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Home My WebLink AboutPM 2007-03 - Certificate of Insurance - 3/4/2009 CENT-PLA-02 NIKI ACO'RD-. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 3/212009 PRODUCER (559)432.0222 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION DIBLIduo&DeFendis Insurance Brokers, LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR License#OE02096 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, P.O. Box 5479 Fresno,CA 93755-5479 INSURERS AFFORDING COVERAGE NAIC# INSURED Central Plaza Sh-a'p*'p'*-in'*g***Center, LLC INSURFR A Scottsdale Insurance Company 575 E. Locust Ave., Suite 203 INSURER B Fresno,CA 93720 INSURER INSURER D INS(IRER F: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE 1:011 THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE 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.AGGREGATE LIMITS S1[OWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. .I- Nsk ADVIL POLICY EFFECTIVE POLICY EXPIRATION LTR INSR0 TYPEOFI URANCE -POLICYNUMBER 12ATE(MMIDDIYY� DATE 1MMIDojYYI UMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,()00 A X COMMERCIALGENERAL LIABILITY CPS0991078 118/2009 1/8/2010 �r G=RERTED --.- --............... X 1p'm C01 $ 100,000 REMISES[Ea occuren CLAIM544A0E I_A]OCCUR MED EXP(Any one Perron) $ 5,000 )C Deductible-NonePERSONAL&ADV INJURY S 1'0 00,0-0*0- GENERAI AGGREGATE 2,000,000 GENLAGGREGArE LIMIT APPLIES PER. PRODUCTS-COMPtOP AGG $ubject to Gen Agg - —x]POLICYPROLOC F—IJE-G I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO 1 (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per pwson) HIRED AUTOS R111 � ';,anges:EMENT DIVIS1101 BODILY INJURY $ Ad NON-OWNED AUTOS PP 0 (Per awdont) PP A t' PROPERTY DAMAGE S I I /- (Per acCident) GARAGE LIABILITYSig U-1 AUTO ONLY-EA ACCIDENT_.$�� ANY AUTO neDate OTHER THAN EA ACC S AUTO ONLY, AGG EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE DEDUCTIBLE $ I RETENTION S 17VI.TS—IATU TH- WORKERS COMPENSATION AND EMPLOYERS'LIABILITY . ANY PROPRIETORJPARTNERJEXECU FIVE E.LEACH ACCIDENT $ OFFiCERIMEMBER EXCLUDED? 11,DISEASE-EA EMPLOYEE $ I( es,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Cancellation Clause, 10 Day Notice for non-payment of premium The City of Fresno,its officers,officials,employees,agents and Volunteers are named additional insured per from CG20 10 07 04 attached as respects to General Liability. Primary Wording per attached UTS-3g(3.92)and Waiver of Subrogation per attached CO 24 0410 93 applies. lRe. 2827 W.Clinton Ave,,Fresno,CA 93705 (Parcel Map No.2007.03) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of Fresno DATE THEREOF,THE ISSUING INSURER WALL ENDEAVOR TO MAIL 30 DAYS WRITTEN Maryann Lewis 140TICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL c/o Construction Management Division 1721 Van Ness Avenue IMPOSE NO OBLIGATION OR LIABIUTY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Fresno,CA 93721- REPRESENTATIVES, AUTHORIZED REPRESENTATIVE --j ACORD 25(2001/08) @ACORD CORPORATION 1988 CENTPLA-02 NIKI IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed.A statement on this certificate does not confer rights to the certificate holder in herr of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s),authorized representative or producer,and the certificate holder, nor does it affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. I ACORD 25(2001/08) ENDORSEMENT SCOTTSDALE INSURANCE C"C)MPANY'O NO. ATTACHED TO AND ENDORSEMFNT EFFECTIVE DATE FORMING APART OF {Id 01 A.M.STANDAHDTIME) NAMED INSURED AGENT NO. POLICY NUMBER CPS0991076 01/08/2009 CENTRAL PLAZA SHOPPING CENTER, LLC 04030 IT IS HEREBY AGREED THAT COVERAGE AS PROVIDED BY CG 2010 7-•04 SHALL, BE PRIMARY 13UT ONLY IN THE EVENT OF THE NA14ED INSUREDI S SOLE NEGLIGENCE. / 03/02/2009 AUTHORIZED REPRESENTATIVE DATE UfS-3y 13-94 INSURED POLICY NUMBER: CPS0991078 COMMERCIAL GENERAL LIABILITY CG 2010 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE ——-——--------- Name of Additional Insured Person(a) Or Oganization(s) location(s)of Covered 01)eratlons THE CITY OF FRESNO C/O CONSTRUCTION hIANAGEMBNT DIVISION ITS OPPICERS, OFFICIALS, EMPLOYEES, 1721 VAN NESS AVENUB AGENTS AND VOLUNTEERS FRESNO, CA 93721 information rec aired to complete this Schedule,If not shown above,will be shown in the Declarations. A. Section 11 -Who Is An Insured is amended to In- B. With respect to the Insurance afforded to these ad- clude as an additional Insured the person(s) or or- ditional Insureds, the following additional exclu- ganlzation(s) shown In the Schedule, but only with sloes apply: respect to liability for"bodily Injury',"property dam- This Insurance does not apply to"bodily injury" or age"or'personal and advertising injury"Caused, in 11 property damage"occurring after: whole or In part,by: 1. All work, including materials, parts or equip- i. Your acts or omissions;or ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project (other than"service, mainte- behalf; nance or repairs)to be performed by or an be- In the performance of your ongoing operations for half of the additional Insured(s)at the location the additional insured(s) at the locallon(s) desIg- of the covered operations has been com- nated above. pleted;or 2. That portion of"your work"out of which the In- jury 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 princi- pal as a part of the same project. CG 20 10 07 04 Copyright,150 Properties,Inc.,2004 Page i of I INSURED ` THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ[[CAREFULLY. CG24U41OQ8 ' WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies Insurance provided under,the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART This endorsement changes tile policy effective on the Inception date of the policy unless another date is indirated,below, 01/08/2009 12:01 A,M.standard time CPS0991078 Named Insured Countersigned by CENTRAL PLAZA SHOPPING CENTER, LLC (Authoked Representative) SCHEDULE Name oyPerson orOrganization: THE CITY OF rnuumo ITS OFFICERS, ornzCzALo, ompuoYDDe, xoouzo AND V000mzuoDa C/o coNGrmncTzoN o3&xaonmomz ozvzaIom 1721 vam mEoa xvomoE FRESNO, CA 93721 . (if no entry appears mbnvn. Information required to complete this endorsement will be shown In the Doo}um*\onu as ' applicable bothis ondommnantj 'rho TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV -COMMERCIAL GENERAL LIABILITY CONDITIONS) Is amended hythe addition nfthe following: Wowaive any right ofrecovery vvamay have against the person ororganization mhmwn !ndh*8ohedge above because of payments we make for Injury or damage arising out of your ongoing operations or"your work'done under-ucontract with that person or organization and included in the "products-completed operations hazunj.~ This waiver applies only to the person vrorganization shown inthe Schedule above. � CG24u*m93 Copyright,InnmuoroSorvicevOffice,Inu.199g Page 1of1 INSURED From:Kim Cameron,CISR,CPSR,CPIW At:DiBuduo&Defendis Insurance Brokers,LLC FaxID:5594317941 To:Kerr)Oate:224/2009 12:56 PM Page:2 of 11 DONBURG•01 13"] ACORD�, CERTIFICATE OF LIABILITY INSURANCE °ATEjMW oo9 Y) PRODUCER (559)432-0222 THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION DiBuduo fL DeFendis Insurance Brokers,LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE LicenseOE02096 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. P.O.Box 5479 Fresno,CA 93755-5479 INSURERS AFFORDING COVERAGE NAIC# INSURED Don Burgess Construction Corporation INSURERA.Liberty Surplus Insurance Company 5680 N.Fresno Street,Suite 105 INSLIRERB:United Financial Casualty Co. Fresno,CA 93710 INSURER C: INSURER D- INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSLIRANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN AtAY HAVE BEEN REDUCED BY PAD CLAIMS. IN9R DDrPOLICY IfUMBEA POLICY FFFECnVE POLICY EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE b 1,000,00 --- A X X CO1.iMERCIALGENERALLIABILlTY DGLSF206844018 412312006 4/23/2049 bAIAA:dtTo AI!WEbPREMISES Eaoaumme S 50,00 CLAIMS MiDE F—XI OCCUR MED EJP tAry one person) S 5,D0 X $5,000 Deductible Per Occ PERSONAL A ADV INJURY S 1,000,DO GENERAL AGGREGATE S 2,000,00 GENLAGGREGATE LIMIT APPLIESPER* PRODUCTS-COMPAPAGG S 2,000,CO POLICY I X i I'HO- LOC AUTOMOBILE LIABILITY COMRINFDSNG(EUMT S 11000,00 B X X ANYAUTO 064350990 611212006 511212009 (he a cider') ALL OV,'N ED AUTOS BODLY INJURY SChFnui Fn AUTn3 (Per Pei S HIRED AUTOS BODILY I N.;URY NOWOY✓NEDA(JTOS �1 (Per ecWer,t) S AGEMENT DIVISION PROPERTYDAMAGE (Peracctler{) s GARAGELLABIIJTY AUTO ONLY-EA ACCIDENT > ANYA.UTO -01 OTHERTHAN EAACC 3 AUTO ONLY: AGG F EXCESWUMBRELLA LIABILITY EACH OCCURRENCE S OCCUR CLAXIS MADE AGGREGATE b E UEDUC T1BLE b RETENTION S S WORKERS COMPENSATIONWC _LfI1T OR EMPLOYERS'LLAIRLITY ANY PROPRIE�RPARTR=R/EXFCUTLVE EL.EACH ACCIDENT S OFFICERJMEMSER EXCLUDEG7 El.DISEASE-EAEMPLOYE S If ym rVzri»o un.-W 31'EC(ALPKOVIS:ONSbeic" EL.DISPASE-POLICY LIMIT b OTHER DESCRIPnOR OF OPERATIONS 1 LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CANCELLATION CLAUSE: 10-Day Notice for NonPayment of premium Re: 2827 W,Clinton Ave.,Fresno,CA 93705 The City of Fresno,Its officers,officials,employees,agents and Volunteers are named addltlonal inBUTed per attached form CGL 103711 03 and {SGL 1038 11 03 as required by written contract. Primary Wording and Waiver of Subrogation applies to General Liability par attached COL1031 04 03 and CGL 1025 0103, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE.ABOVE DESCRIB EO POLICIES BE CANCELLED BEFORE THE EXPIRATION City of Fresno DATE THEREOF,THE ISSUING INSURERY&L ENDEAVOR TO TRAIL 30 DAYS WRITTEN Maryann Lewis c/o Construction Management Division NOTICE TO THE CERTIFICATE HOLDER NAMED TO 311E LIF L BUT FAILURE TO DO SO SHALL 1724 Van Ness Avenue IMPOSE NO OBLIGA7"OR LIAHILITYOFANY IONO UPON IHE INSURER,ITS AGENTS OR Fresno,CA 93721- REPRESENTAnVFS_ AUTHOR2ED REPREEENTATNE ACORD 26(2001108) ®ACORD CORPORATION 1908 From:Kim Cameron,CISR,CPSR,CPIW At:DiBuduo&Defendis Insurance Brokers,LLC FaxID:5594317941 To:Kerrj[Ate:22412009 12:56 PM Page:3 of 11 DONBURG-01 BRNI IMPORTANT If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed.A statement on this certificate does not confer rights to the cerlificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require on endorsement.A statement on this certificate daas not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the Issuing Insurer(s),authorized representative or producer,and the certificate holder,nor does it affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001108) From:Kim Cameron,CISR,CPSR,CPIW At:DiBuduo S Defendis Insurance Brokers,LLC FaxID:5594317941 To:Kerr)Date:21142009 12:56 PM Page:4 of 11 LSI Corj>uratiun Commercial General Liability _ axMAp.evxro,mww�r LIBERTY SURPLUS INSURANCE CORPORATION (A rMmha of tj"". Mutual Groyp,her6rdler'rhr Ognpaayl ENMORSEMENT NO. 3 Effeetivc Date, 4/23/2008 Policy Number: DGUF208844018 rssued Ta: Dan Durgett Conatturuon Cnrporadon THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. ADDITIONAL INSURED—OWNERS,LESSEES OR CONTRACTORS COMPLE ED OPERATIONS XHLDULE Name of Person or Organization; 'llteC:ity of Fresno,it's Officers, Employees,Agents,and Volunteers Location and Description of Completed Operations: 21127 W.Clinton Ave.,Fresno CA 93703 Additional Premium off ao entry oppeart above,information requited to eompltte this enduntmcni will be shown in the Dedua lions as appllr,mble m this codorsen,ent.) Section II—Who is an Insured is amended to include as as insured the person ur organization shown In the Schedule, but only a4th respect to liability arising otst of"pout votk"zt the locadon dcsignattd and described in the ScheduJ1e of this endorAtmeat performed for that insured and included in the"products-completed operAwns hazwe'. CGL 1038 1103 I From:Kim Cameron,CISR,CPSR,CPIW At:DiBuduo&Defendis Insurance Brokers,LLC FaAD:5594317941 To:KeMDate:2/24/2009 12:56 PM Page:5 of 11 LS1 Commercial General Liability " � ��ae4od4xtar}�waCf.y LIBERTY SURPLUS INSURANCE CORPORATION (A mem'xr of liberty Mutual Ehmip,hem mien"the Cumpatn)') EIArDORSEMENT NO. 17 Effectivt Date: 4123/200A PolicyNurnberc DGLSF208844018 Ieatted To: Don Burgess Construction Corporation THIS ENDORMMENTCHANGES THE POLICY. PLSASEREAIJITCAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY A(;AIN$1'OTHERS TO US Ii is 6ceby agreed that'Section A,itcm 8_Transfer of Rights of Ruovc y Agatnct Others rU Us,Ja ini0ifird av faHuws: SCHEDULE Name of Person of Organization: The City of Fresno,it's 0&cus, Employees,Agents,mid Volunteers (1f no entry appcus above,Infonilatiou reyviattl to cotnplcm d»a endourment will be shown in the Dcelusidues as appkable to this endonemenG) The TRANSFER OF RIGHTS OF RECOVE11Y AGAINST OTHERS TO U5 Condition(8cctinn A,— COMMERCIAL GENER 1J,LIA IIiUTV COND17IONS)is amended by the adtLi"i ttf the folktwilog. We waive any right of recovery V!e may luve against the person or otgutization shown in the Scheduk aborts because of pgrnentx v r.make for injuty or damage wising out of your nagoing uperatiDos ut'�aux work"done tattler a utntntct u;idr that person or organization. This w2iwr 2pp5es only to die pm.or)us orgutization shown in;he Schedule above C(31,1023 0103 From:Kim Cameron,CISR,CPSR,CPIW At:DiBuduo&Defendis Insurance Brokers,LLC FaxID:5594317941 To:KerrjDate:2242009 12:56 PM Page:6 of 11 Commercial General Liability LSt i Nm+�o'lEcnyUwd rrrr LIBER'T`Y SURPLUS INSURANCE CORPORATION (AmomberofbbutyMutualGmtru ,heelo,fiu"thetnnp2nT) ENDORSEMENT NO,4 Effeeti►s Ds+rr: 4J23/2000 PoIlcyNumber. DGLMM8844018 IssuedTo. Uon ButgessCunatrucdo°Cunc�xatian THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED—OWNERS,LESSSES OR CONTRACTORS SCITED-ULFI)PERSON OR ORGANIZA,TJON SCHEDULE Name of Persrnn or Orgaointion: The City of Fresno,it's Officers, Employees,Agents,and Volunteers of no entiT appem abort,infonrucion requited w complete this endorsement will be shown in the Dechr tions as applicable to this endorsement) A. Section I1—\Gi,o is An fnsuted is amended to include!ss an in6wed dtr,pentoa ur sugani2adun shown In the Schedule,but only with respect to liability,arising out of your nngtunK operations petfotmed for that insured. B. Mth VSpc:it to the inwrenfr.aMudni to d"a Additional wsurtds,the following exclusion is added: 2. Exclusions ' 17ds i umance clues not apply to`bmWy injury"or"property damage."oceuningaficr. (1) Alt worlt,including materials,parte or equipment hunishtd in connection widr such work,on the pru)ect(other than service,maintenance ur repairs)tar he performed by or on behalf of the adWtio°alinswcdc s)at the site of the cove red tipcmdons has been cornpletect or (2) 'that portion of"your-ace'out ofwhidt the injury ut darmge atisca hss bcca put to eta in tended use by any parson or oxgaiividon 4 det than another wntrzctnr or subconteactor engaged in pethxln4 opcntions for a prfnicipal as a part of the came project CGL 1037 1103 From:Kim Cameron,CISR,CPSR,CPIW At:DiBuduo&Defendis Insurance Brokers,LLC FaxID:5594317941 To:KerrjDate:2/24/1009 12:56 PM Page:7 of 11 LS1 Commercial General Liability _ r►Mr�.,>H,�w��,g, LIBER'T'Y SURPLUS INSURANCE MRPORA"ON (�l mcntxt of)Ibc�tpAft�tval Cir.tup,hutimEL:'Yicfuntunl END0RSEMENT NO. 15 Effective Date: 4/23/2DOE Policy Namber. DGlSF208844018 Issued To. Don BLugess Cotutruetion Corporation THIS TND OR SRMENT CHANGES THE POLY„Y, PLEASE REM IT CAREPULLY. PRIMARY INSURANCE CLAUSE ENDORSEMENT To the cuettt that this imurance is afforded to arty additional insured under the policy,such insurance shall apply as primary and nor contributing with art?ie�;urance cattiud by such adtlitiuttal insured,its teyttited by written enamel. Nothing hetero contained altall he hcU to wave,vary,alwt w cztend,my eunditinn nr provivun of the policy ollrcr than as above stated. CGL 1031 0403 From:Kim Cameron,CISR,CPSR,CPIW At:DiSuduo&Defendis Insurance Brokers,LLC FaxID:5594317941 To:Kerr)Date:2242009 12:56 PM Page:8 of 11 DIBUDUO&DF FENDIS PROORM111F PO BOX 5479 FRESNO,CA 93755 Policy number: 06435099•D Underwritten by: United Financial Casualty Company DON BURGESS CONSTRUCTION insured:CON BURGESS CONSTRUCTION CORPORATION January 23,2009 5680 N.FRESNO,#E105 FRESNO,CA 93710 Fbll(y Period;May 12,2008-May 12,2009 Nag Ing Address UN1ed Financial Casualty Company FC►Box 94739 Additional insured endorsement Cleveland,ON 44101 800.444-4487 For customer service,24 hours a day, Name of Person or Organization 7 days a week THE CITY OF FRESNO 1721 VAN NESS A FRESNO,CA 93721 The person or organization named above is an insured with respect to such 1-(ability coverage as is afforded by the policy, but this insurance applies to said insured only as a person liable for the conduct of another Insured and then only to the extent of that liability. We also agree with you that insurance provided by this endorsement will be primary for any power unit specifically described on the Declarations Page. Limit of Liability Bodily Injury Not applicable Property Damage Not applicable Combined liability $1,000,000 each accident All other terms,limits and provisions of this policy remain unchanged. This endorsement applies to Policy Number;06435099-0 Issued to(Name of Insured): DON BURGESS CONSTRUCTION CORPORATION Effective date of endorsement; 01122/2009 Policy expiration date:05/12/2009 Farn 1198(1104) From:Kim Cameron,CISR,CPSR,CPIW At:DiBuduc&Defendis Insurance Brokers,LLC FaxID:5594317941 To:Kerr)Date:2/24/2009 12:56 PM Page:9 of 11 DONSURG-01 NIKI ACORDTM CERTIFICATE OF LIABILITY INSURANCE °ATEQ3120/Yl'YY) Zizr2oo9 PRODUCER (559)433-0222 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION DIBuduo&DeFendis insurance Brokers, LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE License#0E02096 HOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. P.O.Box 5479 Fresno,CA 93755-5479 INSURERS AFFORDING COVERAGE NAIC N INSURED Don Burgess Construction Corp. INSURERA:Lincoln General Insurance Company 5630 N.Fresno Street,Ste.1D5 INSURER B_ Fresno,CA 93710-0000 INSURFRL:• INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAM EDABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DL'SORIBEO HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSA DD' POLICY NUMBER PODCV EFFEC7IVE POLICY EXPIRATION LIMITS GENERAL LIABI.ITY EACH OCCURRENCE S COPWERCUIL GENERAL LUU3ILlTYcS caxD PREJJISES Ea ocar esu S CLAIMS MADE OCCUR MED EXP(Anyone peraan S PERSONAL&ADV IWURY S GENERALAGGREME $ GUILAGGREGATE LIMIT APPLIES PER: PRODUCTS.COMPIOPAGG $ POLICY PRO- LOC AUTOMOBILE LIABILJTY CDI.IBINEnS1NGLE 1tMR f ANYAUTO DISK M AGEMENT DI ITN (ERwdda°n ALLOVtiNEDAIITDS -\ppr ved: BODILY INJURY 3 SCHEDULED AUTOS � /^ '�.,�;�r v /Changes: I/J� HIRED AUTOS BODILY IN3URY S NON-OWNED AUTOS (Per"awl, Signe Da PROPERTYDAMAGE $ QA RA GELIABILITY AUTO ONLY-EA ACCIDENT 1 ANY AUTO OTHER THAN EAACC $ AUTO ONLY' AGO $ EXCESSNMBRELLALUlBIL1TY EACH OCCURRENCE S OCCUR u CLAIMS MAUE I AUGREGATE S - S nFnucTIRIF _ , RETENTION 5 S WC STATLI OTH- WORKERS COMPE YSATION AND X. ORY LIMITS A EMPLOYERB'UABHJTY GWC00147900 W12008 311/2009 F-LEACIIACCInFNT S 11000,00 ANY PHOHHILWHIPANINEWEMCUTNE E.I.DISEASE-EAEl�PLOYEE $ OFFICERMEMBER EXCLUDED? 1.000,000 l -6de SPEC UAL PROVISICNS Dekw F nISEASF-POLICY LIMIT $ 11000.00 OTHER I DESCRIPTION OF OPE RATIONS I LOCATIONS/VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS 10-Day Cancellation Notice for NonPaymentof premium INonReporting of payroll elver of Subrogation applies per attached WC 99 03 01 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TBE EXPIRATION City of Fresno DATE THEREOF,THE ISSUNOINSURERWILLENDEAVORTOMAIL 30 OAYSWRITTEN Maryann Lewis c/of Construction Management Division Nonce TO THE CERTIFICATE HOLDER NAMED TO THE LFrr,BUT FwLURE TO oososNALL 1721 Van Ness Avenue IMPOSE NO OBLIOATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Froano,CA 93721- REPRESENTATIVES. AUTHOR RED REPEWNTATIVE ACORD 25(2001!08) 0 ACORD CORPORATION 1988 From:Kim Cameron,CISR,CPSR,CPIW At:DiBuduo&Defendis Insurance Brokers,LLC FaxID:5594317941 To:KenDate:2/24/2009 12:56 PM Page:10 of 11 DONBURG•01 NIKI IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the poltcy(les)must be endorsed.A statement on this certificate does not confer rights to the certificate holder in Ileu of such endorsement(s). 11 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 endarsement s). DISCLAIMER 'The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s),authorized representative or producer,and the certificate holder,nor does It affirmatively or negatively amend, oxlend or alter the coverage afforded by the pollcles listed thereon. 4 ACORD 25(2001t0g) I From:Kim Cameron,CISR,CPSR,CPIW At:DiBuduo 8 Defendis Insurance Brokers,LLC FaxID:5594317941 To:KenDate:224/2009 12:56 PM Page: 11 of 11 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 03 01 Ed.01-0B) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy.We will not enforce our right against any person or organization named In the schedule, (This agreement apples only to the extent that you perform work under a written contract that requires you to obtain this agreement"us.) You must maintain payroll recorcJs accurately segregating the remuneration of your employees while engaged In the work desalbed In the Schedule. This agreement shall not operate dlrectty or Indirectly to benefit anyone not named In the Schedule. Schedule 1, (X) Specific Wolver Name of person or organization:City of Fresno,Its officers,officials,employees,agents and volunteers; Maryann Lewtsr c/o Construction Management Divislon Retail Shopping Center Site Improvement,Central Plaza Shopping Center,Fresno,CA (} Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver, Z. Premrum: The premium charge for this endorsement shall be 5 percent of the premium developed on payroll In connection with wank pt:rformed for the above per5on(s)or organlzatlon(s)arising out of the operations described,subject to a minimum premium of$50.x0 per Spedk Waiver and$500,00 for a Blanket Waiver, I I� f 1 i i This endorsement changes the policy to which It Is attad>ed and is e►featva on the date Issued uniess otherwise staled. (The Information below is requirad only when thus endorsement is issued subsequent to preparation of the policy,) Endorsement Effective: 03101/2008 PoScy No.: =01479D0 Endorsement No,: 001 Don Burgess Constructlon Insured: Corp. Insurance Company LINCOIN UNI AL IRS JMCE DOMPANY Counlerslgned By CENTRAL PLAZA SHOPPING CENTER, LLC. 5680 NORTH FRESNO STREET # 105 FRESNO, CA. 93710 January 29, 2008 Mr. Kerry Trost Senior Risk Analyst City of Fresno 2600 Fresno Street, Room 1070 Fresno, CA. 93721-3612 RE: Central Plaza Shopping Center, LLC/Insurance/Worker's Compensation Dear Mr. Trost: Please Consider this a Formal Written Statement that Central Plaza Shopping Center, LLC has No Auto Liability Coverage (No Owned Autos) and No Worker's Compensation Coverage (No Employees). Sincerely, \ � c �Vv Mr. Harvinder Virk Central Plaza Shopping Center, LLC. CO) RISK MANAGEMENT DIVISION i� Appr ved:l( Uj W X App r ved v Changes: Sign Date Cq U- 73 un c