ACORD®
CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDD/YYYY)
01/26/2023
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 CONTACT Corey Martinez
NAME:
Altamont Insurance Brokers, Inc. PHONE (209) 835-6395
A/C No. Extl:
4598 S. Tracy Blvd Ste. 120 I -MAIL [email protected] ADDRESS:
Tracy CA 95377
INSURED
Global Builders Inc.
1740 E Garry Ave Suite 205
Santa Ana CA 92705
FAx No): (209) 835-7395
INC.
INSURER(S) AFFORDING COVERAGE NAIC #
INSURERA: Evanston Insurance Company 35378
INSURER B : State Compensation Insurance Fund 35076
INSURER C :
INSURER D :
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: Certs 22-23 REVISION NUMBER: 1
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 SUER POLICY EFF POLICY EXP
TYPE OF INSURANCE
LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY
A
CLAIMS -MADE
X
OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
X
POLICY
PRO-
JECT
OTHER:
AUTOMOBILE LIABILITY
ANY AUTO
OWNED
AUTOS ONLY
HIRED
AUTOS ONLY
UMBRELLA LIAB
EXCESS LIAB
DED 1 1 RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
B OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
LOC
SCHEDULED
AUTOS
NON -OWNED
AUTOS ONLY
OCCUR
CLAIMS -MADE
YIN
Y
Y Y 3AA622906 12/01/2022 12/01/2023
N/A 9241232-2022
11/08/2022 11/08/2023
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
XIPER
STATUTE I I ERH
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) **City of Placentia is shown as additional insured, but only with respect to the General Liability arising out of operations performed by the named insured"Additional Insured Endorsement form ( MEGL 0009-01 09 18 ) attached.*General Liability Waiver of Subrogation form ( MEGL 0241-01 05 16) attached. *Primary Wording Endorsement Form ( CG 20 01 04 13 ) attached. * Job ref: Santa Fe Avenue Outdoor Dining Platform Project PW 22-06
CERTIFICATE HOLDER
City of Placentia
401 E. Chapman
Placentia
CA 92870
CANCELLATION
1,000,000
100,000
5,000
1,000,000
2,000,000
2,000,000
1,000,000
1,000,000
1,000,000
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
COMMERCIAL GENERAL LIABILITY
POLICY NUMBER: 3AA622906
MARKEL® EVANSTON INSURANCE COMPANY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
LIQUOR LIABILITY COVERAGE FORM
OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE FORM
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE FORM
SCHEDULE
Additional Premium: $Included (Check box if fully earned ®) Please refer to each Coverage Form to determine which terms are defined. Words shown in quotations on this endorsement may or may not be defined in all Coverage Forms.
A. Who Is An Insured is amended to include as an additional insured any person or entity to whom you are required by valid written contract or agreement to provide such coverage, but only with respect to "bodily injury", "property damage" (including "bodily injury" and "property damage" included in the "products -completed operations hazard"), and "personal and advertising injury" caused, in whole or in part, by the negligent acts or omissions of the Named Insured and only with respect to any coverage not otherwise excluded in the policy.
However:
1. The insurance afforded to such additional insured only applies to the extent permitted by law; and
2. The insurance afforded to such additional insured will not be broader than that which you are required by the valid written contract or agreement to provide for such additional insured.
Our agreement to accept an additional insured provision in a valid written contract or agreement is not an acceptance of any other provisions of such contract or agreement or the contract or agreement in total.
When coverage does not apply for the Named Insured, no coverage or defense will apply for the additional insured.
No coverage applies to such additional insured for injury or damage of any type to any "employee" of the Named Insured or to any obligation of the additional insured to indemnify another because of damages arising out of such injury or damage.
B. With respect to the insurance afforded to these additional insured, the following is added to limits of insurance:
The most we will pay on behalf of the additional insured is the amount of insurance:
1. Required by the valid written contract or agreement; or
2. 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.
All other terms and conditions remain unchanged.
MEGL 0009-01 09 18
Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1 with its permission.
POLICY NUMBER : 3AA622906
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
ill
COMMERCIAL GENERAL LIABILITY
POLICY NUMBER: 3AA622906
EVANSTON INSURANCE COMPANY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
SCHEDULE
Name Of Person Or Organization:
Any person(s) or organization(s) with whom the Named Insured agrees, in a written contract executed prior to the 'occurrence", to waive rights of recovery Additional Premium: $ Included
The following is added to Condition 8. Transfer Of Rights Of Recovery Against Others To Us under Section IV — Commercial General Liability Conditions:
We waive any right of recovery we may have against any person or organization shown in the Schedule of this endorsement. This waiver applies only to the person or organization shown in the Schedule of this endorsement.
All other terms and conditions remain unchanged.
MEGL 0241-01 05 16
Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1 with its permission.
ill
MARKEL
COMMERCIAL GENERAL LIABILITY
POLICY NUMBER: 3AA622906
EVANSTON INSURANCE COMPANY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
SCHEDULE
Maximum Annual Limit Of Insurance: $5,000,000
The following changes are subject to the Maximum Annual Limit Of Insurance shown in the Schedule of this endorsement.
In no event will we be liable for damages in excess of the Maximum Annual Limit Of Insurance shown in the Schedule of this endorsement.
A. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under Section — Coverage A, and for all medical expenses caused by accidents under Section I — Coverage C, which can be attributed only to ongoing operations at a single designated construction project:
1. A separate Construction Project General Aggregate Limit applies to each construction project, and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations.
2. The Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A, except damages because of "bodily injury" or "property damage" included in the "products - completed operations hazard", and for medical expenses under Coverage C regardless of the number of:
a. Insureds;
b. Claims made or "suits" brought; or
c. Persons or organizations making claims or bringing "suits".
3. Any payments made under Coverage A for damages or under Coverage C for medical expenses will reduce the Construction Project General Aggregate Limit for that construction project and the Maximum Annual Limit Of Insurance shown in the Schedule of this endorsement. Such payments will not reduce the General Aggregate Limit shown in the Declarations nor will they reduce any other Construction Project General Aggregate Limit for any other construction project.
4. The limits shown in the Declarations for Each Occurrence, Damage To Premises Rented To You and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Construction Project General Aggregate Limit.
B. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under Section — Coverage A, and for all medical expenses caused by accidents under Section I — Coverage C, which cannot be attributed only to ongoing operations at a single construction project:
1. Any payments made under Coverage A for damages or under Coverage C for medical expenses will reduce the amount available under the General Aggregate Limit or the Products -Completed Operations Aggregate Limit, whichever is applicable, and the Maximum Annual Limit Of Insurance shown in the Schedule of this endorsement; and
2. Such payments will not reduce any Construction Project General Aggregate Limit.
MEGL 0313 02 17
Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 2 with its permission.
C. When coverage for liability arising out of the "products -completed operations hazard" is provided, any payments for damages because of "bodily injury" or "property damage" included in the "products -completed operations hazard" will reduce the Products -Completed Operations Aggregate Limit and Maximum Annual Limit Of Insurance shown in the Schedule of this endorsement, but not reduce the General Aggregate Limit nor the Construction Project General Aggregate Limit.
D. If the applicable construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contracting parties deviate from plans, blueprints, designs, specifications or timetables, the project will still be deemed to be the same construction project.
E. The provisions of Section 111 — Limits Of Insurance not otherwise modified by this endorsement will continue to apply as stipulated.
All other terms and conditions remain unchanged.
MEGL 0313 02 17
Includes copyrighted material of Insurance Services Office, Inc., Page 2 of 2 with its permission.
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 If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an en this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER I CONTACT Trish Bowe
StateFarm NAME:
NAME:
310-454-0349
(A/C, No. Ext):
E-MAILL
_ApDRESS: owe.Y@
trish.bb8c statefarm.com
INSURER(S) AFFORDING COVERAGE
INSURER A : State Farm Mutual Automobile Insuran
INSURER B :
1 INSURER C :
1 INSURER D :
IINSURER E :
I INSURER F :
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 ADD SUB POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
INSURED
Trish Bowe, CPCU, ChFC Agent
State Farm Insurance
860 via de la Paz D-1
Pacific Palisades, Ca 90272
Timory, Walid A. & Global Builders, Inc.
1740 E. Garry Avenue, Suite 205
Santa Ana, Ca 92705
provisions or be endorsed.
dorsement. A statement on
FAX
(A/C, No): 310-475-1237
ce Company
NAIC #
25178
A
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE
OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
PRO -
POLICY JECT LOC
OTHER:
AUTOMOBILE LIABILITY
X ANY AUTO
OWNED
AUTOS ONLY
HIRED
AUTOS ONLY
UMBRELLA LIAB
EXCESS LIAB
DED
■
SCHEDULED
AUTOS
NON -OWNED
AUTOS ONLY
RETENTION
OCCUR
CLAIMS -MADE
WO 2KERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
Y/N
Y Y
N/A
697 -2760 -D25 -75A 10/25/2022 04/25/2023
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
E.L
E.L
E.L
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Business Auto 2017 Toyota Tacoma Pickup
Project: SANTA FE AVENUE OUTDOOR DINING PLATFORM PROJECT
CERTIFICATE HOLDER CANCELLATION
City of Placentia
401 E. Chapman Ave..
Placentia, California 92870
PER OTH-
STATUTE ER
EACH ACCIDENT
DISEASE - EA EMPLOYEE
DISEASE - POLICY LIMIT
1,000,000
1,000,000
1,000,000
1,000,000
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
Completed by an authorized State Farm representative. If signature is required, please contact a State Farm agent.
© 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849.14 04-13-2022