2021/04/01 California Drilling and Blasting Co. Inc.page 2 of 3
Client#: 1259976 305ASCENMUL
ACORD. CERTIFICATE OF LIABILITY INSURANCE FOATE(MM/DD/YYYY)
3/30/2021
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 any rights to the certificate holder in lieu of such endorsement(s).
PRODUCER NAMO TE: Lori R€cke
McGriff Insurance Services PF1oNE — FAX
2400 E Katella Ave Suite 1100 MA , Ext): 714 941-2909 (A,r.• N�):
Anaheim, CA 92806 ADDAMS: Iricke@mcgriff.com
714 941-2800 _ INSURER(q AFFORDING COVERAGE NAIC #
INSURER A : United States Fire Insurance Co. 21113
INSURED INSURER B • Carolina Casualty Insurance Co. 10510
California Drilling & Blasting Co Inc.
P.O. Box 669
South Pasadena, CA 91031-0689
INSURER C:
INSURER D : --
INSURER E,
INSURER F I
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS
INDICATED.
CERTIFICATE
EXCLUSIONS
IS TO CERTIFY THAT THE POLICIES
NOTWITHSTANDING ANY REQUIREMENT,
MAY BE ISSUED OR MAY PERTAIN,
AND CONDITIONS OF SUCH
TYPE OF INSURANCE
OF
POLICIES.
ADDL
SR
INSURANCE
THE
U6R
wyR
LISTED BELOW HAVE BEEN
TERM OR CONDITION OF ANY
INSURANCE AFFORDED BY THE
LIMITS SHOWN MAY HAVE BEEN
POLICY NUMBER
5069011662
5069011662
ISSUED TO
CONTRACTOR
POLICIES
REDUCED
POLICY EFF
(MM/DD/YYYY�
34/01/2021
34/01/2021
THE INSURED
OTHER DOCUMENT
DESCRIBED
BY PAID CLAIMS.
POLICY '77�p
WWrap1YYYYk
04/01/202
NAMED ABOVE FOR THE POLICY PERIOD
WITH RESPECT TO WHICH THIS
HEREIN IS SUBJECT TO ALL THE TERMS,
Ina
LTR
A
A
_ LIMITS
EACH OCCURRENCE $1 000 000
X_ COMMERCIAL GENERAL LIABILITY
��
_ k CLAIMS -MADE "I OCCUR
{ 7(]jiENTEO
},SEs{Eayccurr _
VIED EXP (Any one person)
$100,000
_
$5�0_00
PERSONAL & ADV INJURY
_
$1 000 000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY a JECT 0 LOC
OTHER:
GENERAL AGGREGATE
$_2�00
PRODUCTS - COMP/OP AGG
$ 2 000 0O0
$
1 000000
GClMBINED.SINGLE LIMIT
AUTOMOSILELIABILITY
r_:�Xx
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
AUTOS ONLY X AUTOS ONLY
04/01/2022
BODILY INJURY (Per person)
$
$
BODILY INJURY (Per accident)
PROPERTY0 MADE
per acclderti
$
A
nUMBRELLA
LIAB
EXCESS LIAB
X
OCCUR
CLAIMS -MADE
5238123192
CCWC142008
D4/01/2021
04/01/202
EACH OCCURRENCE
AGGREGATE
$10,000r"
$10,000,000
$
DED I X1 RETENTION $0
_
X PER OTH-
STATUTE _— B
B
WORKERS COMPENSATION
AND EMPLOYERS' LUIBLLITY Y / N
ANY PFIOPRIETOFVPARTNERII:XECUTIVE
OFFICE WMEMBER EXCCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N/A
D4/01/2021 04/01/202
E.L. EACH ACCIDENT $1 000 00O
j. ..'.
E.L. DISEASE - EA EMPLOYEE $1,0001000
-
E.L. DISEASE - POLICY LIMIT I s1,000,000
_
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
Verification of Insurance
pert I II-IU,v I t: NVLUtH CANCELLATION
Menifee Fire Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
29844 Haun Road ACCORDANCE WITH THE POLICY PROVISIONS.
Sun City, CA 92586
AUTHORIZED REPRESENTATIVE
21505
01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD
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