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AC"R" CERT' IFICAT' E OF LIABILITY INSURANCE DATE (MM/DD,YYYY) 12 / 14 / 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 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 C A a Catherine Montoya y Milestone Risk Management & Insurance Services AHCNNo Ext : ( 949 ) 852 - 0909 FAX No ; ts3s > es2-u31 License No . OB72766 E-MAIL ADDRESS: cmontoya@milestonepromise . com 8 Corporate Park , Suite 130 INSURERS AFFORDING COVERAGE NAIC # Irvine CA 92606 INSURERA : Everest indemnity Insurance 10851 INSURED INSURERB : West American Insurance Company 44393 Wayne Perry , Inc . INSURER C ; Everest National Ins . Co . 10120 8281 Commonwealth Ave . INSURERD : Ohio Casualty Insurance Company 24074 INSURER E : Buena Park ' CA 90621 INSURERF : COVERAGES CERTIFICATE NUMBER: 18 -19 CITY 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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, ILNSR TR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP POLICY NUMBER MM/DD/YYYY MMIDDYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EFib1L00079 -181 EACH OCCURRENCE $ 11000 , 000 A CLAIMS-MADE OCCUR DAMAGE TO RENTED 300 , 000 '.. PREMISES Ea occurrence $ X Contr . Pollution Liab . $1 , 000 , 000 Each occurrence 12/31 /2018 12 /31 /2019 MED EXP (Any one person) $ 25 , 000 X Prof . Liab - Claims Made $1 , 000 , 000 Each Claim PERSONAL & ADV INJURY $ 11000 , 000 GEN'LAGGREGATE LIMITAPPLIES PER: Each Suhject to $2 , 000 , 000 F GENERALAGGREGATE $ 21000 , 000 '.. POLICY � PRO ❑ LOC Policy Aggregate 2 , 000 , 000 JECT PRODUCTS - COMP/OPAGG $ OTHER: $ '.. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident 110001000 B X ANYAUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BAp, ( 19 ) 59235968 12 /31 /2018 12 /31/2019 BODILY INJURY (Per accident) $ AUTOS AUTOS - NON-OWNED PROPERTY DAMAGE HIREDAUTOS AUTOS Per accident $ $ UMBRELLALIAB X OCCUR EACH OCCURRENCE $ 10 , 000 , 000 A X EXCESS LIAR CLAIMS-MADE AGGREGATE $ 10 , 000 , 000 DED X RETENTION $ 0 Ericu00052-181 12/31 /2018 12/31 /2019 $ WORKERS COMPENSATIONPER OTH- AND EMPLOYERS' LIABILITY Y / N X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 11 000 , 000 C OFFICER/MEMBER EXCLUDED? ❑ NIA (Mandatory In NH) CA10003737-181 12/31/2018 12/31/2019 E.L. DISEASE - EA EMPLOYEE $ 11000 , 000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 17000 , 000 D Installation Floater B14059216368 12/31 /2018 12 /31/2019 Limit / Deductible $ 250K / $ 2 , 500 D Rented/Leased Equipment BM059216368 12 /31/2018 12 /31 /2019 Limit / Deductible $ 150k / $ 2 , 500 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101 , Additional Remarks Schedule, maybe attached If more space is required) RE : Costco Roadway Improvements - 525 Alakawa St . , Honolulu , HI 96817 - Add 1 Additional Lane for 350 ' From the Shopping Center Entrance Eastbound to Facilitate a Left Hand Turn Pocket Into the Gas Station . Certificate holder is named as an additional insured per the attached endorsement . CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City & County of Honolulu THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn : DPP Permit Center ( CEB ) ACCORDANCE WITH THE POLICY PROVISIONS. 650 S . King St . Honolulu , HI 96813 AUTHORIZED REPRESENTATIVE Catherine Montoya / CAM �Zz -� © 1988 -2014 ACORD CORPORATION . All rights reserved. ACORD 25 (2014101 ) The ACORD name and logo are registered marks of ACORD INS025 (201401)