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`�.�°"� CERTIFICATE OF LIABILITY INSURANCE
<br />DATE
<br />iINSR McII
<br />/121201YY)
<br />01/12/2015 '
<br />RTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
<br />CATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
<br />F93,ELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br />ENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />ANT; If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
<br />and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br />e holder in lie
<br />Crosby Insurance, Inc
<br />8181 E. Kaiser Blvd
<br />Anaheim H
<br />Hills, CA 92808
<br />John Sheffield
<br />CONT
<br />NAMEACT John Sheffield
<br />PHONE
<br />714-221-5255
<br />(AIC Na Extl' No No714-221-5210
<br />_
<br />DRE
<br />D
<br />ASS: ADDRESS
<br />_
<br />cusTOMERIon NPGCO-J
<br />INSURER(S) AFFORDING COVERAGE NgICd
<br />INSURERA:lronshore Special Ins Co
<br />_
<br />INSURED &GraNPG, Inc., aka: Nelson Paving
<br />Produdi g, Goldstar Asphalt cts
<br />INSURER R: General Ins Co of America
<br />INSURER C: Liberty Ins Underwriters
<br />P.O. Box 1515
<br />INSURER D:ICW Group
<br />Perris, CA 92572
<br />INSURER E : F
<br />PERSONALBApV INJURY
<br />INSURER F:
<br />--
<br />a.�rt i Irw,v I t rvunl rstrc: 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 RFFN RI'm lcFn nY PAIn cl Alnnc
<br />!LTR
<br />TYPE OF INSURANCE
<br />iINSR McII
<br />POLICY NUMBER
<br />POLICY Err
<br />F MMIDD/YYY
<br />POLICY EXP
<br />MMIODIYYYY
<br />LIMITS
<br />A
<br />G ENERAL LIABILITY
<br />X COMMERCIAL GENERAL LIABILITY
<br />II
<br />!CLAIMS -MAGE J. jOCCUR
<br />—,,
<br />I
<br />IAGS0058702
<br />11/15/2015111/15/2016
<br />!EACH OCCURRENCE
<br />5 1,000,000
<br />RNTED
<br />DAMAGE T%.E
<br />PREMISES occurrence
<br />$ 50,000
<br />MED EXP (Any one person)
<br />$ $,OOO
<br />PERSONALBApV INJURY
<br />S 1,000,000
<br />--
<br />GENERAL AGGREGATE
<br />s 2,000,00
<br />- ..
<br />GEML AGGREGATE LIMIT APPLIES PER:
<br />Ra- LOU
<br />POLICV R PIFC
<br />AUTOMOBILE LIABILITY
<br />I x I ANY AUTO
<br />ALL OWNED Autos
<br />_ SCHEDULED AUTOS
<br />X HIRED AUTOS
<br />NON -OWNED AUTOS
<br />;_X Hired Phys Darn
<br />UMBRELLA LIAR L� OCCUR
<br />X EXCESS LIAR
<br />_X CLAIMS -MADE!
<br />—I
<br />B(Ea
<br />I
<br />.,
<br />I
<br />I
<br />j
<br />I 1
<br />1100002437206
<br />24 -CC -206754-9
<br />(INCL PHYSICAL DAMAGE
<br />$50,000 MAXIMUM LIMIT
<br />F 11/15/2015.
<br />F
<br />I
<br />N115/2015
<br />I
<br />11/15/2016
<br />I
<br />11/1512016.
<br />LPRODUCTs- COMP/OP AGO
<br />$ 2,000,000
<br />I COMBINED SINGLE LIMIT
<br />accident)
<br />$
<br />$ 1,000,000
<br />I BODILY INJURY(P., person)
<br />_
<br />3
<br />BO0I LYINUURY(Par accideni)I
<br />I
<br />$
<br />PROPERTYDAMAGE
<br />(PER ACCIDENT)
<br />3
<br />Comprehensive
<br />15 $1,000 de
<br />FCollision
<br />EACH OCCURRENCE
<br />-
<br />$ $1,000 de
<br />$ 5,000,00
<br />AGGREGATE
<br />$ 5,000,000
<br />__.
<br />I
<br />FDEDUCTIBLE
<br />RETENTION
<br />5
<br />(EQUIPMENT
<br />iFROM
<br />WORKERS PLOYERCOMPENSATION I
<br />YIN I
<br />AND ROPRIEERS'LIRTNEFY
<br />ANY PROPRIETORI EXCLUDED'
<br />O Mandatory in km EXCLUDED? ❑ ,NIA
<br />(MantlatoryinNH) I
<br />If yes, describe under
<br />DESCRIPTION OFOPERATIONS below
<br />RENTED
<br />OTHERS
<br />I
<br />WVE5028828 01
<br />24 -CC -103652-1
<br />01(01/2016101/01/201]IF
<br />11/15/201511
<br />I—
<br />FEL
<br />it 15120161
<br />IDed
<br />X I WCSTATU- 0TH-'
<br />TQ YLIMITG. ER
<br />EACH ACCIDENT
<br />_EL DISEASE - Eq EMPLOYEE
<br />_
<br />$ 1,000,00
<br />$ 1,000,00
<br />_
<br />DISEASE -POLICY LIMIT 3 1,000,000
<br />Limit 500,000
<br />1,000
<br />ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required)
<br />If cancelled for non-payment of premium only 10 days notice will be given,
<br />reyqired by written contract, Additional Insured (General and Auto
<br />lability) Primary and Non -Contributing (General Liability) and Waiver of
<br />ubro aiion (General and Auto Liability and Workers Compensation) can apply.
<br />ew t',�o nstruction exclusion apply. Excess Policyfollows Orm.
<br />CERTIFICATE HOLDER CANCELLATION
<br />FORINFO
<br />For Information Purposes Only
<br />-specific certificates can be
<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 />Issued upon request-
<br />AUTHORIZED REPRESENTATIVE
<br />J.%
<br />C0 1988-2009 ACORD CORPORATION. All rights reserved.
<br />CORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
<br />
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