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ac®R& CERTIFICATE OF LIABILITY INSURANCE
<br />Og
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />10/1
<br />10/11//201177
<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(les) must have ADDITIONAL INSURED provisions or be endorsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br />PRODUCER
<br />CONTACT
<br />NAME:PHONE_ _ Gabriel Hill -
<br />Insurance & Surety Services, LLC
<br />FAX
<br />4195 Chino Hills Parkway #403
<br />(AIg No E.1, (909) 203-7979 ! (AIC Nol:_(909) 614-7387
<br />--
<br />Lic 0167797
<br />E-MAIL -_-
<br />ADDRESS: gabriel®isscllc.com
<br />Chino Hills CA 91709
<br />X Owners & Contr.Prot. _
<br />INSURER(S) AFFORDING COVERAGE NAIL#
<br />INSURERA: United Specialty Insurance Com 12537_
<br />_
<br />INSURED (909) 591-4095
<br />- _-_
<br />INSURERS west American Insurance Compan
<br />---- _
<br />94393
<br />Foddrill Construction Corporation
<br />GENERAL AGGREGATE $ 2,000,000
<br />hEN'L AGGREGATE LIMIT APPLIES PER:
<br />INSURERC:Benchm%rk InsuranceCompany
<br />41394
<br />P.O. Box 826
<br />_ _
<br />INSURER D:
<br />. ''.
<br />INSURER E:
<br />Chino CA 91708
<br />INSURER F:
<br />OTHER.
<br />COVERAGES CERTIFICATE NUMBER: cert ID 119 REVISION NUMRFR-
<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 />EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />INSR --- ADOLSUBR -
<br />LTR TYPE OF INSURANCE D'PA/D POLICY NUMBER MM/�OY� MMFODM/YY LIMITS
<br />A X', COMMERCIAL GENERAL LIABILITY
<br />20 Civic Center Plaza M-30
<br />AUTHORIZED REPRESENTATIVE
<br />Santa Ana CA 92701
<br />EACH OCCURRENCE, $ 1,000,000
<br />_
<br />CLAIMS -MADE �' OCCUR
<br />Y Y ATN-SF1720121
<br />01/01/2017
<br />01/01/2018
<br />PREMISES (Eaoccurrence1 - $ 50,000
<br />X Owners & Contr.Prot. _
<br />M ED EXP (Any one person)._$ 5,000
<br />_
<br />PERSONAL&ADV INJURY $ 1,000,000_
<br />GENERAL AGGREGATE $ 2,000,000
<br />hEN'L AGGREGATE LIMIT APPLIES PER:
<br />_ PRO-
<br />POLICY! JECT PRO- `..JLOG
<br />. ''.
<br />_
<br />PRODUCTS -COMP/OPAGG'$ 2,000,000
<br />---._.-_
<br />Empl Benefits Liab!$ 11000,000
<br />OTHER.
<br />AUTOMOBILE
<br />_
<br />LIABILITY
<br />1
<br />COMBINED SINGLE LIMIT
<br />(Ea accident) '$ 1,000,_000
<br />B
<br />X
<br />ANY AUTO
<br />'', BAw57472619
<br />08/05/2017
<br />01/01/2018
<br />BODILY INJURY (Per person) j $
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />I
<br />) $ BODILY INJURY Per accldenl
<br />HIRED NON -OWNED
<br />'',
<br />_
<br />FPROPERTY DAMAGE -
<br />$
<br />AUTOS ONLY _ AUTOS ONLY
<br />Per acc!d.
<br />_
<br />$
<br />1101/01/2017
<br />A
<br />UMBRELLAB
<br />X
<br />y
<br />Y
<br />BTN1723692
<br />01/01/2018
<br />EACHOCCURRENCE $ 3,000,000
<br />X_
<br />LIAS
<br />OCCUR MADE
<br />AGGREGATEj$
<br />_
<br />_3_,000,000
<br />DED I X I RETENTION$ 10,0001
<br />1 I$
<br />WORKERS COMPENSATIONPER
<br />'.Ol/Ol/2017
<br />X OTH-
<br />C
<br />AND EMPLOYERS' LIABILITY YIN
<br />Y
<br />CST5009382
<br />Ol/Ol/201 B'
<br />STATUTE ER_:
<br />ANYPROPRIETOR/PARTNER/EXECUTIVEE.L
<br />EACH ACCIDENT $ 1,000,000
<br />OFFICER/MEMBEREXCLUDED7 �
<br />NIA
<br />-- --
<br />, EL.DISEASE EA EMPLOYEE .$ 1,000,000
<br />- -
<br />(MandatorylnNH)
<br />If yes, describe under
<br />DESCRIPTIONOFOPERATIONS below
<br />I
<br />!
<br />E. L. DISEASE POLICY LIMIT $ 1,000,000
<br />�I'II$
<br />$
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
<br />Certificate holder is additional insured per attached CG 2010 04/13 and CG 2037 07/04semen s.
<br />Primary wording applies per attached USIC VEN 10402 11/07 endorsement. waiver of-p� do �
<br />applies per attached CG 2404 10/93 and WC 040306 04/84 endorsements.
<br />gas
<br />0�lc�
<br />CERTIFICATE HOLDER CANCELLATION
<br />©1988-2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />Page 1 of 3
<br />aE
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />City of Santa Ana
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />20 Civic Center Plaza M-30
<br />AUTHORIZED REPRESENTATIVE
<br />Santa Ana CA 92701
<br />--
<br />©1988-2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />Page 1 of 3
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