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CERTIFICATE OF INSURANCE <br />CHECKLIST <br />City of Newport Beach <br />This checklist Is comprised of requirements as outlined by the City of Newport Beach.' <br />Date Received; 1129/15 Dept. /Contact Received From: Terresa <br />Date Completed: 1/29/15 Sent to; Teresa By: Chris <br />Company /Person required to have certificate: GRC Associates Iuc <br />Type of contract: All Others <br />GENERAL LIABILITY <br />PRIMARY & NON - CONTRIBUTORY WORDING (Must be <br />EFFECTIVE /EXPIRATION DATE: 12/1/14- 12/1/15 <br />A. <br />INSURANCE COMPANY: Travelers Property$ Casualty Insurance Company <br />B. <br />AM BEST RATING (A-: VII or greater): A+:XV <br />C. <br />ADMITTED Company (Must be California Admitted): <br />W <br />Is Company admitted In California? <br />® Yes ❑ No <br />D. <br />LIMITS (Must be $1 M or greater): What is limit provided? <br />1,000,000/2,000,000 <br />E. <br />ADDITIONAL INSURED ENDORSEMENT— please attach <br />® Yes ❑ No <br />F. <br />PRODUCTS AND COMPLETED OPERATIONS (Must <br />EFFECTIVE /EXPIRATION DATE: 12/1/14- 12/1/15 <br />Include); Is It included? (completed Operations statue does <br />A. <br />INSURANCE COMPANY: RLIlnsurance Company <br />not apply to Waste Haulers or Recreation) <br />Z Yes ❑ No <br />G. <br />ADDITIONAL INSURED FOR PRODUCTS AND <br />C. <br />ADMITTED COMPANY (Must be California Admitted): <br />COMPLETED OPERATIONS ENDORSEMENT (completed <br />Is Company admitted In California? <br />Operations status does not apply to Waste Haulers) <br />® Yes ❑ No <br />H. <br />ADDITIONAL INSURED WORDING TO INCLUDE (The City <br />UM, $2M min for Waste Haulers); What is limits provided? <br />its officers, officials, employees and volunteers): Is it <br />E. <br />LIMITS Waiver of Auto Insurance / Proof of coverage (if individual) <br />included? <br />9 Yes ❑ No <br />I. <br />PRIMARY & NON - CONTRIBUTORY WORDING (Must be <br />Included): Is it Included? <br />0 Yes ❑ No <br />J. <br />CAUTION! (Confirm that loss or liability of the named insured <br />is not limited solely by their negligence) Does endorsement <br />Include "solely by negligence" wording? <br />❑ Yes Z No <br />K. <br />ELECTED SCMAF COVERAGE (RECREATION ONLY): <br />NIA ❑ Yes ❑ No <br />L. <br />NOTICE OF CANCELLATION: <br />❑ NIA ® Yes ❑ No <br />II. AUTOMOBILE <br />LIABILITY <br />EFFECTIVE /EXPIRATION DATE: 12/1/14- 12/1/15 <br />A. <br />INSURANCE COMPANY: RLIlnsurance Company <br />B. <br />AM BEST RATING (A- : VII orgreater) A++:XV <br />C. <br />ADMITTED COMPANY (Must be California Admitted): <br />Is Company admitted In California? <br />ZZI Yes ❑ No <br />D, <br />LIMITS - If Employees (Must be $1M min. BI & PO and $500,000 <br />UM, $2M min for Waste Haulers); What is limits provided? <br />1,0001000 <br />E. <br />LIMITS Waiver of Auto Insurance / Proof of coverage (if individual) <br />(What is limits provided ?) <br />NIA <br />F. <br />PRIMARY & NON - CONTRIBUTORY WORDING (For Waste <br />Haulers only): <br />Z N/A ❑ Yes ❑ No <br />G. <br />HIRED AND NON -OWNED AUTO ONLY: <br />❑ NIA 0 Yes ❑ No <br />H. <br />NOTICE OF CANCELLATION: <br />❑ N/A ® Yes ❑ No <br />25B -40 <br />