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SCRWA - OMI - Insurance Certificate (2019)ACORV CERTIFICATE OF LIABILITY INSURANCE FATE /19 /2DIYYYY) /19/2018 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: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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 LIC #0437153 1- 212 - 948 -1306 Marsh Risk & Insurance Services CIRTS_Support@jacobs.com CONTACT NAME: PHONE FAX 1- 212 - 948 -1306 (AIC. No. E :O: A/C, No): E-MAIL 633 W. Fifth Street ADDRESS: INSURER (S) AFFORDING COVERAGE NAIC q HDO G71096750 INSURERA: ACE AMER INS CO 22667 Los Angeles, CA 90071 INSURED INSURER B: OPERATIONS MANAGEMENT INTERNATIONAL, INC. INSURER C. INSURER D: $ 500,000 9191 South Jamaica Street INSURER E: X INSURER F: Englewood, CO 80112 -5946 COVERAGES CERTIFICATE NUMBER: 53115530 REVISION NUMBER: 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 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MWDDIYEFF MMIDD/YYYY LIMITS • X COMMERCIAL GENERAL LIABILITY HDO G71096750 07/01/18 07/01/19 EACH OCCURRENCE $ 7,000,000 _ CLAIMS -MADE � OCCUR RENTED DAMAGE TO occurrence PREMISES S $ 500,000 MED EXP (Any one person) $ 5,000 X CONTRACTUAL LIABILITY PERSONAL & ADV INJURY $ 7,000,000 _ AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 10, 000, 000 GEN'L POLICY E1 PEA D LOG PRODUCTS - COMP/OP AGG $ 10,000,000 $ OTHER: • AUTOMOBILE LIABILITY ISA H25158684 07/01/18 07/01/19 COMBINED SINGLE LIMIT Ea accident $ 2,000,000 BODILY INJURY (Per person) $ X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTYDAMAGE Per accident $ UMBRELLALIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR DED RETENTION $ $ • • A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANYPROPRIETORIPARTNERJEXECUTIVE OFFICERIMEMBEREXCLUE (Mandatory in NH) NIA WLR C6479033A (ADS) WCU C64789533 (LA, OH, T SCF C64789570 (WI) 07/01/18 97/01/18 07/01/18 07/01/19 07/01/19 07/01/19 ER X STATUTE OERH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 IF yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) LOCATION: Englewood, CO. RE: OPERATION, MAINTENANCE AND MANAGEMENT SERVICES FOR THE SOUTH COUNTY REGIONAL WASTEWATER AUTHORITY. THE CERTIFICATE HOLDER IS INCLUDED AS AN ADDITIONAL INSURED ON THE GENERAL LIABILITY AND AUTOMOBILE LIABILITY POLICIES AS REQUIRED BY WRITTEN CONTRACT OR AGREEMENT. *$2,250,000 SIR for states of: LA, OH, TX. *THE TERMS, CONDITIONS, AND LIMITS PROVIDED UNDER THIS CERTIFICATE OF INSURANCE WILL NOT EXCEED OR BROADEN IN ANY WAY THE TERMS, CONDITIONS, AND LIMITS AGREED TO UNDER THE APPLICABLE CONTRACT.* I:tKIR -IUAIt HULUtK GANGLLLAIIUN SOUTH COUNTY REGIONAL WASTEWATER AUTHORITY 7351 ROSANNA STREET GILROY, CA 95020 ACORD 25 (2016/03) Cert_Renewal 53115530 USA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988 -2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ffir �n w O �4 7 z W r NOTICE TO OTHERS ENDORSEMENT -- SCHEDULE - EMAIL ONLY w 0 "Nerved Insured ,Jacobs Engineering Group Inc _ __ j �ndorsamontNumber Ij 13 PoLcy 5yrnoot ! Policy Nurnbw Pairey Period tiffective Date of Endorsement HDO 1 G71096750 07/01/2018 T© 07/01121019 ....... �,a,... _v ...., ..... i Issued By (Narnn of Insurance Company) Z ACE American Insurance Company insert the pocky number The remaivider of the Information is to be oomptated only whOn Ih is aunt * ,aaued eubsequertf to the prepatafein nr the pohpy THIS ENDORSEMENT CHANGiES THE POLICY. PLEASE REAM IT CAREFULLY. A. If we cancel the Policy prior to its expiration date by notice to you or the first Named Insured for any reason other than nonpayment of premium, we will endeavor, as set out below, to send written notice of cancellation, via such electronic notification as we determine, to the persons or organizations listed In the schedule that you or your representative provide or have provided to us (the "Schedule ") You or your representative must provide us with the e -mail address of such persons or organizations, and we will utilize such e-mail address that you or your representative provided to us on such Schedule. B. The Schedule mist be initially provided to us within 15 days after, 1. The beginning of the Policy period, if this endorsement is effective as of such date. or IL This endorsement has been added to the Policy, if this endorsement is effective after the Policy period commences. C. The Schedule must be in an electronic format that is acceptable to us, and must be accurate D. Our delivery of the notification as described in Paragraph A, of this endorsement will be based on the most recent Schedule in our records as of the date the notice of cancellation is mailed or delivered to the first Named Insured E. We will endeavor to send such notice to the e-mail address corresponding to each person or organization indicated in the :schedule at least 30 days prior to the cancellation date applicable to the Policy F. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) or organizations) named in the Schedule in the event of a pending cancellation of coverage. We have no legal obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of cancellation to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of any kind upon us, our agents or representatives, will not extend any Policy cancellation dale and will not negate any cancellation of the Policy. G. We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for any incorrect information that you or your representative provide to us. If you or your representative does not provide us With a Schedule, we have no responsibility for taking any action under this endorser -rent. In addition, it neither you not your representative provides us with e-mail address information with respect to a particular person or organization, then we shall have no responsibility for taking action with regard to such person or entity under this endorsement. H. We may arrange with your representative to send such notice in the event of any such cancellation. L You will cooperate with us in providing the Schedule, or in causing your representative to provide the Schedule. J. This endorsement does riot apply in the event that you cancel the Policy. ALL-32685 (01111) Page 1 of 2 P526002HOol All other terms and conditions of the Policy remain unchanged ___..._.._. Authorized Representative ALL -32685 (01/11) Page 2 of 2 ttt NOTICE TO OTHERS ENDORSEMENT — SCHEDULE — EMAIL ONLY Named Insured ,Jacobs Engineering Group Inc. Endorsement 3 Number Policy Symbol l Policy Number Policy Period Effective Date of Endorsement ISA H25158664 07/0112018 TO 07/01/2019 Issued By (Name of Insurance Company) ACE American Insurance Company Insert the policy number The remainder of the Information is to be completed only when this endorsement Is Issued subsequent to the preparation of the policy THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. A. If we cancel the Policy prior to its expiration date by notice to you or the first Named Insured for any reason other than nonpayment of premium, we will endeavor, as set out below, to send written notice of cancellation, via such electronic notification as we determine, to the persons or organizations listed in the schedule that you or your representative provide or have provided to us (the "Schedule "), You or your representative must provide us with the e-mail address of such persons or organizations, and we will utilize such e-mail address that you or your representative provided to us on such Schedule. B. The Schedule must be initially provided to us within 15 days after: i. The beginning of the Policy period, if this endorsement is effective as of such date; or it. This endorsement has been added to the Policy, if this endorsement is effective after the Policy period commences. C. The Schedule must be in an electronic format that is acceptable to us; and must be accurate. D. Our delivery of the notification as described in Paragraph A. of this endorsement will be based on the most recent Schedule in our records as of the date the notice of cancellation is mailed or delivered to the first Named Insured. E. We will endeavor to send such notice to the e-mail address corresponding to each person or organization indicated in the Schedule at least 30 days prior to the cancellation date applicable to the Policy. F. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) or organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no legal obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of cancellation to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of any kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate any cancellation of the Policy. G. We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for any incorrect information that you or your representative provide to us. If you or your representative does not provide us with a Schedule, we have no responsibility for taking any action under this endorsement. In addition, if neither you nor your representative provides us with e-mail address information with respect to a particular person or organization, then we shall have no responsibility for taking action with regard to such person or entity under this endorsement. H. We may arrange with your representative to send such notice in the event of any such cancellation. I. You will cooperate with us in providing the Schedule, or in causing your representative to provide the Schedule. J. This endorsement does not apply in the event that you cancel the Policy. ) %LL -32685 (011.11) ,Page 1 of 2 w 0 11) 0 w P526UU 28002 tAll other terms and conditions of the Policy remain unchanged, Authorized Representative ALL -32885 (01 /11) gage 2 of 2 a, r Wnrkers' Cmmnensatton and Emnlovers' Llability Pollev Named Insured _ Endorsement Number JACOBS ENGINEERING GROUP INC. 600 WILSHIRE BOULEVARD, SUITE 1000 Policy Number LOS ANGELES CA 90017 SymboI:WLR Number. C647033A Policy Period Effective Date of Endorsement 07 -01 -2018 TO 07 -01 -2019 07 -01 -2018 _ _ Issued By (Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY _ Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the polio NOTICE TO OTHERS ENDORSEMENT — SCHEDULE — EMAIL ONLY A. If we cancel this Policy prior to its expiration date by notice to you or the first Named insured for any reason other than nonpayment of premium, we will endeavor, as set out below, to send written notice of cancellation, via such electronic notification as we determine, to the persons or organizations listed in the schedule that you or your representative provide or have provided to us (the "Schedule'). You or your representative must provide us with the e-mail address of such persons or organizations, and we will utilize such e-mail address that you or your representative provided to us on such Schedule. B. The Schedule must be initially provided to us within 15 days after: I. The beginning of the Policy period, if this endorsement is effective as of such date; or ii. This endorsement has been added to the Policy, if this endorsement is effective after the Policy period commences. C. The Schedule must be in an electronic format that is acceptable to us; and must be accurate. D. Our delivery of the notification as described in Paragraph A. of this endorsement will be based on the most recent Schedule in our records as of the date the notice of cancellation is mailed or delivered to the first Named Insured. E. We will endeavor to send such notice to the e-mail address corresponding to each person or organization indicated in the Schedule at least 30 days prior to the cancellation date applicable to the Policy. F. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) or organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no legal obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of cancellation to the person(s) or organization(s) shown in the Schedule shall impose no obligation or liability of any kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate any cancellation of the Policy. G. We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for any incorrect information that you or your representative provide to us. If you or your representative does not provide us with a Schedule, we have no responsibility for taking any action under this endorsement. In addition, if neither you nor your representative provides us with e-mail address information with respect to a particular person or organization, then we shall have no responsibility for taking action with regard to such person or entity under this endorsement. H. We may arrange with your representative to send such notice in the event of any such cancellation. I. You will cooperate with us in providing the Schedule, or in causing your representative to provide the Schedule. J. This endorsement does not apply in the event that you cancel the Policy. All other terms and conditions of this Policy remain unchanged. This Endorsement is not applicable in the states of AZ, FL, ID, ME, NC, NJ, NM,TX and WI. -- ---- -- - - -- - - - ___ Authorized Representative WC 99 03 68 (01/11) Page 1 w .f, 0 0 w Pi2W02HUO2 SUPPLEMENT TO CERTIFICATE OF INSURANCE NAME OF INSURED: OPERATIONS MANAGEMENT INTERNATIONAL, INC. SUPP (10 /00) DATE 06/19/2018 O