2013/12/15 Go Live Technology, Inc. POLICYHOLDER COPY
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• P.O. BOX 8192, PLEASANTON, CA 94588
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CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 02-24-2014 GROUP:
POLICY NUMBER: 9060693-2013
CERTIFICATE ID: 7
CERTIFICATE EXPIRES: 06-12-2014
06-12-2013/06-12-2014
CITY OF MENIFEE SP JOB:MENIFEE GIS ROADMAP
29714 HAUN RD
MENIFEE CA 92586-6540
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer.
We will also give you 30days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy.
Authorized Representative President and CEO
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT N0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2014-02-24 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED:
CITY OF MENIFEE
ENDORSEMENT X1600 - CHENETTE, RICHARD P,S T - EXCLUDED.
ENDORSEMENT N2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 12-04-2013 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
EMPLOYER
GO LIVE TECHNOLOGY, INC. SP
1401 W BALBOA BLVD APT B
NEWPORT BEACH CA 92661
[P18,SP]
(REV.1-2et2) PRINTED : 02-24-2014
GOLIV-1 OP ID:MR
CERTIFICATE OF LIABILITY INSURANCE °" `MM'°°RYY"'
02/24/14
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(les) must 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 endorsements.
PRODUCER 714.755-1575 NINTAME CT Service Desk,Ext 120
AC I Commercial Insurance me a ;714-755-1575 Are No:714.352-3728
505 E.First St.Suite E. 714-755�124 PHONE PAK
Tustin,CA Commercial
ADDRESS:service@aciinsure.COm
ACI Commercial Insurance
INSURERISJ AFFORDING COVERAGE NAIC S
INSURED
NSURERA:UNITED STATES LIABILITY INS CO
26 Live Technology,Inc.632 Via Cuervo INSURER B:
Mission Viejo,CA 92691 INSURER C:
FINSURER
-
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 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.
NSR
TR TYPEOF INSURANCE POLICY NUMBER MMN YD F MOMIUD IXP LIMITS
GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
A X COMMERCIAL GENERAL LIABILITY X MTK15602768 12/15113 12/16/14 PDAMAGE TO REN I REMISE (Ea
.0 $ 300,000
CLAIMS-MADE OCCUR MEDEXP(Anyompenen) E 10,000
PERSONAL S ADV INJURY E 1,000,000
GENERAL AGGREGATE E 2,000,000
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG E 2.000,000
POLICY X PRO- LOC E
AUTOMOBILE LIABILITY Ea BRUIN En SINGLE LIMIT 1,000,000
A ANYAUTO MTK15802768 12115113 12115/14 BOOILYDuuRY(Per person) f
ALL OWNED SCHEDULED
AUTOS AUTOS BODILY INJURY(
P..a danl) E
Ix
HIREDAUTOS X NON-OWNED
AUTOS POPPEUR, nDAMAGE E
S
UMBRELLA LJAB OCCUR
EACH OCCURRENCE 3
EXCESS LIAB CLAIMS-MADE -
AGGREGATE $
DED I I RETENTION 1.
WORKERS COMPENSATION - WCSTATU- OTH-
AND EMPLOYERS'LIABILITY YIN
TORYLIMIT PR
ANY PROPRIETOR/PARTNE UEXECUTIVE EL EACH ACCIDENT
OFFICER/MEMSER EXCLUDED? NIA E
(ManderorylnNMI E.L.DISEASE-EA EMPLOYE S
ny desaibeundm
DE SCRIPTION OF OPERATIONS balm E.L.DISEASE-POLICY LIMA $
A ERRORS 8 OMISSIONS MTKISS0276B 12/15113 12/15114 OCCURENCE 1,000,000
CLAIMS MADE AGGREGATE 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORDIG1,AddlUonal Remadm Schedule,Umoro epaeolsmqulnd)
CITY OF MENIFEE, MENIFEE GIS ROADMAP, OFFICERS EMPLOYEES, AGENTS AND
UTHORIZED VOULUNTEERS ARE NAMED AS ADDITIONAL INSURED PER ATTACHED FORM
HP 134(06-09) -
CERTIFICATE HOLDER CANCELLATION
CITY297
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY OF MENIFEE ACCORD H THE POLICY PROVISIONS.
29714 HAUN ROAD
MENIFEE,CA 92586 AUTHORIZEDREP ENTATIVE
ACi Co rcial Insurance
01 ACORD CORPORATION. All rights reserved.
ACORD 25 12010105) The ACORD name and logo are registered a of ACORD
UNITED STATES:LIABILITY INSURANCE GROUP
WAYNE, PENNSYLVANIA
This eadaseihent modifies insurance provided under.the following:
Bi1SINESSOWNERS COVERACE.FOR11'I
BLANKET ADDITIONAL INSURED
SECTION II—LIABII YTI C.Who.l-s.An Itlsared is atnend'ed to,include as an additional'
insured any persons)or organ zation(s).for whomyou are performing"your wore underit
written-contract or agreement,.that requires such person(s)or:organizations)to be added as an
additional insured on your policy. 5uchperson(s)ororganizaton(s)is an additional insured
onlywitli respect to,'liabili(y fdr"bodily injury';'�,roperty damage"or."personal and advertising
injury"occurring after the efkfive date.of such conizact or agreement that.is caused,;in whole or
in part by;
a Your acts or omissions;or'
b. The acts or.omissions of those acting on your behalf;;
in the performance,of'f our'work"foi the additional insured..
Coverage for an additional insured under this endorsement ends when"your work"•for that
additional insured ends or is puffo its intended use by any person or organization
SECTION II—LIABILITY;B.EXCLUSIONS,•3.Applicable To Both Business Liability
Coverage And Medical Expenses Coverage,is=ended to add the following with.respect to
this endorsement only
There'is no coverage under this endorsement for-loss or expense,including but not limited-to
the cost of defense for"bodily-injury"or"propeitiy,damage""or"personal and advertising
injury"occurring:
a. After all of`your work' including materials,parts or equipment furnished in connection
with"your.work"and,performed uoderthe above referenced written contract(s)or
ag�eement(s)ltas ended;or
b. W1ien that portion of"your work"out ofwhich the"bod3ty injttty*',"property damage"or
"personal and advertising injury"arises and performed under the.above referenced
written contract(s)or-agreement(s)has been put to its intended use by any person or
organization;
whichever occurs first
All other terms and conditions of this policy remain unchanged. This endorsement is a part-of
your policy and takes effect on the effective date of your,policy unless another effective date is
shown.
BP 134(06-09) Page 1 of I