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PROOF OF INSURANCE (2012) CLOSEDk.-- CERTIFICATE OF LIABILITY INSURANCE 6 /12� oil THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: H the certificate holder Is an ADOrrIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER "TA Fred Dean Premier One Insurance Services PHONe (949) 727 -2025 isa9l�s� -9si9 100 Pacifica Ste 480 E-"L .info9pr arone..com Irvine CA 92618 INSURED I Water, Inc. 18 Goodyear #100 POLICY NUMBER: SN953959 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY, ADDITIONAL INSURED - PRIMARY AND NONCONTRIBUTORY - AUTOMATIC STATUS WHEN REQUIRED IN CONTRACT OR AGREEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. sections II - Who Is An Insured is amended to include as an additional insured any person or organization when you and such person or organization have agreed In writing in a contract or agreenent that such person or organization be added as an additional insured on your policy, Such person or" organization is an additional insured only with respect to liability" for "bodily injury "" " "property damage" or "personal and advertising Injury,° caused, in whole or in part, by your acts or omissions, or the acts or omissions of those acting on your behalf: 4. In the performance of your ongoing operations for the additional insured; or 2. In connection with premises owned by or rented to you. But only for: 1. The limits of insurance specified in such written contract or agreement, but in no event for limits of insurance in excess of the applicable limits of insurance of this policy; and 2. "Occurrences" or coverages not otherwise excluded in the policy to which this endorsement applies. 13. Status as an additional insured for the person or organization to which this endorsement applies: 1. Commences during the policy period and after such written contractor agreement has been executed; and 2. Ends when: a. Your ongoing operations for that additional insured are completed; b. The contractor's contract or agreement is terminated; c. The lease of premises expires; or d. Your policy cancels or expires; whichever occurs first. C. The following is added to 4,a. of Other Insurance of Section IV - Corrirmerciat General Liability Conditions: If required in a written contract, your policy is primary and noncontributory in the event of an "occurrence" caused, in whole or in part, by your acts or omissions, or the acts or omissions of those acting on your behalf that occurs while performing ongoing operations for the additional insured, or in connection with premises owned by or rented to you. D. With respect to the insurance afforded to the additional insured, the following exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work on this project, including materials, parts, or equipment furnished in connection with such work (other than service, maintenance, or repairs), to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portions of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. otl1' 't rrs and conditions of this policy remain unchanged. 4 L805 (05109) Includes copyrighted material trvm Insurance Services Olce, Inc., with its permission. Commercial Certificate of Insurance Agency . Nancy Brandon Name . 31629 Outer Highway 10 Ste A & . Redlands, CA 92373-7590 Add rem . 909-794-8191 ,St. 99 Dist:. 30 Insured Agent 353 Narne I WATER INC. & 19 GOODYEAR STE# 100 Address IRVINE, CA 92618 I F A R M E R S ........ F .. . . ..... Issue Date (MMIDD /YY) 07/03/2012 This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend, extend or alter the coverage afforded by the policies shown below. Companies Providing Coverage: cf,niparty A Truck Insurance Exchange Lever company B Farmers Insurance Exchange Letter Company C Mid-Century Insurance Company Letter campany D Lefler Coverages This is to certify that the policies of insurance listed below have been issued to the insured named above for the policy period indicated. Notwithstanding any requirement, term Or condition of any contract or other document with respect to which this certificate may he issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms, exclusions and conditions of such policies. Units shown may have been reduced by naid cialins. Co. Type of Insurance Policy Number Policy Effective Date (M%41DDIYY) Policy Expintion Date (MMfFJD/YY) Policy Limits ---------- - ---- - --- General Liability --- - ------ ------ --------- General Aggregate $ Commercial General Products- Co mp/OPS Aggregate, $ Liability Personal & - Occurrence Version I Advertising Injury $ Contractual - Incidental Each Occurrence 1 $ Only Fire Damage Ary one fife () $ Owners & Contractors Prot Medical Expense (Any one person) $ C Automobile Liability 1094399020 09/04/2011 09/0412012rcm Combined Single. Limit All Owned Cositniercial $ 1,000,000 Autos Niffily In Illy Scheduled Autos (I'll lWrsai� $ K f-I I red A u i os Bodily 111jilly c Non-Owited Amos (Per 36cident) Garage Liability Property Damage - — — -- - -- ---------------------- -- Garage Aggregate $ Umbrella Liability Limit Workers' Compensation Statutory and Each Accident Disease - FAC11 EMPIUYCT� Employers' Liability Disease - Policy Limit S Description of Operations/Vehicles /Rest.. pera tions/Vehicles/ResLricliojrl,,i/Specia I Items: Vehicle(s): 1999 TOYOTA TACOMA XTR 4TAVL52N5XZ504628; 2004 TOYOTA TACOMA XTR 5TEVL52N64Z339169; 2004 CHEVROLET EXPRESS G1 I GCFG 15X441162716; 1997 WELLS CARGO 1 WC200D I 9V4029506; 2005 CHEVROLET SILVERADO 1GCEC19T85ZI71209 Frititw-erywrit - (TV, APPT WART F WIT I RF-DFI IVFzRFr) WITH POT ICYA Certificate Holder Cancellation Should any of the above described policies he cancelled before the expiration date Naine City of El Segundo thereof, the issuing company will endeavor to mail 30 days written notice to the Wastewater Supervi, to certificate holder named to the left, but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its ag Address �mts o , r representatives. Author — -- — ------ ....... ....... ..... . . - . . .......... . . --------- . ..... - ......... 4-94 Copy Dlslfibution. Service Center Copy and Agent's Copy 'Phis endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated b0ow. (ri'm followhig "All aching 0a use" llukxl bo canpWled unty when the endorserneni Is tmed wbsequent to preparafti difiep0q), This endorsement, effective 12:01 AM 02/15/2012 forms a part of Policy No. WC 001-60-6519 Issued to I WATER, INC By GRANITE STATE INSURANCE COMPANY We have a right to recover our payments from anyone liable for an injury covered by this policy.. We will riot enforce OUr right against any person or organization with whom you have a written contract that requires you to obtain this agreement from us, as regards any work you perform for such person or organization, The additional premium for this endorsement shell be 2, 00 % of the totat estimated workers compensation premium for this policy, WC, 04 03 61 Countersigned by (Ed. 111901 n. Authadzed Representative