ACORO®
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
01/25/2023
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 endorsement(s).
PRODUCER
INSURED
Atchley & Associates Insurance Services
6864 Indiana Ave
Suite 200
Riverside
Aneen Construction, Inc.
9860 Indiana Avenue Unit 18
Riverside
CA 92506
CA 92503 -
CONTACT
NAME'
PHONE
(Ale. Nn Fvf)•
E-MAIL
ADDRFSS•
Betsy Michel
(951) 275-0340
[email protected]
INSURER(S) AFFORDING COVERAGE
INSURER A : Evanston Insurance Company
INSURER B :Infinity Select Ins. Co.
1 INSURER C :
INSURER D :
1 INSURER E :
INSI,LE?
FAX
NnL•AX (000)000-000-
!,
NAIC #
35378
20260
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.
INSR ADDL SUBR POLICY EFF POLICY EXP
1 TR TYPE OF INSURANCE INgnJanin POLICY NUMBER (MM/DD/YYYY) (MM/nn/YVYVI LIMITS A X
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE
X
OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
PRO-
JECT
POLICY
OTHER:
B AUTOMOBILE LIABILITY
ANY AUTO
OWNED
AUTOS ONLY
X HIRED
AUTOS ONLY
UMBRELLA LIAB
EXCESS LIAB
X
X
LOC
SCHEDULED
AUTOS
NON -OWNED
AUTOS ONLY
OCCUR
CLAIMS -MADE
DED RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
A Contractor's Pollution Liability
Deductible: $2,500
Y/N
N/A
CPS7588317
504-61017-6727-001
05/26/2022 05/26/2023
07/07/2022 07/07/2023
CPLMOL 113549 10/12/2022 10/12/2023
EACH OCCURRENCE
$ 1,000,000
100,000
5,000
1,000, 000
2,000,000
1,000, 000
DAMAGE TO RENTED
PRFMISFS (Fa nca vrancal $
MED EXP (Anv one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
PRODUCTS - COMP/OP AGG $
$ 1,000,000
EACH OCCURRENCE $
AGGREGATE $
COMBINED SINGLE LIMIT
(Fa arririent)
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE
(Per senirientl
PER OTH-
RTATIITF FR
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT $
Per Occurrence
General Aggregate
Transporation Pol.
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: Main Street and Crowther Ave Parking Lot Improvements - City Project #2204 and #2205 The City of Placentia, its officers, employees, representatives, attorneys, and volunteers are named as additional insured.
Primary and Non -Contributory Wording applies per attached. 30 days notice will be sent should any of the above described policies be cancelled before the expiration date thereof.
CERTIFICATE HOLDER CANCELLATION
City of Placentia
401 E. Chapman Ave.
Placentia,
CA 92870-
$1,000, 000
$2,000,000
$1,000,000
Al 126344
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
© 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
Policy No. CPS7588317
jjk SCOTTSDALE INSURANCE COMPANY°
CHANGE ENDORSEMENT NO. 2
Effective Date 10 / 0 5/ 2 0 2 2
Named Insured ANEEN CONSTRUCTION INC
Agent No. 04040
12:01 A.M. Standard Time
COVERAGE PART INFORMATION—Coverage parts affected by this change as indicated by ® below:
❑ Commercial Property
❑ Commercial General Liability
❑ Commercial Crime
❑ Commercial Inland Marine
❑ Commercial Liquor Liability
❑ OCP Liability
CHANGE DESCRIPTION
0.00 In consideration of no change in premium, it is hereby understood and agreed that the following amendments have been made to this policy.
1. One (1) Additional Insured is added to the policy per form CG2010 12/19 attached.
2. One (1) Blanket Additional Insured is added to the policy per form GLS -150s 07/06 attached.
PREMIUM CHANGE
Additional $ 0. 00 Return $ 0.00
/
AUTHORIZED REPRESENTATIVE DATE
UTS-244L 06-92
kSCOTTSDALE INSURANCE COMPANY°
SCHEDULE OF FORMS AND ENDORSEMENTS
Policy No. CPS7588317
Named Insured ANEEN CONSTRUCTION INC
Effective Date 10/05/2022
12:01 A.M. Standard Time
Agent No. 04040
COMMON POLICY
UTS-244L 06-92 CHANGE ENDORSEMENT FORM
UTS-SP-2 12-95 SCHEDULE OF FORMS AND ENDORSEMENTS
COMMERCIAL LIABILITY
GLS -104L 06-92 SCHEDULE OF GENERAL LIABILITY CHANGES
GLS -150s 07-06 BLANKET ADDITIONAL INSURED ENDORSEMENT
CG 20 10 12-19 ADDITIONAL INSURED -OWNERS, LESSEES OR
CONTRACTORS -SCHEDULED PERSON OR ORGANIZATION
UTS-SP-2 (12-95)
Policy No.:
Named Insured:
SCOTTSDALE INSURANCE COMPANY°
SCHEDULE OF GENERAL LIABILITY CHANGES
CPS7588317 Effective Date: 10/05/2022
12:01 A.M., Standard Time
ANEEN CONSTRUCTION INC AgentNo.: 04040
CLASS CODE INFORMATION AFFECTED BY THIS CHANGE IS ADDED, DELETED OR CHANGED AS INDICATED.
THE FOLLOWING CLASS CODE INFORMATION IS: ADDED
Code No. Premium Basis
49950 INCLUDED Premises/Operations
Premises Exposure
1 Classification:
ADDITIONAL INSURED - OWNER, LESSEE OR CONTRACTOR - SCHEDULED PERSON OR ORGANIZATION PER FORM CG 20 10
THE FOLLOWING CLASS CODE INFORMATION IS: ADDED
Code No. Premium Basis
49950 INCLUDED
Premises
Classification:
Exposure
1 Rate Premium
INCLUDED INCLUDED
Products/Completed Operations
Rate Premium
Premises/Operations
Rate Premium
INCLUDED INCLUDED
BLANKET ADDITIONAL INSURED ENDORSEMENT PER FORM GLS (HI) 150S Products/Completed Operations THE FOLLOWING CLASS CODE INFORMATION IS:
Code No. Premium Basis
Premises Exposure
Classification:
THE FOLLOWING CLASS CODE INFORMATION IS:
Code No. Premium Basis
Premises Exposure
Classification:
GLS -104L (6-92)
Rate Premium
Premises/Operations
Rate Premium
Products/Completed Operations
Rate Premium
Premises/Operations
Rate Premium
Products/Completed Operations
Rate Premium
ENDORSEMENT
k SCOTTSDALE INSURANCE COMPANY® NO.
ATTACHED TO AND
FORMING A PART OF
POLICY NUMBER
ENDORSEMENT EFFECTIVE DATE
(12:01 A.M. STANDARD TIME)
NAMED INSURED AGENT NO.
CPS7588317 10/05/2022 ANEEN CONSTRUCTION INC 04040
COMMERCIAL GENERAL LIABILITY
CG 20 01 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY AND NONCONTRIBUTORY -
OTHER INSURANCE CONDITION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
The following is added to the Other Insurance
Condition and supersedes any provision to the
contrary:
Primary And Noncontributory Insurance
This insurance is primary to and will not seek
contribution from any other insurance available
to an additional insured under your policy
provided that:
(1) The additional insured is a Named Insured
under such other insurance; and
CG 20 01 04 13
(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.
© Insurance Services Office, Inc., 2012 Page 1 of 1
POLICY NUMBER: CPS7588317 COMMERCIAL GENERAL LIABILITY
CG 20 10 12 19
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 Orpanization(s)
City of Placentia
401 E . Chapman Ave .
Placentia CA 92870
Location(s) Of Covered Operations
PER CONTRACT AND/OR AGREEMENT
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 12 19
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., 2018 Page 1 of 2
C. With respect to the insurance afforded to these 2. Available under the applicable limits of additional insureds, the following is added to insurance; Section III — Limits Of Insurance: whichever is less.
This endorsement shall not increase the applicable
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
© Insurance Services Office, Inc., 2018 CG 20 10 12 19
ACCORD�
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
01/31/2023
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 endorsement(s).
PRODUCER
BIBERK
P.O. Box 113247
Stamford, CT 06911
INSURED
Aneen Construction, inc.
9860 indiana ave 18
Riverside, CA 92503
COVERAGES
CONTACT
NAME:
IPHONE 844-472-0967
(A/C. No. Extl:
I E-MAIL ADDRESS: [email protected]
FAX 203-654-3613
(A/C, No):
INSURER(S) AFFORDING COVERAGE
INSURERA: Berkshire Hathaway Direct Insurance Company
INSURER B :
INSURER C:
INSURER D :
INSURER E :
INSURER F :
CERTIFICATE NUMBER: REVISION NUMBER:
NAIC #
10391
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.
INSR
LTR
TYPE OF INSURANCE
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE
OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO LOC
JECT
OTHER:
AUTOMOBILE LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
UMBRELLA LIAB
EXCESS LIAB
DED RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS LIABILITY
ANYPROPRI ETOR/PARTNER/EXECUTI V E
A OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
OCCUR
CLAIMS -MADE
YIN
Y
Professional Liability (Errors &
Omissions): Claims -Made
ADDL SUBR POLICY EFF POLICY EXP
INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY)
N/A N9WC562902
04/19/2022 04/19/2023
LIMITS
EACH OCCURRENCE
DAMAGE TO RENTED
PREMISES (Ea occurrence)
MED EXP (Any one person)
PERSONAL & ADV INJURY
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGG
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
PROPERTY DAMAGE
(Per accident)
EACH OCCURRENCE
AGGREGATE
PER
X I STATUTE
OTH-
ER
E.L. EACH ACCIDENT $ 1,000,000
E.L. DISEASE - EA EMPLOYEE $ 1,000,000
E.L. DISEASE - POLICY LIMIT $ 1,000,000
Per Occurrence/
Aggregate
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Exclusions:
Tamer Khalil;
CERTIFICATE HOLDER
City of Placentia
401 E.Chapman ave
Placentia, CA 92870
CANCELLATION
0 0
0 0
0 0
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
© 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
City of Placentia
401 E.Chapman ave
Placentia, CA 92870