2022/09/22 Act 1 Construction, Inc.ACORi}CERTIFICATE OF LIABILITY INSURANCE
2t6l
THIS CERTIFICATE IS ISSUEO AS A IUATTER OF INFORJTIATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRUATIVELY OR ]{EGATIVELY AMEND, EXTET{D OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. TH|S CERTIFICATE OF INSURANCE OOES NOT CONSTTTUTE A CONTRACT BETTYEEN THE |SSU|NG TNSURER(S), AUTHORTZEO
REPRESENTATIVE OR PROOUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: It tho ca lficato holder is an AOOITIONAL INSUREO, tho policy{ios) must have AODITIONAL INSUREO provisions o, be ondorsed.
l, SUBROGAION lS WAIVED, subject to lhe torms and conditioG o, tho policy, cenain policios may .equirc an ondo.somont. A statement on
this cortificate does not contor rights to ths cs.tificato holder h laeu of such endorsement(s).
FRooucER NeMront Insurance Services
777 l\ilariners lsland Blvd., Suite 250
San lvlateo. CA 94404 650-488,8565
Oscar.osorio l.com
IN AFFORDING COVERAGE
rNsuRER a : Palomar specially lnsurance company 20338
INSURED
Act 1 Construction, lnc
444 6th St
Norco CA 92860
rNsuR€R 6 : AGCS Marine lnsurance Comoanv 22837
INSURER E
COVERAGES
THIS IS IO CERTIFY THAT THE POLICIES OF INSURANCE LISTED EELOW HAVE BEEN ISSUED TO THE INSURED NAMEO ABOVE FOR THE POLICY PERIOD
INDICATED NOTWTHSTANOING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTII RESPECT TO WIICH THIS
CERTIFICATE MAY 8E ISSUEO OR MAY PERTAIN, THE INSURANCE AFFOROED 8Y THE POLICIES OESCRIBEO HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDIfIONS OF SUCH POLICIES LIMITS SHOW! MAY HAVE EEEN REOUCEO BY PAIO CLAIMS.
GEN L AGGREGATE LIMIT APPIIES PERI
OTHER
5$? E*
PAGL 2222069 2t6/2023 2t612024 s1 000 000
s 300,000
MED EXP (A.y ono poGon)s 5,000
PERSONAL & AOV INJURY sj 000 000
s2,000,0006ENERALAGGREGATE
PROOUCTS COMP/OPAGG s2.000.000
Proiects GeneralAoq s5,ooo.ooo
AI,TO OSILE L1ABILJJY
OWNED SCHEDULED
AUTOS
NON-OW!EO
AUTOS ONLY
COMBINEOSINGLE LIMIT
BOOTLY INJURY (Pd person)
s
$aOD LY INJURY (P.r accrdont)
$
s
EXCESS LIAB
OCCUR PALXS 2222070 2t6t2024 s5.000.000
s5.000.000
OED RETENTION S s
t/{oRKERS COf PEr{SAnOfi
AND EIIPI.OYERS' UAEILITY
ANYPROPRIETO&PARTNER/EXECUTIVE
OFFICER/MEMBEREXCLUOEO?
DESCRIPTION OF OPERATIONS b€IM
I OIH,
$E L EACH ACC DENT
EL DISEASE EA EMPLOYEE $
EL DISEASE.POLICYLMT s
B
B
B
Conlractors Equipmenl
Eusiness fursonal Property
Scheduled Equipment
sM193087999
s[4LS3087999
sM193087999
9122t2022
9t2212022
9122t2022
9t22t2023
9t22t2023
9t22t2023
Rented/Leased: $500,000
$30,000
$578,321
DESCRTpT|ON OF OPERAITONS
'
LOCAnONS / VEHTCLES (ACOFO 101, Ad<rition.t R.n.r*. Sch.dut., m.y b. .trch.d moo .p.c. '. GquiEd)
RE: QuailValley New Fire Station *5, 29745 Goelz Rd., Menibe, CA 92587
City of [4enibe and its elec-ted offcials, offic€rs, employees, agents, represenlali\es, consultants, conkact employees and volunleers are included
as addrlronal insured on a primary and non-conlnbulory basrs as respecls lherr rnteresls in the project rebrenced above. rf required by wflllen
conlract A waiver of subrogatron apphes on all colerage marked as such. if requlled by written contracl Thrrly (30) days pflor wfillen notce of
cancellation and/or reduclion in coverage of any nature.
CERTIFICATE NUMBER:REVISION NUMBER:
CERTIFICATE HOLOER CANCELLATION
Citv of Menifee
29644 Haun Rd
I\ilenibe CA 92586
I
SHOULD ANY OF THE ABOVE DESCRISED POLICIES BE CANCELLEO BEFORE
rHE EXPIRATION DATE TIIEREOF. NOTICE WILL BE DELIVEREO IN
ACCORDANCE WITH THE POLICY PROVISIONS,
AU THORIZED REPRESENTA TIVE
Rod Sockolov
@ I 988-201 5 ACORD CORPORATION. All righb rssorved.
ACORO 25 (2016103) The ACORD namo and logo are regietelod mark3 of ACORD
l:319:.5 :." rl- cr, is/ w( l,eased Equrp, EPp, sch.d Equip G..r ororjo r./6/20?t ]t:r6:r3 aM iFsT) paqe I of lThrs ar'r'iL'dre cdncFls and supersedps AIL prFvlously ,)<Leo..errrfrrd.cs,
www.newfronl.com
COIIME RCIA L GEN ERAL LIABILITY EACH OCCURRENCE
2t6t2023
tr
Act 1 Conslruction, lnc
POLICY NUMBER. pAGL 2222o6s COMMERCIAL GENERAL LIABILITY
cG 20 37 04 t3
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
Name Of Additional lnsured Person(s)
Or Organization(s)Location And Description Of Completed Operations
Citv of
29844
Menibe
H aun
CA
Rd,
92586It4enibe
RE: QuailValley New Fire Station #5, 29745 Goetz Rd., N,lenifee, CA I
lnformation required to complete this Schedule, if not shown above, will be shown in the Declarations
587
A. Section ll - Who ls An lnsured 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" or
"property damage" caused, in whole or in part, by
"your work" at the location designated and
described in the Schedule of this endorsement
performed for that additional insured and
included in the "products-completed operations
hazad".
However:
1. The insurance afforded to such additional
insured only applies to the extent permitted
by law; and
2. lf 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.
B. Wth respect to the insurance afforded to these
additional insureds, the following is added to
Section lll - Limits Of lnsurance:
lf 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
2. Available under the applicable Limits of
lnsurance shown in the Declarations:
whichever is less.
This endorsement shall not increase the applicable
Limits of lnsurance shown in the Declarations.
O lnsurance Services Office, lnc.,20'12
cG 20 37 04 13
_,- ..", -t. .,. , _Fpr\ad-. A p.^r u._.,
Page I of 1
This endorsement modifies insurance provided under the following:
SCHEDULE
Act I Construction.lnc
POLICY NUI\iIBER . p|cL2222!xs COMMERCIAL GENERAL LIABILITY
cc 20 10 04 13
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 lnsured Person(s)
Or Organization(s)Location(s) Of Covered Operations
Citr ol Menitce
298J4 Haun Rd
Menifee CA 92586
RE Quarl Vallc) Ncw Fire Stalion #5.29745 CoctT Rd , Mcnrlic. CA 9:5
lnformation required to complete this Schedule, if not shown above, will be shown in the Declarations
'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.
C. VMth respect to the insurance afforded to these
additional insureds, the following is added to
Section lll - Limits Of lnsurance:
lf 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
@ lnsurance Services Office, lnc.,2012
cG 20 10 04 13
lh. rt-r..n,' ,' t,pv o.;.y 2/6/2021 Il:15:13 Al1 (PsTr Paqe I or 7
A. Section ll - Who ls An lnsured 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. lfcoverage provided to the additional insured is
required by a contract or agreement, the
insurance atforded 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.
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:
Page 1 of 2
2. Available under the applicable Limits of
lnsurance shown in the Oeclarations:
whichever is less.
This endorsement shall not increase the
applicable Limits of lnsurance shown in the
Declarations.
@ lnsurance Services Office, lnc., 2012
cG 20 10 04 't3
'. e.'.1. o'6, L .1. ..d iLI/-rr, le.4Lt. a.. iUUst/ -5jp,t
Page 2 ol 2
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY AND NONCONTRIBUTORY -
OTHER INSURANCE CONDITION
This endorsement modifies insurance provided under the following
The following is added to the Other lnsurance
Condition and supersedes any provision to the
contrary:
Primary And Noncontributory lnsurance
This insurance is primary to and will not seek
contribution from any other insurance available
to an additional insured under your policy
provided that:
('l) The additional insured is a Named lnsured
under such other insurance, and
Policy NumberPAGL 2222069
COMMERCIAL GENERAL LIABILITY
cG 20 01 04 13
CG 20 01 04 13 @ lnsurance Services Office, lnc.,?012
_:37i.'5 r', "1- GL, XS, x. reaeed Equrp, Orc.r o.or10 :/6/:0:l rr:lb:t3Thrs.er'rli.dte,:ancel5 drd suparscdes Arl prFv.oualy rssueo ce!rrtr.a!es.
Page I of 1
(2) You have agreed in writing in a contract or
agreement that this insurance would be
primary and would not seek contribution
from any other insurance available to the
additional insured.
COMMERCIAL GENERAL LIABILIry COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILIry COVERAGE PART
POLICY NUMBER . p1cL2222o6s COMMERCIAL GENERAL LIABILITY
cG 24 04 12 '.tg
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGATNST OTHERS TO US (WAIVER OF SUBROGATION)
This endorsemenl modities insurance provided under the following
COMMERCIAL GENERAL LIABILITY COVERAGE PART
ELECTRONIC DATA LIABILITY COVERAGE PART
LIQUOR LIABILITY COVERAGE PART
POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES
POLLUTION LIABILITY Lll\il|TED COVERAGE PART DESIGNATED SITES
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
RAILROAD PROTECTIVE LIABILITY COVERAGE PART
UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS
SCHEDULE
lnformation required to complete this Schedule, if not shown above, will be shown in the Declarations
The following is added to Paragraph 8. Transfer Of
Rights Of Recovery Against Others To Us of
Section lV - Conditions:
We waive any right of recovery against the person(s)
or organization(s) shown in the Schedule above
because of payments we make under this Coverage
Part. Such waiver by us applies only to the extent
that the insured has waived its right of recovery
against such person(s) or organization(s) prior to
loss. This endorsement applies only to the person(s)
or organization(s) shown in the Schedule above.
CG 24 04'12 19 O lnsurance Services Office, lnc., 201 I Page 1 of 1
Name Of Person(s) Or Organization(s):
All persons or organizations as required by written contract with the insured.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
cs l27e:l:
wc 00 03 13
(Ed.4-84)
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce
our right against the person or organization named in the Schedule. (This agreement applies only to the extent that
you perform work under a written contract thal requires you to obtain this agreement from us.)
This agreement shall not operate direclly or indirectly to benefit anyone not named in the Schedule.
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
Schedule
This endorsement changes lhe policy to which it is attached and is effective on the date issued unless otherwise stated
(Tho lnlormalion bolow is required only whon lhls endorsamenl is issu€d subsequent lo preparalion ol the policy.)
Endorsement ElfectiveDate Policy No.Endorsement No
Policy Ellective Date:l7l t/2022
lnsureqfl l{o{ls'ruc"on.
rnc
Nor.o ( A 92li6l,
DBA:
Ca(ier Name / Code
wc 00 03 13
to Premium $
Counlersigned by
(Ed.4-84)
O 1983 NallonalCouncll on Compensation lnsurance,
lI:16:13 Ax (PsT) I P.ge I of ?
Page 1ol 1