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17-0125_GONG ENTERPRISES, INC_Insurance CertificatePOLICYHOLDER COPY STATE COMPEN:,ATION INSURANCE P.O. BOX 8192, PLEASANTON, CA 94588 FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 08-01-2018 CITY OF SAN .JUAN CAPISTRANO 32400 PASEO ADELANTO SAN .JUAN CAPISTRANO CA 92675-3603 SG GROUP : POLICY NUMBER: 1258757-2018 CERTIFICATE 10: 39 CERTIFICATE EXPIRES: 07-01-2017 07-01-2018/07-01-2017 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form apprdved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not <~mend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding ;my requirement. term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms. exclusions. and conditions. of such policy. ~tlq ;L_ .dl~ Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #1600 -KEN GONG PRES -EXCLUDED. ENDORSEMENT #1600 -KATHY GONG DRTR -EXCLUDED. ENDORSEMENT #1600 -DAVID GONG SEC -EXCLUDED. ENDORSEMENT #1800 -STUART GONG TRES -EXCLUDED. ENDORSEMENT #1600 -TOM GONG DRTR -EXCLUDED. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07-01-1994 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER GONG ENTERPRISES, INC 7755 CENTER AVE STE 1100 HUNTINGTON BEACH CA 92647 REV.7-2014) SG [HIM,CN) PRINTED 08-01-2016 SG ~ LIABILITY INSURANCE r OA TE (MWOOIYYYY) ACORD CERTIFICATE OF ~ 3/28/2016 THIS CERTIFICATE IS ISSUED AS A MATIER 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: If the cortlflcate holder is an ADDITIONAL INSURED, the policy( los) must be endorsed. If SUBROGATION IS WAIVED, subject to tho terms and conditions of the policy, certain policies may roquiro an endorsement. A statement on this certificate docs not confer rights to the certificate holder In liou of such ondorsomont(s). PRODUCER CONTACT -~'---WILLIS OF ILLINOIS . INC. ~HONE (888) 780-5381 ---=:J r~~. c;o~,.(8nJ 737 -8~~ AlC.l'IQ...E.ul . 233 S WACKER DR,SUITE 2000 ~~Jlli.bL Certificate@hanover.com CHICAGO,IL 60606 --. ---1-______ J!I.~!,!RER(SI AFFORDING COVERAGE NAIC • INSURER A : Citizens Ins Co of America )iS34 --. ---------·-··--·-·----·-····--··-· ···-~ .... -----· -~~ s ; Hanover Insurance Co ·-----···-· ----r ··· fNSU REO 22292 GONG ENTERPRISES INC -~-·· -------------··-------- ~SURER£_: _____ .. ------------i 7755 CENTER AVE #11 00 I HUNTINGTON BEACH . CA 92647 .Jt:'§!,J .R~---------·-·· -- _fN§_UjlER E . .. ----.. ---- INSURER F COVERAGES CERTIFICATE NUMBER · REVISION NUMBER· Tf11S IS TO CERTIFY THAT THE POLICI ES OF INSURANCE LISTED BELOW HAVE BE EN ISSUED TO THE INSURED NAMED ABOVE FOR THE POL ICY PERIOD INDICATE D NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHI CH THIS CERTIFICATE MA Y BE ISSUED OR MAY PERTAIN , THE INSURANCE AFFORDED BY THE POLIC IES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCI~ POLICIES . LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INS_R _ ------------~~: ---------------l POLICY EFF ,j POLICY EXP ~---·--------· ------ ITR TYPE OF INSUR ANCE POLICY NUMBER 1 MMIOOIYYYY MMIOOIYYYY LIMITS CENE:RA L UABILITY I I 1 ~agccuRRENce I , 1 .ooo .ooo ! X . COMM oRC>\L GENERA!. LIAfJIL<TY I J:TO"REt:mo-~ ---- fX"I I f '""'"'"''""""""'-" 1 ,,ooo.ooo " A ' CLAf MS-MACE X OCCUR OBC A361099 02 1 03/25/2016 03/25/2017 ME OEXP(Anyono~l_ __ ~O~O~ -- I --- I ---! ~R_50NA_L &ADV_!_N.AJ'lV _ ! S 1,900,000 --! ' ' I GEI'IERAL AGGREGAn: s 2,000,000 i·------------I I I ( PRODUCTS . COOP/Of> AGG . :·; 2. 000,000 _ G[N"L .oGGilEGA Tt UMff APPUES PER I POLCV :Xl '181 n LOC I i l ~---. 's AUTOMOBILE LJADILITY 1rx 1' I I . ~'r~.s'~~ UMli s 1 .000 .000 I -l ANY AUTO I 03/25/2016 ! BODILY INJURY (Pet per-""1 1 j S A I • AL l OWNED ~ SO<EDLJLEO I I OBC A361099 02 03/25/2017 OOO;LY ;;JURY (Per~~~ . --·- AUTOS I AUTOS I . X • NON-01'\tiED JifOPEFffY DAMAGE -· · ·;---- HolltDAUTOS >--.AUTOS . -· I I :!'~--I -- I I I s UMBRELLA LIAS I ... i OCCUR II II I EACH OCCURRENCE I s ~EXCESS LIAS r ., CLAI MS -IolADE I AGGREGATE __ =-l $ .. ···- --- OED , l RE1EIHION s ' I s WORKERS COIIPENSA TfON I I I 1 v-.c STATu-I j OJH · AND EMPLOYERS ' LIABfLITY y 1 N • ..r.Oill'..L!Mlr.s ~ r· --------- hNY PRQPRIETORIPARTN ERJEXEC\11 fVE D I' E L EACH ACCOENT S OF FI CCJl.<EMBEfl EXClU DED? N I A I -··· ·-_ .. ~ .. - (M~ndarory in NH) I E L OiSEASt: • EA EMP LOYE g S If yU., dUC11tle undW -- rlF"f'Q,plf,.,_,O<""<D<TVWC.""'"' I I E L DISEAS E POLICY LIMfT s , Architects and Eng meers ,,, I 03/25/2016 03/25/2017 1 B Professional Liability I I LHC 9884791 04 $1 ,000 .000 Per Claim Claims-Made Coverage $2 ,000 ,000 Aggregate DESCRIPTION OF OPERATIONS /LOCATIONS I VEHICLES (Attach ACORD 101 , Add i Uon.~l Rom•rko Sohodulo ,lf mor10 opaoels roqui1'1!d) , The City of San Juan Capistrano is an Additional insured pursuant to the terms and ' conditions of form : 391 -1586 (General Liability Broadening Endorsement). Additional Insured IS pnmary and noncontributory to the extent provided by form 391 -1586. CERTIFICATE HOLDER CANCELLATION C i ty of San Juan Capistrano Attn : City Clerk SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 32400 PaseD Adelanto THE EXPIRATION DATE THEREOF , NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. San Juan. Capistrano, CA 92675 AUTHORflEO REPRESENlA TIVE I a~~~ © 1988-2010 ACORD CORPORATION. Ali nghts rosorvod . ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD .~&\'\Hanover ~ Insurance Group . OBCA361099 1309570 THIS ENDORSEMENT CHANGES THE POLICY . PLEASE READ IT CAREFULLY . GENERAL LIABILITY SUPPLEMENTARY ENDORSEMENT This endorsement modifies insurance provided under the following : BUSINESSOWNERS COVERAGE FORM I. Additional Insured by Contract, Agreement or Permit Under SECTION II • LIABILITY, C. Who Is An Insured, Paragraph 4. is added as follows: a. Any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract , agreement or permit 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 "bodi ly i njury", "property damage" or "personal and advertis i ng injury" caused , in whole or in part , by : (1) Your acts or omissions; or (2) The acts or omissions of those acting on your behalf, but only with respect to : (3) "Your work" for the add iti onal insured(s) at the location designated in the contract, agreement or permit; or (4) Premises you own, rent, lease, control or occupy . This insurance applies on a primary basis if that is required by the written contract , agreement or permit. b . This provision does not apply: (1) Unless the written contract or written agreement has been executed or permit has been issued prior to the "bodily injury", "prope rty damage" or "personal and advertising injury"; (2) To any person or organization in cluded as an insu red by an endorsement issued by us and made part of this Policy; (3) To any lessor of equipment: (a) After the equipment lease expires; or (b) If the "bodily injury", "property damage" or "personal and advertising inl·ury" arises out of the sole negligence o the lessor; (4) To any: (a) Owners or other interests from whom land has been leased which takes place after the lease for that land expires; or (b) Manag _ers or lessors of premises if: (i) The occurrence takes place after you cease to be a tenant in that premises ; or (ii) The "bodily injury", "property damage" or "personal and advertising injury" arises out of structural alterations, new construction or demolition operations performed by or on behalf of the manager or lessor ; or (5) To "bodily injury ", "property damage " or "personal and advertising injury" arising out of the rendering of or the failure to render any professional services. This includes but is not limited to any professional services as an architect . or engineer arising out of any construction agreement or activities under which any insured or anyone acting on any Insured's behalf provides or provided service. advice , expertise or work . Construction includes, but is not limited to , the plan , conception, design , build, construct, assembly, development, safety, erection , formation, reconstruct , rehabilitation , repair , or any 1mprovem_ent made . to real property . Constr~~t1on also Includes the hiri ng , su~e .r':'1s1on or management of any of these act1v1t1es . However, this exclusion does not apply to liability arising out of an insured's presence at a jobsite that was not caused by professional activities listed in the above paragraph . c. Additional insured coverage provided by this provision will not be broader than coverage provided to any other insured . d. All other insuring agreements, exclusions , and conditions of the policy apply. II. Additional Insured by Contract, Agreement or Permit - Primary and Non-contributory The following is added to SECTION 11'1 -COMMON POLICY CONDITIONS: M. Other Insurance 1. Additionallnsureds If you agree in a written contract, written agreement or permit that the insurance provided to any person or organization 1ncluded as an Additional Insured under SECTION II • LIABILITY, Part C • Who is An Insured, is primary and non-contributory the following applies: ' If other valid and collectible insurance is available to the Additional Insured for a loss we cover under SECTION II • LIABILITY, Part A. Coverages, Paragraph 1., Business Liability our obligations are limited as follows : a. Primary Insurance This insurance is primary to other insurance that is ava ilable to the Additional Insured which covers lhe Additional Insured as a Named Insured . 391-1586 0211 Includes copyrighted material of Insurance Services Offices, Inc., with its permission Page 1 of 2 , 391-1586 02 11 We will not seek contribution from any other insurance available to the Additional Insured except: (1) For the sole negligence of the Additional Insured; (2) When the Additional Insured is an Addit ional Insured under another primary liability policy; or (3) When b .(2) below applies . If this insu rance is primary , our obligations are not affected unless any of the other insurance is also primary . Then, we will share with all that other insurance by the method described in b .(3) below . b . Excess Insurance This insurance is excess over: (1) Any of the other insurance, whether primary , excess, contingent or on any other basis : (a) That is Fire, Extended Coverage, Builder's Risk, Installation Risk or similar coverage for "your work"; (b) That is Fire insurance for premises rented to the Additional Insured or temporarily occupied by the Additional Insured with permission of the owner ; (c) That is insurance purchased by the Additional Insured to cover the Additional Insured s liability as a tenant for "property damage" to premises rented to the Additional Insured or temporarily occupied by the Additional Insured with permission of the owner; or (d) If the loss arises out of the maintenance or use of aircraft, "autos" or watercraft to the extent not subject to Exclusion g. of SECTION II -LIABILITY , Part A . Coverages, 1. Business Liability. When this insurance is excess, we will have no duty under SECTION II -LIABILITY, Part A . Coverages, 1. Business Liability to defend the insured against any "suit" if any other insurer has a duty to defend the insured against that "suit". If no other insurer defends , we will undertake to do so , but we will be entitled to the insured's rights against all those other insurers. When this insurance is excess over other insurance, we will pay only our share of the amount of the loss, if any, that exceeds the sum of: (1) The total amount that all such other insurance would pay for the loss in the absence of this insurance ; and (2) The total of all deductible and self-insured amounts under all that other insurance. We will share the remaining loss , if any , with any other insurance that is not described in this Excess Insurance provision and was not bought specifically to apply in excess of the Limits of Insurance shown in the Declarations of this Coverage Part . c. Method Of Sharing If all of the other insurance permits contribution by equal shares , we will follow this method also . Under this approach each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains , whichever comes first. If any of the other insurance does not permit contribution by equal shares, we will contribute by limits . Under this method , each insurer's share is based on the ratio of its appl icable lim it of insurance to the total applicable limits of insurance of all insurers . Ill. Aggregate Limit of Insurance (Per Project) a. For purposes of the coverage provided by this endorsement, D. Liability and Medical Expenses Limits of Insurance under Section II -Liability is amended by adding the following: The General Aggregate Limit under D. Liability and Medical Expenses Limits of Insurance applies separately to each of "your projects" or each location listed in the Declarations . b. For purposes of the coverage provided by this endorsement F. Liability And Medical Expenses Definitions under Section II -Liability is amended by adding the following: a. "Your project" means: i. Any premises, site or location at , on , or in which "your work" is not yet completed; and ii. Does not include any location listed in the Declarations . IV. Blanket Waiver of Subrogation Paragraph K. Transfer Of Rights Of Rec9very Against Others To Us in Section Ill -Common Policy Conditions is amended by the addition of the following : We will waive any right of recovery we may have against any person or organization when you have agreed in a written contract, permit or agreement to waive any rights of recovery against such person or organization because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard". Includes copyrighted material of Insurance Services Offices , Inc., with its permission Page 2 of 2