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1994-0921_D.M. KISLING CONSTRUCTION_Insurancek . s• 0• CONTRACTOR'S CERTIFICATE REGARDING WORKER'S COMPENSATION Description of Contract: CAPISTRANO VALLEY WATER DISTRICT VIA CASCADA MAIN RELOCATION CALLE DORADO MAIN EXTENSION Labor Code Section 3700: "Every employer except the State and all political subdivisions or institutions thereof, shall secure the payment of compensation in one or more of the following ways: (a) By being insured against liability to pay compensation in one or more insurers duly authorized to write compensation insurance in this State. (b) By securing from the Director of Industrial Relations a certificate of consent to self -insure, which may be given upon furnishing proof satisfactory to the Director of Industrial Relations of ability to self -insure and to pay any compensation that may become due to his employees." I am aware of the provisions of Section 3700 of the Labor Code which requires every employer to be insured against liability for worker's compensation or to undertake self-insurance in accordance with the provisions of that code, and I will comply with such provisions before commencing the performance of the work of this contract. Dated: g , 1994 (Seal) T>. tom(. �CIS�IIJG- L�w�STRUCTIO►.� Contractor By — Official Title In accordance with Article 5 (commencing at Section 1860), Chapter 1, Part 7, Division 2 of the Labor Code, the above certificate must be sighed and filed with the awarding body prior to performing any work under this contract. -RPIfi\MRDTHFLC\CNTRCOnCNTRABDE.DOC B-31 WORAERS COMPENSATION CONTRACTOR'S CERTIFICATE I OF I 0• 0• CERTIFICATE OF INSURANCE Description of Contract: CAPISTRANO VALLEY WATER DISTRICT VIA CASCADA MAIN RELOCATION CALLE DORADO MAIN EXTENSION Type of Insurance: WORKER'S COMPENSATION INSURANCE THIS IS TO CERTIFY that the following policy has been issued by the below -stated company in conformance with the requirements of Article C -8(i) of the General Provisions and is in force at this time. The Company will give at least 30 days written notice by certified mail to the Owner and Engineer prior to any material change or cancellation of said policy. POLICY NUMBER WC 1 23686912 EXPIRATION DATE 12/04/94 D.M. KISLING CONSTRUCTION CO. Named Insured (Contractor) P.O. Box 250 Street Number Laguna Beach, CA 92652 City and State LIMITS OF LIABILITY Statutory Limits under the laws of the State of California CNA Companies Insurance Company P.O. Box 2300 Street Number Brea, CA 92622 City and State By 7 Company Representative (SEE NOTICE ON PAGE 2 OF 3) WORKER'S COMPENSATION -RPLC\NIRDTIWLC\CNTRMCNTRABDE.DOC B-32 CERTIFICATE OF INSURANCE I OF 00 0 • STATE OF CALIFORNIA ) ) SS. COUNTY OF RIVERSIDE ) on this 28th day of September 1994 before me personally came James A. Dilks to me personally known (or identified by • satisf actory evidence), who being duly sworn, did depose and say: that authorized representative of the CNA Companies and acknowledged to me that He an executed the within instrument on behalf of said insurance company. IN WITNESS WHEREOF, I have signed and affixed my official seal on the date in this certificate first above wri Insurance Company Agent for Service of Process in California CNA Companies Named P.O. Box 2300 Street Number Sfir Agen PO Box 3569 Street Number Brea, CA 92622 Rancho Cucamonga, CA 91729 City and State City and State 714-255-2200 Telephone Number 909-483-5800 Telephone Number This certification or verification of insurance is not an insurance policy and does not amend, extend, or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with respect to which this certificate or verification of insurance may be issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms, exclusions, and conditions of such policies. WORKERS COMPENSATION -RPLC\NMTIIFLC\CNTRC'nCNTRABDE.DOC B-33 CERTIFICATE OF INSURANCE 2 OF 3 Ile NOTICE: 0 • No substitution or revision to the above certificate form will be accepted. If the insurance called for is provided by more than one insurance company, a separate certificate in the exact above form shall be provided for each insurance company. WORKER'S COMPENSATION -RPLCIAMTHFLCICN7RC71CNTRABOE.DOC B-34 CERTIFICATE OF INSURANCE 3 OF 3 INSURANCE ENDORSEMENT Description of Contract: CAPISTRANO VALLEY WATER DISTRICT THE VIA CASCADA MAIN RELOCATION CALLE DORADO MAIN EXTENSION Type of Insurance: WORKER'S COMPENSATION INSURANCE This endorsement forms a part of Policy No. WC 1 23686912 It is agreed that with respect to such insurance as is afforded by the policy, the Company waives any right of subrogation it may acquire against the Owner, the Engineer, the Owner's Representative, and their consultants, and each of their directors, officers, agents, and employees by reason of any payment made on account of injury, including death resulting therefrom, sustained by any employee of the insured, arising out of the performance of the above referenced contract. This endorsement does not increase the Company's total limits of liability. D.M. Kisling Construction Co. CNA Companies Named Insurance Company P.O. Box 250 P.O. Box 2300 Street Number Street Number Laguna Beach, CA 92652 Brea, CA 92622 City and State City and State By mpany Representative (SEE NOTICE ON PAGE 2 OF 2) WORKER'S CONUENSATION -RPLCM1MT IFLC\CNTRCI�CNTRABDE.DOC B-35 INSURANCE ENDORSEN NT 1 OF 2 410 • 0 STATE OF CALIFORNIA ) ) SS. COUNTY OF RIVERSIDE ) On this 28th day of September 1994 before me personally came James A. Dilks to me personally known (or identified by satisfactory evidence), who being duly sworn, did depose and say: that is an authorized representative of the CNA Companies and acknowledged to me that He instrument on behalf of said insurance company. executed the within IN WITNESS WHEREOF, I have signed and affixed my official seal on the date in this certificate first above written. WAMECOUNN Notary MVCo M-bPh"jL"2I.1*? I NOTICE: No substitution or revision to the above endorsement form will be accepted. If the insurance called for is provided by more than one policy, a separate endorsement in the exact above form shall be provided for each policy. WORK'ER'S COMMSATION -RPLC\MRDTIWLC\CNTRC'nCNTRARDE.DOC B-36 INSURANCE ENDORSEMENT 2 OF 2 0 • 0 • CERTIFICATE OF INSURANCE Description of Contract: CAPISTRANO VALLEY WATER DISTRICT VIA CASCADA MAIN RELOCATION CALLE DORADO MAIN EXTENSION Type of Insurance: LIABILITY INSURANCE THIS IS TO CERTIFY that the following policies have been issued by the below -stated company in conformance with the requirements of Article C-8 (i) of the General Provisions and are in force at this time: LIMITS OF LIABILITY In thousands (1.000) POLICY EXPIRATION NUMBER DATE Each Occurrence Aggregate A503456515 A. GENERAL LIABILITY 07/01/95 Bodily Injury $ $ Property Damage $ $ Bodily Injury and Property Damage Combined $1,000 $ 2,000 Personal Injury $1,000 $ A903456513 B. AUTOMOBILE LIABILITY 07/01/95 Bodily Injury (Each Person) $ $ Bodily Injury (Each Occurrence)$ $ Bodily Injury and Property Damage Combined $ 1,000 $1,000 A001045011 C. EXCESS LIABILITY 07/01/95 Bodily Injury and Property Damage Combined $ 3,000 $3,000 LIABJUTY INSURANCE -RPLC\NMDT[MZ\CNTRCnCNTRABDE.DOC B-37 CERTIFICATE OF INSURANCE I OF 4 0 0 • The following types of coverage are included in said policies (indicated by "X" in space): Including Loading and Unloading YES X A. GENERAL LIABILITY: Owned YES X Comprehensive Form YES X NO Premises -Operations YES X NO Explosion and Collapse Hazard YES X NO Underground Hazard YES X NO Products/Completed Operations Hazard YES X NO Contractual Insurance YES X NO Completed Operations YES X NO Broad Form Property Damage Including Completed Operations YES X NO Independent Contractors YES X NO Personal Injury YES X NO B. AUTOMOBILE LIABILITY Comprehensive Form Including Loading and Unloading YES X NO Owned YES X NO Hired YES.X NO Non -Owned YES X NO C. EXCESS LIABILITY Umbrella Form YES X NO Other Than Umbrella Form YES NO This certificate or verification of insurance is not an insurance policy and does not amend, extend, or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate or verification of insurance may be issued or may pertain, the insurance afforded by the policies described herein is 11ABIUTY INSURANCE -RPLC\N=TDFLCICINTRCnCNTRABDE.DOC B-38 CERTIFICATE OF INSURANCE 2 OF 4 0 • 0 • subject to all the terms, exclusions, and conditions of such policies. The Company will give at least 30 days written notice by certified mail to the Owner and the Engineer prior to any material change or cancellation of said policies. D.M. Kisling Construction Co. CNA Companies Named P.O. Box 250 Street Number Laguna Beach, CA 92652 City and State STATE OF CALIFORNIA ) ) SS. COUNTY OF RIVERSIDE ) Insurance Company P.O. Box 2300 Street Number Brea, CA 92622 City anState By Company Representative (SEE NOTICE ON PAGE 4 OF 4) On this 28th day of September , 199, before me personally came James A. Dilks to me personally known (or identified by satisfactory evidence), who being duly sworn, did depose and say: that He is an authorized representative of the CNA Companies and acknowledged to me that He executed the within instrument on behalf of said insurance company. IN WITNESS WHEREOF, I have signed and affixed my official seal on the date in this certificate first above written. wls GAR= sQhMV cpm,+pp�y» I Notar !Nolan P�bAe - CdfaN� RNERSIDE COMW Comm. EM*68 JIM a UABIUTY INSURANCE -RPLC\MRDT D'LC\CNTRC'DCNTRABDE.DOC B-39 CERTIFICATE OF INSURANCE 3 OR 4 00 0 • Insurance Company Agent for Service of Process in California CNA Companies Sfingi & Hannon Inc_ Rarvirac Named Agent P.O. Box 2300 Street Number Brea, CA 92622 City and State 714-255-2200 Telephone Number NOTICE: P.O. Box 3969 Street Number Rancho Cucamonga_ C� A 91799 City and State Wmax,F.1 TelephoneNumber No substitution or revision to the above certificate form will be accepted. If the insurance called for is provided by more than one insurance company, a separate certificate in the exact above form shall be provided for each insurance company. Insurers must be authorized to do business and have an agent for service of process in California and have an "A" policyholder's rating and a financial rating of at least Class VII in accordance with the most current A.M. Best's Rating. LIABILITY INSURANCE -RPLCVAMDTIU'LC\CNTRCrnCNTRABDE.DOC B-40 CERTIFICATE OF INSURANCE 4 OF 4 09 •0 INSURANCE ENDORSEMENT Description of Contract: CAPISTRANO VALLEY WATER DISTRICT VIA CASCADA MAIN RELOCATION & CALLE DORADO MAIN EXTENSION Type of Insurance: LIABILITY INSURANCE This endorsement forms a part of Policy No. ENDORSEMENT The Owner, the Engineer, the Owner's Representative, and their consultants, and each of their directors, officers, agents, and employees are included as additional insureds under said policies but only while acting in their capacity as such and only as respects operations of the named insured, his contractors, any subcontractor, any supplier, anyone directly or indirectly employed by any of them, or anyone for whose acts any of them may be liable in the performance of the above -referenced contract. This insurance shall not apply if the loss or damage is ultimately determined to be the result of the sole and exclusive negligence (including any connected with the preparation or approval of maps, drawings, opinions, reports, surveys, designs, or specifications) of one or more of the aforesaid additional insureds. The insurance afforded to these additional insureds is primary insurance. If the additional insureds have other insurance which might be applicable to any loss, the amount of this insurance shall not be reduced or prorated by the existence of such other insurance. The Contractual Liability Insurance afforded is sufficiently broad to insure all of the matters set forth in the article entitled "Indemnity" in the General Provisions of the above -referenced contract except those matters set forth in the second paragraph thereof. This endorsement does not increase the Company's total limits of liability. D.M. KislinQ Construction Co Named Insured (contractor) P.O. Box 250 Street Number Laguna Beach, CA 92652 City and State CNA Companies Insurance Company P.O. Box 2300 Street Number Brea, CA 92622 it and State By Company Representative ( NOTICE ON PAGE 2 OF 2) LIABILITY INSURANCE -RPLC\NIRDTIWLCICNTRCInCNTRABDE.DOC B-41 ENDORSEMENT I OF 0 • 0 • STATE OF CALIFORNIA ) ) SS. COUNTY OF RIVERSIDE ) On this 28th day of September 199 4, before me personally came James A. Dilks to me personally known (or identified by satisfactory evidence), who being duly sworn, did depose and say: that an authorized representative of the CNA Companies acknowledged to me that executed the within instrument on behalf of said insurance company. IN WITNESS WHEREOF, I have signed and affixed my official seal on the date in this certificate first above written WgGAaC4► ( --- s ary oedrallo Notary u ! NdRole - Cdf RIVERSIDE COUNTY MY Comm. En*m AIN 106 1997 NOTICE: No substitution or revision to the above endorsement form will be accepted. I£ the insurance called for is provided by more than one policy, a separate endorsement in the exact above form shall be provided for each insurance company. Insurers must be authorized to do business and have an agent for service of process in California and have an "A" policyholder's rating and a financial rating of at least Class XI in accordance with the A.M. Bests' rating A:VII. LIABILITY rNSURANCE -RPLCkMRDTI[FLC\CNTRCnCNTRABDE.DOC B-42 ENDORSEWNT 2 OF 0 • 0 . CERTIFICATE OF INSURANCE Description of Contract: CAPISTRANO VALLEY WATER DISTRICT THE VIA CASCADA MAIN RELOCATION CALLE DORADO MAIN EXTENSION Type of Insurance: BUILDER'S RISK "ALL RISK" INSURANCE THIS IS TO CERTIFY that the following numbered policies have been issued by the below -stated company in conformance with the limits and requirements as set forth in Article C-8 (i) of the General Provisions. This Certificate of Insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement, term, or condition of the contract with respect to which this Certificate is issued, the insurance afforded by the policies described herein is subject to all the terms, exclusions and conditions of such policies. The company will give at least 30 days written notice by registered mail to the District and Engineer/ Architect prior to any material change or cancellation of said policy. Effective Expiration Policy Number Date' Date'- Limits of Liabilitv3 A5 03456515 07/01/95 $345,000 1 Not after contract start date. Z Not sooner than contract completion date. 3 Not less than contract amount. ° Deductible: not more than 5% or $10,000, whichever is less; 5% for flood. BUILDERS RISK -RPLC\NMTHFLC\CNTRCT\CNTRABDE.DOC B-43 CERTIFICATE OF INSURANCE I OF 0 • 0 • D.M. Kisling Construction Co. _ CNA Comnaniaa Named Insured (Contractor) Insurance` Company P.O. Box 250 p_n_ nnY 21nn Street Number Street Number Laguna Beach, CA 92652 FrPa "A 9699 City and State City and State By ( /Company Representative ENOTICE ON PAGE 3 OF 3) STATE OF CALIFORNIA ) SS. COUNTY OF RIVERSIDE ) On this 28th day of RPntPmhar 199 A , before me personally came James A. Dilks to me personally known (or identified by satisfactory evidence), who being duly sworn, did depose and say: that representative of the CNA Companies He is an authorized and acknowledged to me that he/sbe executed the within instrument on behalf of said insurance company. IN WITNESS WHEREOF, I have signed and affixed my official seal on the date in this certificate first above written. Nota COMM. • "7: i Notary PubAC _ CaAtanb ! RIVERSIDE COMW QhMv Camm. EWWW JUN 2M 1"7 -RPLC\MRDTHF1,C\CNTRCT\CNTRABDE.DOC B-44 BUILDER'S RISK CERTIFICATE OF INSURANCE 2 OF 3 0 • Insurance Company Agent for Service of Process in California CNA Companies Named P.O. Bxo 2300 Street Number Brea, CA 92622 City and State 714-255-2200 Telephone Number NOTICE: 0 • Sfingi & Hannon Ins. Services Agency P.O. Box 3569 Street Number Rancho Cucamonga, CA 91729 City and State QnQ-4R1-1;RO0 Telephone Number No substitution or revision to the above certificate form will be accepted. If the insurance called for is provided by more than one insurance company, a separate certificate in the exact above form shall be provided for each insurance company. Insurers must be authorized to do business and have an agent for service of process in California and have an "A" policyholder's rating and a financial rating of at least Class XI in accordance with the A.M. Bests' rating A:VII. BUILDER'S RISK -RPLCWRDTTDZCICNTRCnCNTRAEDE.DOC B-45 CERTIFTCATE OF INSVRANCE3 OF3 6 • 0, INSURANCE ENDORSEMENT Description of Contract: CAPISTRANO VALLEY WATER DISTRICT THE VIA CASCADA MAIN RELOCATION CALLE DORADO MAIN EXTENSION Type of Insurance: BUILDER'S RISK "ALL RISK" INSURANCE This endorsement forms a part of Policy No. A5 03456515 The Owner, the Engineer, the Owner's Representative, and their consultants, and each of their directors, officers, agents, and employees are included as additional insured under said policy but only while acting, or alleged to have been acting, in their capacity as such with respect to the above -referenced contract. This insurance afforded to these additional insureds is primary insurance. If the additional insureds have other insurance which might be applicable to any loss, the amount of this insurance shall not be reduced or prorated by the existence of such other insurance. This endorsement does not increase the Company's total limits of liability. D.M. Kisling Construction Co. Named Insured (Contractor) P.O. Box 250 Street Number Laguna Beach, CA 92652 City and State By Company Representative (SEE NOTICE ON PAGE 2 OF 2) CNA Cnmp anlpS Insurance Company P.O_ Box non Street Number Brea, CA 92629 City and State BUILDER'S RISK -RPLC\MRDTFWLC\CNTRCT\CNTRABDE.DOC B-46 INSURANCE ENDORSEIVIENT I OF STATE OF CALIFORNIA ) SS. COUNTY OF RIVERSIDE ) On this 28th day of September 1994 before me personally came James A. Dilks to me personally known (or identified by satisfactory evidence), who being duly sworn, did depose and say: that HP is an authorized representative of the CNA Companies and acknowledged to me that he/sdxe executed the within instrument on behalf of said insurance company. IN WITNESS WHEREOF, I have signed and affixed my official seal on the d t i t i c rt'ficate first above wr.t n. WIS GARCIA COMM.i0i Notary PWAe — CaCd Mfaria f PNERS"000NIV Notary u My Comm. BVMJ IN 2M 1907 No substitution or revision to the above endorsement form will be accepted. If the insurance called for is provided by more than one policy, a separate endorsement in the exact above form shall be provided for each insurance company. Insurers must be authorized to do business and have an agent for service of process in California and have an "A" policyholder's rating and a financial rating of at least Class XI in accordance with the A.M. Best's Rating A:VII. BUILDER'S RISK -RPLCTAP,DTRF'LC\CNTRCTICNTRABDE.DOC B-47 INSURANCE ENDORSEVffNT 2 OF 2