EVIDENCE OF COMMERCIAL PROPERTY INSURANCE THIS IS EVIDENCE THAT INSURANCE AS IDENTIFIED BELOW HAS BEEN ISSUED, IS IN FORCE, AND CONVEYS ALL THE RIGHTS AND PRIVILEGES AFFORDED UNDER THE POLICY. Sample PRODUCER NAME, CONTACT PERSON AND ADDRESS Code: Visions Insurance Agency 1611 E. seventeenth Street www.insurancevisions.com CA 1298774 AGENCY CUSTOMER ID: INSURED NAME AND ADDRESS PHONE: FAX: ABC Construction Company, Inc. 800.427.3253 (714) 285-4282 Sub-Code: COMPANY NAME AND ADDRESS LOAN NUMBER EFFECTIVE DATE NAIC NO: Document ADDITIONAL NAMED INSURED(S) CA 92703 Date IF MULTIPLE COMPANIES COMPLETE SEPARATE FORM FOR EACH EXPIRATION DATE THIS REPLACES PRIOR EVIDENCE DATED: Broadmore Framing Company PROPERTY INFORMATION (Use additional sheets if more space is required) LOCATION/DESCRIPTION Premises situated at: Building, Business Personal Property & Business Income CA 92703 COVERAGE INFORMATION CAUSE OF LOSS FORM BASIC COMMERCIAL PROPERTY COVERAGE AMOUNT OF INSURANCE: YES NO BROAD 2,150,000 SPECIAL OTHER POLICY NUMBER CONTINUED UNTIL TERMINATED IF CHECKED BUSINESS INCOME/RENTAL VALUE If YES, LIMIT: Actual Loss Sustained # of mos: BLANKET COVERAGE If YES, indicate amount of insurance on properties identified above: TERRORISM COVERAGE Attach signed Disclosure Notice / DEC IS COVERAGE PROVIDED FOR 'CERTIFIED ACTS' ONLY? If YES, SUB LIMIT: N/A DED: IS COVERAGE A STAND ALONE POLICY? If YES, LIMIT: DED: DOES COVERAGE INCLUDE DOMESTIC TERRORISM? If YES, SUB LIMIT: N/A DED: 1,000 COVERAGE FOR MOLD If YES, LIMIT: DED: MOLD EXCLUSION (If 'YES' specify organization's form used) REPLACEMENT COST Per ISO Form AGREED AMOUNT Included COINSURANCE If YES, % EQUIPMENT BREAKDOWN (If Applicable) If YES, LIMIT: 2,150,000 DED: 24 hours LAW AND ORDINANCE - Coverage for loss to undamaged portion of building If YES, LIMIT: 1,075,000 DED: 1,000 - Demolition Costs If YES, LIMIT: 25% DED: 1,000 - Incr. Cost of Construction If YES, LIMIT: 250,000 DED: 1000 EARTHQUAKE (If Applicable) If YES, LIMIT: DED: FLOOD (If Applicable) If YES, LIMIT: DED: WIND / HAIL (If Applicable) If YES, LIMIT: DED: PERMISSION TO WAIVE SUBROGATION PRIOR TO LOSS REMARKS - Including Special Conditions (Use additional sheets if more space is required) CA 92705 DED: 61554 650,000 6 750,000 Anthem Insurance Company 180 Dove Avenue Newport Beach CA-38474376763-VB-04 5/20/2005 CA 5/20/2006 Included where required by contract 92662 P 05 2928383 1,000 See attached endorsement CP 12 18 06 95, as interest may appear CANCELLATION THE POLICY IS SUBJECT TO THE PREMIUMS, FORMS, AND RULES IN EFFECT FOR EACH POLICY PERIOD. SHOULD THE POLICY BE TERMINATED, THE COMPANY WILL GIVE THE ADDITIONAL INTEREST IDENTIFIED BELOW 30 *DAYS WRITTEN NOTICE,AND WILL SEND NOTIFICATION OF ANY CHANGES TO THE POLICY THAT WOULD AFFECT THAT INTEREST, IN ACCORDANCE WITH THE POLICY PROVISIONS OR AS REQUIRED BY LAW. * TEN DAYS FOR NON-PAYMENT OF PREMIUM ADDITIONAL INTEREST NAME & ADDRESS LENDER SERVICING AGENT NAME AND ADDRESS MORTGAGEE LOSS PAYEE Mortgage Management Corp Attn: Beth Roberts P. O. Box 23 Anaheim CA 92640 AUTHORIZED REPRESENTATIVE Mike Mulligan ACORD 28 (2003/10) O c ACORD CORPORATION 2003 created at www.e CertsONLINE.com
POLICY NUMBER P 05 2928383 ABC Construction Company, Inc. Broadmore Framing Company COMMERCIAL PROPERTY CP 12 18 06 95 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LOSS PAYABLE PROVISIONS This endorsement modifies insurance provided under the following: BUILDING AND PERSONAL PROPERTY COVERAGE FORM BUILDERS' RISK COVERAGE FORM CONDOMINIUM ASSOCIATION COVERAGE FORM CONDOMINIUM COMMERCIAL UNIT-OWNERS COVERAGE FORM STANDARD PROPERTY POLICY Provisions Applicable Loss Lender's Contract Payable Loss Payable Of Sale SCHEDULE Description of Property Loss Payee (Name & Address) Premises situated at: CA 92703 Building, Business Personal Property & Business Income A. When this endorsement is attached to the STANDARD PROPERTY POLICY CP 00 99 the term Coverage Part of this endorsement is replaced by the term Policy. The following is added to the LOSS PAYMENT Loss Condition, as indicated in the Declarations or by an 'X' in the Schedule: B. LOSS PAYABLE For Covered Property in which both you and a Loss Payee shown in the Schedule or in the Declarations have an insurable interest, we will: 1. Adjust Losses with you; and 2. Pay any claim for loss or damage jointly to you and the Loss Payee, as interests may appear. CP 12 18 06 95 Page 1 of 2
C. LENDER'S LOSS PAYABLE 1. The Loss Payee shown in the Schedule or in the Declarations is a creditor including a mortgageholder or trustee whose interest in Covered Property is established by such written instruments as: a. Warehouse receipts; b. A contract for deed; c. Bills of lading; or d. Financing statements. e. Mortgages, deeds of trust, or security agreements. 2. For Covered Property in which both you and a Loss Payee have an insurable interest: a. We will pay for covered loss or damage to each Loss Payee in their order of precedence, as interests may appear. b. The Loss Payee has the right to receive loss payment even if the Loss Payee has started foreclosure or similar action on the Covered Property. c. If we deny your claim because of your acts or because you have failed to comply with the terms of the Coverage Part, the Loss Payee will still have the right to receive loss payment if the Loss Payee: (1) Pays any premium due under this Coverage Part at our request if you have failed to do so; (2) Submits a signed, sworn proof of loss within 60 days after receiving notice from us of your failure to do so; and (3) Has notified us of any change in ownership, occupancy or substantial change in risk known to the Loss Payee. All of the terms of this Coverage Part then apply directly to the Loss Payee. d. If we pay the Loss Payee for any loss or damage and deny payment to you because of your acts or because you have failed to comply with the terms of this Coverage Part: (1) The Loss Payee's rights will be transferred to us to the extent of the amount we pay; and (2) The Loss Payee's rights to recover the full amount of the Loss Payee's claim will not be impaired. At our option, we may pay to the Loss Payee the whole principal on the debt plus any accrued interest. In this event, you will pay your remaining debt to us. 3. If we cancel this policy, we will give written notice to the Loss Payee at least: a. 10 days before the effective date of can- cellation if we cancel for your nonpayment of premium; or b. 30 days before the effective date of can cellation if we cancel for any other reason. 4. If we elect not to renew this policy, we will give written notice to the Loss Payee at least 10 days before the expiration date of this policy. D. CONTRACT OF SALE 1. The Loss Payee shown in the Schedule or in the Declarations is a person or organization you have entered a contract with for the sale of Covered Property. 2. For Covered Property in which both you and the Loss Payee have an insurable interest we will: a. Adjust losses with you; and b. Pay any claim for loss or damage jointly to you and the Loss Payee, as interests may appear. 3. The following is added to the OTHER INSURANCE Condition: For Covered Property that is the subject of a contract of sale, the word 'you' includes the Loss Payee. Page 2 of 2 CP 12 18 06 95
POLICY NUMBER ABC Construction Company, Inc. Broadmore Framing Company COMMERCIAL GENERAL LIABILITY CG 20 18 11 85 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED MORTGAGEE, ASSIGNEE, OR RECEIVER This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: Designation of Premises: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) 1. WHO IS AN INSURED (Section II) is amended to include as an insured the person(s) or organization(s) shown in the Schedule but only with respect to their liability as mortgagee, assignee, or receiver and arising out of the ownership, maintenance, or use of the premises by you and shown in the Schedule. 2. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. CG 20 18 11 85
Producer Insured CERTIFICATE OF LIABILITY INSURANCE Sample S AFFORDING COVERAGE C Document ABC Construction, Inc. Broadmore Framing Company, Inc. COVERAGES A B D THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR A B Visions Insurance Agency 1611 E. seventeenth Street 800.427.3253 www.insurancevisions.com CA 1298774 TYPE OF INSURANCE GENERAL LIABILITY COMMERCIAL GENERAL LIAB CLAIMS MADE GEN'L AGG LIMIT APPLIES PER POLICY PROJECT LOC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS GARAGE LIABILITY ANY AUTO EXCESS LIABILITY OCCUR CLAIMS MADE DEDUCTIBLE 10000 OCCUR RETENTION WORKERS' COMPENSATION & EMPLOYERS' LIABILITY Mike Mulligan CA 92705 CA 92703 POLICY NUMBER POLICY EFFECTIVE DATE MM/DD/YY Anthem Insurance Company POLICY EXPIRATION DATE MM/DD/YY GL462784-00 5/20/2005 5/20/2006 UMB-00-813488725 5/20/2005 5/20/2006 Casualty Risk Insurance Company c/o Beechum & Associates EACH OCCURRENCE FIRE DAMAGE (Any 1 fire) MED EXP (Any one person) PERSONAL & ADV INJURY GENERAL AGGREGATE PRODUCTS-COMP/OP AGG Date (mm/dd/yy) LIMITS COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) AUTO ONLY - EA ACCIDENT OTHER THAN EA ACC AUTO ONLY: AGG EACH OCCURRENCE AGGREGATE STATUTORY LIMIT OTHER EL EACH ACCIDENT EL DISEASE - EA EMPLOYEE EL DISEASE - POLICY LIMIT 1,000,000 50,000 Excluded 1,000,000 2,000,000 1,000,000 5,000,000 5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS The Certificate Holder is hereby named as an Additional Insured - Mortgagee per the attached endorsement CG 20 18 11 85 Premises at:,, CA 92703 CERTIFICATE HOLDER Building in CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL DAYS 30 * WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRE- SENTATIVES. * 10 Days for Non-Payment of Premium AUTHORIZED REPRESENTATIVE Mike Mulligan ACORD 25-S (7/97) created at www.e CertsONLINE.com O c ACORD CORPORATION 1988
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 certificate holder in lieu 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. ACORD 25-S (7/97) created at www.e CertsONLINE.com