER F-
Escondido CA 92029
COVERAGES CERTIFICATE NUMBER: CL2121968482 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.
LTR
TYPE OF INSURANCE
JNSD
,VWD
POLICY NUMBER
MM DD/YYYY
MM DD/YYYY
LIMITS
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
CLAIMS -MADE 7 OCCUR
PREM SES(Eao=nyrkcs
$ 300,000
MED EXP (Any one person)
$ 5,000
PERSONAL & ADV INJURY
$ 1,000,000
A
Y
DT22COOS13576ATIL21
02/18/2021
02/18/2022
GEN'LAGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,000
HPOLICY X PRO JECT F1 LOC
PRODUCTS - COMP/OP AGG
$ 2,000,000
$
OTHER:
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
Ea &o en
$ 1,000,000
BODILY INJURY (Per person)
$
ANYAUTO
A
OWNED SCHEDULED
AUTOS ONLY AUTOS
Y
8100SO955232126G
02/18/2021
02/18/2022
BODILY INJURY (Per accident)
$
IRO PERTY011MAGE
Per a0dj.t
$
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
Medical payments
$ 5.000
UMBRELLA LAB
X
OCCUR
EACH OCCURRENCE
$ 4,000,000
X
AGGREGATE
$ 4,000,000
A
EXCESS LIAB
CLAIMS -MADE
Y
CUPOS1373832126
02/18/2021
02/18/2022
DED RETENTION $
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
N/A
CSWK0000002670
09112/2019
09/12/2020
%,/
STATUTE ERH
E.L. EACHACCIDENT
$ 1,000.000
E.L. DISEASE -EA EMPLOYEE
$ 1,000,000
IF yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
INLAND MARINE
C
IMFLP20202100300
02/18/2020
02/18/2021
RENTED/LEASED EQP
$100,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
*10 day notice of cancellation for non-payment of premium shall apply.*30 days written notice of cancellation for all other reasons.
**City of Menifee and its officers, employees, agents, and authorized volunteers shall be named Additional Insured on a Primary and Non -Contributory
basis. A Waiver of Subrogation applies as required by written contract.
RE: CIP 20-12 ADAMS AVENUE STREET IMPROVEMENTS PHASE 2
C:tK I It-IUA I t HULULN LoAINULLLA I IUIN
City of Menifee and its officers, employees, agents, and authorized
volunteers
29844 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
me-
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD