2022/05/21 Rolcom, Inc.o.oG
CERTI FICATE OF LIABILITY INSU RANCE OAIE (MM/DDIYYYY)
0511212022
THISCERTIFICAfE IS ISSUEDASAMATTEROF INFORMANON ONLYANDCON'ER5 NO RIGHTS UPONTHE CERTIFICATE HOIDER.THIS CERTIFICATE DOES NOIAFFISMATIVE!YOi NEGATIVELY
AMEND, EXIENDORALTERTHE COVERAGEAFFORDED SYTHE POLICIES SEIOW THISCERTIFICATEOF INSURANCE DOES NOTCONSTITT'TEACONTRACTBETWEENTHE ISSUING INSURER(S),
AU-THORIZED REPREsENTATIVE OR PROOUCER, AND THE CERTIFICATE HOtDER.
PRODUCER
Devin Wozencraft(9727371 )
660 N Santiago St
Sanla Ana cA 92701-3942
CONTACI
NAME: Oevin Wozencraft
PHONE
{A,/c, No, ExI): 949475-9730 (a/c, o):866-538-7660
E.MAI!
AoDRESS: dwozencraft@farmOrsagent.com
INSURER(S) Af FOROING COVERAGE
INSUREO
ROLCOI\4 INC
240 0TT ST
CORONA cA 92882
INSURERA: TtuCklnsUrance Exchange 21709
tNsURaR B: Farmers lnsurance Exchange 21652
I SUREnCi Mid Century lnsurance Company 21687
INSURER D:
INSURER E:
COVERAGES CER'TIFICAIENUMBER REVISION NUMAER
TIIIS ISTOCERT FY THAI THE POIICIES OfINSURANCE LISTED BELOW HAVE BEEN ISSUEDTOTHE INSUREO NAMEABOVE FORTHE POLICY PERIOO INDICATEO, NOTWITHSIANOINGANY
R EOUIREM ENI, IERM OR CONDITION OFANY CONTRACTOR OTHER OOCUMENTWITH RESPECTTO!A/HICH THIS CERTIFICATE MAY gE ISSUEDOR MAYPERTAIN, THE INSIIRANCEAFFORDEO BYIHE
POLICIES DESCRIBEO HEREIN I5 5UB]ECI'TOALLTHETERMS, EXCLUSIONSANOCONOITIONSOFSUCH POLICIE5 L]M tTS SI.]OWN MAY HAVE BEE N RE OUCED BY PAIO CLAIMS,
lNsn
TTR TYPEOFINSURANCE ADOTL
INSD
SUAR POLICYNUMBCR POLICYEFF LIMITS
COM M E RCIAI GE N ERAL IIABITITY
] .*,rr"oo,OCCUR
EICHOCCURRENCE $
DAMAGETORENIED
PREMISES(Ea occu(erce)$
MEO EXP (Anyone pe6on)I
PERSONAL &ADV INIURY $
GEN'L AGGREGATE LIMITAPPLIES PER
POLICY
OTHER:
PROI€CT LOC
6ENERALAGGREGATE $
PRODUCTS - COMP/OPACG !
s
AUTOMOBILE LIASIIITY
OWNEDAUTOS
ONLY X
HIREOAUTOS
ONLY X NON.OWNEO
AUTOS ONLY
N 604372641 0512112023
COMEINEO SINGL€ IIM IT t 1,000,000
BoDILY NIURY(Perp.ren)s
BODILY NIURY(Per accident)$
PROPERW OAMAGE $
$
UMBRETLALIAB
EXCESSIIAB
OCCUR
CLAIMSMADE
EACHOCCURRENCE !
AGGREGATE $
DEO REIENTION I
WORKERSCOMPENSAIION
AN O EMPLOYEFS ' LIAB ILIIY
ANY P ROPRIETOR/ PARTN ER/
EXECUT VE OFFICE R/ME MBER
ExCLUOED? (Mandatory ln NH)
ll yes, describe under OESCRIPTION OF
f
STATUTE $
E L, EACH ACCIDENI 5
€L DISEASE POLICYLIMIT s
DESCRIPIION OE OPERATIONS/LOCATIONS/VEHICLE5 (ACORD l0l,Additional RemarksSch.dul., m.y b. atta.hed ifho.espacels ruqqkod)
City of Manifee Engineering Departmenl named as additional insured
CERIIf ICATE HOLOER
SHOUTDANYOFTHEABOVEDESCRIBEDPOIICIESBECANCELIEOBETORETHEEXPIRAIION
OATE T}IEREOF, NOTICE wlLL BE OELIVENED IiI ACCORDANCE WITH THE POt!CY PROVISIONS,Engineering Department
29714 Haun Rd AUTHOR I2E D REFiES E NIATIVE
O1988-2015 ACORD CORPORATION. All Rights Reserued
The ACORD name and logo are registered marks ofACORD
ACORD 25 (2016/03)
3I,1759 ll-15
SCHEOULED
AUTOS 05t21t2022
E L, DIS€ASE EAEMPLOYEE
POLICY NUMBER 60137264t COMMERCIAL AUTO
cA 20 48 02 99
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DES!GNATED INSURED
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORIVI
MOTOR CARRIER COVERAGE FORM
TRUCKERS COVERAGE FOR|\il
Wth respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless
modified by this endorsement.
This endorsement identifies person(s) or organization(s) who are "insureds" under the Who ls An lnsured Provi-
sion of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form.
This endorsement changes the policy effective on the inception date of the policy unless another date is indi-
cated below.
Endorsement Effective
05t2112022
Countersigned By
(Authorized Representative)
Named lnsured
ROLCOM INC
SCHEDULE
Name of Person(s) or Organization(s): CITY OF MENIFEE ENGINEERING DEPARTMENT
(lf no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to the endorsement.)
Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extentthat person or organization qualifies as an "insured" under the Who ls An lnsured Provision contained
in Section ll of the Coverage Form.
cA 20 48 02 99 Copyright, lnsurance Services Office, lnc., 1998 Page l ofl tr