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LDAND -1 OP ID: BP <br />,4coRL7° CERTIFICATE OF LIABILITY INSURANCE <br />1�..► -'' <br />003106/2017 ) <br />0 3/0 612 01 7 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to <br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br />certificate holder in lieu of such endorsement(s). <br />PRODUCER <br />Supple- Merrill & Driscoll Inc. <br />Insurance Agents and Brokers <br />25$ W Foothill Blvd, Ste 102 <br />Upland, CA 91786 <br />James A. Dilks <br />CONTACT <br />NAME: <br />PHONE FAX <br />Arc No Eat: ac No: <br />E -MAIL <br />ADDRESS: <br />INSURERS AFFORDING COVERAGE <br />NAIC# <br />INSURER A: Gemini Insurance Co. <br />10833 <br />INSURED L.D. Anderson IDC. <br />INSURER B: Insurance Company of the West <br />$ 1,000,00 <br />2750 S. Lilac Avenue <br />Bloomington, CA 92316 -3214 <br />INSURERC: RSUI Indemnity Company <br />X <br />INSURER O: Westchester Sur Lines Ins. Co. <br />10172 <br />INSURERS: Ohio Casualty Insurance Co. <br />24074 <br />DAMAGE TO RENTED <br />PREMISES Ea occurrence <br />INSURER F: Ohio Security Ins. Co. <br />24062 <br />CLAIMS -MADE "OCCUR <br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />_EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INSR <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />J= <br />UB <br />wvB <br />POLICYNUMBER <br />MMIUOYEFF <br />POLICY <br />LIMITS <br />GENERAL LIABILITY <br />EACH OCCURRENCE <br />$ 1,000,00 <br />A <br />X COMMERCIAL GENERAL LIABILITY <br />X <br />VOGPOO1730 <br />10/01/2016 <br />10/01/2017 <br />DAMAGE TO RENTED <br />PREMISES Ea occurrence <br />$ 50,00 <br />CLAIMS -MADE "OCCUR <br />MED EXP (Any one person) <br />$ 6,00 <br />PERSONAL B ADV INJURY <br />$ 1,000,00 <br />$10,000 Ded EM <br />$5,000 Ded AOP <br />GENERAL AGGREGATE <br />$ 2,000,00 <br />C�Iw. <br />GENT AGGREGATE LIMIT APPLIES PER <br />PRODUCTS - COMPIOPAGG <br />$ 2,000,00 <br />PPROVEP <br />$ <br />JECT —1 POLICY X PRO- LOC <br />T <br />AUTOMOBILE LIABILITY <br />COMBINED SINGLE LIMIT <br />Ea accident) <br />$ 1,000.00 <br />BODILY INJURY (Per Person) <br />$ <br />E <br />X ANY AUTO <br />X <br />BA057363826 <br />10/01/2016 <br />10/0112017 <br />BODILY INJURY (Per accident) <br />$ <br />ALLOWNED SCHEDULED <br />AUTOS <br />PROPERTY DAMAGE <br />PERACCIDEN <br />$ <br />NON -OWNED <br />HIRED AUTOS AUTOS <br />$ <br />X $500 Ded. <br />UMBRELLA LIAB <br />X <br />OCCUR <br />EACH OCCURRENCE <br />$ 8,000,00 <br />X <br />AGGREGATE <br />$ 8,000,00 <br />EXCESS LIAB <br />CLAIMS -MADE <br />NHA241004 <br />10/01/2016 <br />10/01/2017 <br />DED RETENTION$ <br />S <br />I <br />B <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />ANY PROPRIETOR! PARTNER /EXECUTIVE YIN <br />OFFICERIMEMBER EXCLUDED? <br />(Mandatory in Hill <br />NIA <br />WVE 5006856 -05 <br />10/01/2016 <br />10/01/2017 <br />X WCSTATU- OTH- <br />TORY LIMITS ER <br />E.L. EACH ACCIDENT <br />$ 1,000,000 <br />E.L. DISEASE - EA EMPLOYEE <br />$ 1,000,000 <br />I E.L. DISEASE - POLICY LIMIT <br />$ 1,000,000 <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />F <br />Equipment Floater <br />BKS 56164595 <br />10/01/2016 <br />10/01/2017 <br />Total Sch 2,474,517 <br />D <br />Pollution <br />G27508339003 <br />10/01/2016 <br />1010112017 <br />OCCIGA lmil /2mil <br />DEWMP71ON OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is retained) <br />The City of Riverside is named as additional insured as respects the <br />insured's operations. Endorsements CG 20 10 04 13 6 CA 88 10 01 13 attached <br />and applies. <br />*30 days notice of cancellation applies. <br />COFRIVE <br />City of Riverside <br />Public Works Department <br />3900 Main Street <br />Riverside, CA 92522 <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />U 1988 -ZU1U AcOKD cUKYUHA I ION. All rights reservea. <br />ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD <br />