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2021/06/29 Clearwater Pipeline, Inc.CLEAPIP-01 'A`_`-'M"' CERTIFICATE OF LIABILITY INSURANCE DATD/YYYY) �� s12812zs,Iz021 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 endarsement s . I PRODUCER LICense # 0757776 C CT Chad Hill HUB International Insurance Services Inc. PHONE FA% PO Box 5345 779-8549 Na :t951 742-4679 Riverside, CA 92517;chad.hilll@hubinternational.com INSURED Clearwater Pipeline, Inc. P.O. Box 357 Perris, CA 92572 INSURER F : rk Insurance C COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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 TYPE OF INSURANCE ADD SUER POLICY NUMBER POLICY EFF POD ICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE l� OCCUR PD Ded: $2,000 X AO177373004 IA0177373001 6/29/2021 6/29/2022 EACH OCCURRENCE $ 1,000,000 °AMAGEE TRENTED EMI 100,000 X MED EXP me arson 15,000 PERS L&ADVINJURY 1'000,000 GENT. AGGR TE LIMIT. APPLIES PER: POLICY JECT LOC HER, RALA RE TE $ 2,000,000 PR D 7S - MPJ G $ 2,000,000 POLLUTION 1,006,000 A AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS AUTOS ONLY X AUTUS ONLY 6/29/2021 6/29/2022 COMBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY (Perperson) S Ix BODILY INJURY Peracciden BODILY $ ��OP� MAGE S UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE DED RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE REFICE MBE; EXCLUDED? Y L eadao. nNH If yes, describe under OF OPERATIONS below NIA iCST5021525 5/1/2021 5/1 /2022 X PERSTAIUIE OTH- E.L EACH ACCIDENT 1,000,000 E.LDISEASE- EAEMPLOYE 1,t)�0,00� E.L DISEASE - POLICY LIMIT 1,000,000DESCRIPTION DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Encroachment Permit. The City of Menifee is Additional Insured with regard to General Liability when required by written contract per the attached endorsement form CG2010 04/13. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Menifee, Engineering Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ry g g P ACCORDANCE WITH THE POLICY PROVISIONS. 29714 Haun Road Menifee, CA 92586 AUTHORIZED REPRESENTATIVE OXUA L_ . ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: A0177373004 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 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) Any person or organization you are required to add as All locations per written contract, agreement or an permit. additional insured under a written contract or Description: agreement All jobs performed that have a written contract, in effect prior to any accident, injury, loss or damage. agreement, or permit. 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. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 10 0413 A0177373 Middlesex 1 00001 0000000000 21175 0 N 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 additional insured(s) at the location 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. © Insurance Services Office, Inc., 2012 70a8a1e-2c36497e-9178-e878e806c08a Page 1 of 2 06/24/2021 C. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13 A0177373 Middlesex 06/24/2021