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HomeMy WebLinkAboutCOI_ MD Rubberized Crackfill_4.16.25SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 4/16/2025 Burnham Risk &Insurance Solutions 15901 Red Hill Ave,Ste 100 Tustin CA 92780 Brenda Juarez 714-505-7000 714-573-1770 brenda.juarez@baldwin.com License#:0F69771 Great American Excess &Surplu 37532 HARD&HA-02 Partner Reinsurance Company of 38636MDRubberizedCrackfill,LLC 32 Rancho Circle Lake Forest CA 92630 BITCO General Insurance Corpor 20095 Markel American Insurance Comp 28932 2001350726 B X 1,000,000 X 250,000 10,000 1,000,000 2,000,000 X Y Y VCP2025091-01 4/15/2025 4/15/2026 2,000,000 Contractor Pollution 1,000,000 C 1,000,000 X X X Y Y CAP 3756973 4/15/2025 4/15/2026 D X 5,000,000 X MKLV5EUL106108 4/15/2025 4/15/2026 5,000,000 C X Y Y WC 3756975 4/15/2025 4/15/2026 1,000,000 1,000,000 1,000,000 A Professional Liability Pollution Liability PCM E502853 05 4/15/2025 4/15/2026 Each Occurance Annual Aggregate 1,000,000 2,000,000 General Liability Additional Insured,Primary and Noncontributory,and Waiver of Subrogation applies per attached endorsements.General Liability Aggregate limit per project applies per attached endorsements.Auto Liability Additional Insured,Primary and Noncontributory,and Waiver of Subrogation applies per attached endorsements.Work Comp Waiver of Subrogation applies per endorsement WC040306.30 day Notice of cancellation applies per attached endorsements. RE:W.O.#H15088;Apple Valley,CA,Hot applied crack sealing at maintenance sites on various County roads in the Town of Apple Valley.glaipwv/auaiwv San Bernardino County and its officers,employees,agents and volunteers are included as Additional Insureds as respects General Liability and Auto Liability per attached endorsements.This insurance shall apply as Primary and Non-Contributory per attached endorsement.Waiver of Subrogation for General Liability and Auto Liability:See Attached Endorsements. San Bernardino County Department of Public Works 825 East Third Street,Room 120 San Bernardino CA 924150835