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 •
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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
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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