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2020/09/16 Bucknam Infrastructure Group, Inc. Certificate of Liability Insurance (3)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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 THISCERTIFICATE 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED?(Mandatory in NH) DESCRIPTION OF OPERATIONS belowIf yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIREDAUTOS ONLY 11/5/2020 60606 MENIFEE OCEANSIDE ILCHICAGO 233 S. WACKER DR, STE 2000 WILLIS TOWERS WATSON MIDWEST INC Certificate@Hanover.com (888) 780-5381 (866) 828-2424 Hanover Insurance Co Hanover American Ins Co Citizens Ins Co of America 22292 36064 31534 4 4 4 2,000,000 1,000,000 10,000 2,000,000 4,000,000 4,000,000 A 4 4 Y Y OBC A399956 06 09/16/2020 09/16/2021 2,000,000 A 4 4 4 Y Y OBC A399956 06 09/16/2020 09/16/2021 OBC A399956 06 09/16/2020 09/16/2021 WZC A399946 06 3,000,000A Y 4 1,000,000 1,000,000 1,000,000 C B Architects & Engineers Prof Liab Y Y N N LHC H023717 01 09/16/2020 09/16/2021 09/16/2020 09/16/2021 City of Menifee and its officers, employees, agents, and volunteers Additional Insured on the General Liability pursuant to the terms and conditions by form 391-1586. Additional Insured is Primary and Noncontributory to the extent provided by form 391-1003 (pg 79 of 81). Waiver of Subrogation as provided by form 391-1003 (pg 80 of 81). Waiver of Subrogation as provided by form WC040306. Cancellation Notice will be provided to the Certificate Holder pursuant to endorsement: 401-1235. 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. CA 92056 CA 92586 BUCKNAM INFRASTRUCTURE GROUP INC 3548 SEAGATE WAY STE 230 29844 HAUN ROAD ATTN: ACCOUNTS PAYABLE CITY OF MENIFEE 3,000,000 Claims-Made: $2M Ea Claim/$2M Agg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THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO DESIGNATED ENTITY(S) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART HANOVER COMMERCIAL FOLLOW FORM EXCESS AND UMBRELLA POLICY COMMERCIAL PROPERTY COVERAGE PART BUSINESS AUTO COVERAGE FORM BUSINESSOWNERS COVERAGE FORM SCHEDULE Name of Designated Entity Mailing Address or Email Address Number Days Notice (In formation required to complete this Schedule, if not shown above, will be shown in the Declarations.) If we cancel this policy for any reason other than nonpayment of premium, we will give written notice of such cancellation to the Designated Entity(s) shown in the Schedule. Such notice may be delivered or sent by any means of our choosing. The notice to the Designated Entity(s) will state the effective date of cancellation. Unless otherwise noted in the Schedule above, such notice will be provided to the Designated Entity(s) no more than the number of days in advance of the effective date of cancellation that we are required to provide to the Named Insured for such cancellation. Such notice of cancellation is solely for the purpose of informing the Designated Entity(s) of the effective date of cancellation and does not grant, alter, or extend any rights or obligations under this policy. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. Page 1 of 1 City of Menifee 29844 HAUN ROAD 30 Attn: Accounts Payable Menifee, CA 92586 OBC A399956 06