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A CQRQ0
<br />CC CERTIFICATE OF LIABILITY INSURANCE
<br />DATE (MM/DDIYYYY)
<br />6/8/2016
<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 />Alliant Insurance Services, Inc.
<br />333 Earle Ovington Blvd.
<br />Suite 700
<br />CONTNAME: Forward All Certificate Revision Requests to
<br />PHONE FAX
<br />oU. the Below E -Mail
<br />wiz AIL. NorthStarGroupServices@alliant.com
<br />INSURER(S) AFFORDING COVERAGE NAIC #
<br />Uniondale NY 11553
<br />INSURER A: National Union Fire Ins Co Pittsbur 19445
<br />GL 5388321 (AOS)
<br />GL 5388322 (NY)
<br />INSURED
<br />INSURERB:AMERICAN GUAR & LIAB INS 26247
<br />NorthStar Demolition and Remediation, LP
<br />wsURERC:NEW HAMPSHIRE INS CO 23841
<br />404 North Berry Street
<br />Brea, CA 92821-3104
<br />INSURER AMERICAN INS CO 16535
<br />— —
<br />INSURERE:AGCS Marine Insurance Company 22837
<br />INSURER F
<br />COVERAGES CERTIFICATE NUMBER- 1982657791
<br />RFVI!SION NIIMRFR-
<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 />ADDLISUBIR
<br />INSD
<br />WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MM/DDIYYYY
<br />POLICY EXP
<br />MM/DD/YYYY
<br />LIMITS
<br />A
<br />A
<br />X '.,, COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE ❑X OCCUR
<br />Y
<br />Y
<br />GL 5388321 (AOS)
<br />GL 5388322 (NY)
<br />7/1/2016
<br />7/1/2016
<br />17/1/2017
<br />7/1/2017
<br />EACH OCCURRENCE $2,000,000
<br />DAMAGE TO RENTED —
<br />PREMISES Ea occurrence $300,000
<br />MED EXP (Any one person) $25,000
<br />X Contractual Llab
<br />PERSONAL & ADV INJURY $2,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE $4,000,000
<br />j
<br />POLICY [_X] PE O IF^—]I LOC
<br />j OTHER:
<br />_
<br />PRODUCTS - COMP/OP AGG $4,000,000
<br />--� $
<br />A
<br />A
<br />AUTOMOBILE LIABILITY
<br />X 'i ANY AUTO
<br />Y
<br />Y
<br />CA 5101686
<br />CA 5101687 (MA)
<br />7/1/2016
<br />7/1/2016
<br />j 711(2017
<br />7/112017
<br />(
<br />N NGLI $
<br />(EaO accident 2 OOD 000
<br />BODILY INJURY (Per person) $
<br />ALL OWNEDSCHEDULED
<br />AUTOS AUTOS
<br />NON -OWNED
<br />X '.. HIRED AUTOS X AUTOS
<br />BODILY INJURY (Per accident) ( $
<br />PERT
<br />PROPERTY DAMAGE
<br />Per PERT n) $ _
<br />�$
<br />BX
<br />A
<br />-UMBRELLA LIAB
<br />X
<br />OCCUR
<br />Y
<br />Y
<br />j SXS0195929-00
<br />4840279
<br />7/112016
<br />7/1/2016
<br />7/1/2017
<br />7/1/2017
<br />EACH OCCURRENCE $25,000,000
<br />AGGREGATE $25,000,000
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DED I RETENTION $
<br />$
<br />C
<br />C
<br />C
<br />C
<br />C
<br />C
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY Y / N
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />OFFICER/MEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />N / A
<br />y
<br />WC 034157306 AOS
<br />WC 034157307 (IL,KY,NC)
<br />WC 034157308 (NJ,PA)
<br />WC 034157309 (AZ,VA)
<br />WC 034157310 (CA)
<br />WC 034157311 (FL)
<br />7/1/2016
<br />7/1/2016
<br />7/1/2016
<br />7/1/2016
<br />7/1/2016
<br />7/1/2016
<br />7/1/2017
<br />7/1/2017
<br />7/1/2017
<br />7/1/2017
<br />7/1/2017
<br />7/1/2017
<br />PER OTH-
<br />X STATUTE ER
<br />_
<br />E.L. EACH ACCIDENT $1,000,000
<br />_ -
<br />E.L. DISEASE - EA EMPLOYEE $1,000,000
<br />E.L. DISEASE - POLICY LIMIT $1,000,000
<br />C
<br />D
<br />E
<br />Workers Compensation
<br />Poll/Prof Incl.Mold/Fungus/Asbest
<br />Leased/Rented Equipment
<br />Y
<br />y
<br />Y
<br />y
<br />WC 034157312 (MA & MONO)
<br />( PEC 019441400
<br />MX193060362
<br />7/1/2016(
<br />5/1/2016
<br />7/1/2016
<br />7/1(2017
<br />7/1/2017
<br />7/1/2017
<br />$1,000,000
<br />Ea Claim: $10,000,000 Agg: $15,000,000
<br />Limit $1,500,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />RE: On -Call Demolition Services.
<br />City of Santa Ana is included as Additional Insured on a Primary and Non -Contributory basis as respects General Liability, Automobile
<br />Liability, and Umbrella Liability as required by written contract. Waiver of Subrogation is included and applies in favor of the Additional
<br />Insured as required by written contract.
<br />f
<br />(l E VlC WC Ld H C f UNtC E HER DiA dr L r
<br />lR_KI IrJGAI t_ HULUtK UANGGLLAI IUN OU L1ay5 IVUIICe U1 t..anGelldtlOn
<br />City of Santa Ana
<br />20 Civic Center Plaza (M-30), P.O. Box 1988
<br />Santa Ana CA 92702-1988
<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 />6C__/'4W_
<br />O 1988-2014 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
<br />
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