PROOF OF INSURANCE (2020 - 2020) CLOSEDDATE (MMIDD/YYYY)
'��`�"`R CERTIFICATE OF LIABILITY INSURANCE
10/25/2019
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).
PRODUCERCONTACT Stacee Warner
NAME:
Craft Guard Insurance Services PHONE, FX0: 760-814-0020 FAX , Nup. 844-960-5600
1930 S COAST HWY STE 200 ADDR1ESS, info@craftguardinsurance.com
INSURER($) AFFORDING COVERAGE NAIC #
OCEANSIDE CA 92054-6455 INSURER A: INFINITY AUTO INS CO 11738
INSURED INSURER B: AIX Specialty Insurance Company 12833
Ruiz Concrete and Paving Inc. INSURER C: Trisura 16188
DBA Ruiz Engineering INSURER 9:
1344 temple Ave. INSURER E:
Long Beach, Ca. 90804 INSURER F:
COVERAGES CERTIFICATE NUMBER: 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' TYPE OF INSURANCE ADOLi UBR POLICY NUMBER IMMMiDDryYYYb IMWDDNYYY
ICY EXP
�O D q' LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
E
MAVEfOREN IED $ 50,000
CLAIMS -MADE X OCCUR PREMISES (Ea arrurrence),
DESCRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
The following entity is listed as additionally insured per attached documents
The per occurrence limit on GL states $1,000,000 but with the Excess Liability policy on top and
as follow forms it will cover and additional $1,000,000 Excess to satisfy the $2,000,000
requirement
CERTIFICATE HOLDER CANCELLATION
City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS.
EI Segundo, CA 90245
AUTHORIZED REPRESENTATIVE
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
MED EXP (Any one Person) $ 5,000
B i y y SIZGL0511A21994406/20/2019
06/20/2020 PERSONAL &ADV INJURY $ 1,000,000
^
GEN'L AGGREGATE LIMIT APPLIES PER!
ENERALAGGREGATE $ 2,000,000
GENERAL
X '', POLICY [7, jEt,fi E] LOC
.
PRODUCTS - COMP/OP AGO $ 2,000,000
OTHER,
$
AUTOMOBILE LIABILITY 1
COMBINED SINGLE LIMIT i s 1,000,000
(Ea ac idewo)
X ANY AUTO
BODILY INJURY (Per person) S
A OWNED
AUTOS ONLY AUTOS y y 504610125978001
0$/02/2019
08/02/2020 BODIpLYHI� INJURY (Per accidenl)„ $
TOS NON OWNED
$
AUTOS ONLY „ AUTOS ONLY
„ (Pea ,au wdeol
I
$
UMBRELLA LIAB OCCUR
n
1 EACH OCCURRENCE $ 00'000
C Y Y TRXS0001090
EXCESS LAB MS -MADE 1
10/24/2019
06/20/2020
AGGREGATE $
DED RETENTIONS
$
WORKERS COMPENSATION
IPC O H-
AND EMPLOYERS' ILITY YI❑
ANYP OPRIETOR/PARBNER/EXECUTIVE
EL EACH$
OFFICER/MEMBER EXCLUDED. N/A
(Mandatory in NH)
$
E,L. DISEASE - EA EMPLOYEE!If
yes, describe under
DESCRIPTION OF OPERATIONS below
EL DISEASE POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
The following entity is listed as additionally insured per attached documents
The per occurrence limit on GL states $1,000,000 but with the Excess Liability policy on top and
as follow forms it will cover and additional $1,000,000 Excess to satisfy the $2,000,000
requirement
CERTIFICATE HOLDER CANCELLATION
City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS.
EI Segundo, CA 90245
AUTHORIZED REPRESENTATIVE
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
Ae!��
$p1eiclialty,
Ciompiariy
THIS I SFAMNT CS.aLNM TIM POCK' PLEASE READ IT CAREFULLY.
AIX SPECIALT3i INSURANCE CO fPANY
X4110 1 SMOVIKEW, 31C I M MI am Fm I I M I Iva",
ADDITIONAL INSURED ENDORSMENT
The section of the policy entitled III. – NVHO IS AN INSURED is d to include as an additional insured any person or
organization for whomr you are performing operations when you and such person or organization haves agreed in a legally enforceable
written contract or a,greenient entered into before your woik co aced, that such person or organization be added as an additional
insured on you policy. The coverage afforded by this endorsement is only (1) with respect to liability in connection w%th the original
Named Insured's ongoing operations perfb=d for said Additional Insured during the tem of this policy, and (2) only if the
Additional Insured performs all obligations required under this policy -
The co%wage afforded to an Additional lnsm *d is limited to a claimmade for a Covered Loss not covered by other insurance available
to an Additional Insured, and is limited by the pimRsions of the Insuring Aga^e+ went, Exclusions, Conditions set forth in the policy
and all endorsements thereto.
No coverage is aBorded under the "products -completed operations hazard' for an Additional Iusared pursuant to this endorsement_
The coverage afforded to an Additional Insured under this endorsement ends as of the date of completion, abandonment, or termination
of the work of the Named Insured at any lobsite, project, or structure- There is no coverage hereunder for any Additional Insured in
connection with any claim or suit invols* any claim for damage that takes place or is alleged to take place followk—a completion of
the. Named lnsured's wioik.
The "lroork" of the Named Insured will be deemed completed as of the date all work, including; materials, parts or eqtupment firmished
in connection with such work, on the project or any structure therein (other than senwe, maintenance or repairs) to be perforined by or
on bebalf of the additional insured(s) at the location of the covered operations has been completed, or when that portion of `your work"
out of iwinch the injury or damage arises has been put to its intended use by any person or organization, including anotber contractor or
subcontractor engaged in perfornung operations as part of the same project, whichever is earlier.
The coverage provided for the Additional Insared is only to the extent that the additional insured is held liable for the negligence or
strict liability of the Named Insured, and is only to the extent of and in the proportion Additional Iffiared is held liable for the
negligence or strict liability/conductlacts of the Named Insured_ No coverage is provided for liability based upon the acts, errors or
missions of the Additional Insured_
If expressly required by a written and legally enforceable contact entered into by the Named Insured prior to comniencement of wu&
by the Named Insured for the Additional Insured, then the insurance afforded by the policy to the Additional Inswed shall be primary
insurance, and any insurance or self-insurance maintained by the above Additional Insured shall be excess of the insurance afforded
to the Named Insured and shall not contribute to it -
If expressly required by a written and legally enforceable contract entered into by the Named Insured prior to commencement of wo&
by the Named Insured fDr the Additional Insared, them we waive any right of subrogation we may have against an entity that is an
Additional. Insured per the temps of this endorsement because of payments we make for injury or damage ansmg out of `yon Rork„
'performed makes such written and legally enforceable contract with that Additional Insured_
Except as set forth abatre, all of the term. conditions and ewhisious of the policy apply and rennin in effieci.
Policy No.: SIZGLO51IA2199U AIX Specialty Insarance Company
3250 Grey Hawk Ct, Ste. Z
Date: 0492W2019 Carlsbad- ^ A '?010
Time: 12:01 a.m.
Ala� Representative
AIX Al OPWS 00 01 0319 Pape 1 of 1
TRISiJRA
Trisura Specialty Insurance Company
COMMERCIAL EXCESS LIABILITY COVERAGE
DECLARATIONS
INSURED'AGENT
Craft Guard lnc, DBA C�raft Guard Insurance Services
1930 South Coast Hwy. Ste #22013
Date: iom412019 Ooean side, CA 920E4
Time: 12:01 a.m.
POLICY NO.: TRX3001311090
ITEM 1. Named Insured.- Ru-Lz Concrete & Paving Inc
DBA- DBA Ruiz Engineering
Mailing Address'. 1,344 Terripte Avenue, Long Beach, CA 90804
Phys:�cal Address: 7344 Temple Avenue, Long Beacm, CA P0804
ITEM 2. POLICY PERIOD: 1=4,12oig tO DW213120213
(12:01 ALM. Iprevailing time at the address stated in Itefil 1. above)
ITEM 3. RETROACTN'E DATE- Not Applicable
ITEM 4. COVERAGE: FNomng Form Commercial Excess Liability
ITEM 5. EXCESS LIABILITY LIMITS: si,000,000 Per Occurrence, Per C1 ai im or Per ILoss
(per Followed Policy)
$1 d000,0100 Aggregate, where appkwNe
ITEM 6. CONTROLLING UNDERLYlNG PCILICY: Sl.ZGL051 IA,219944
ITEM 7. SCHEDULE OF UNDERLYING INSURANCE
See form # SISTRIXS SUI 01 1118
ITEM 8. Premium: $1,003.5B
Association Dues: $201013
Surplus Lines Tax: $341.11
Stamping Tax: $2.01
Total- $1,235.7,0
ITEM 9. COMMERCIAL EXCESS LIABILITY POLICY FORM.- SISTRIXS CO 0104, 13 together with endorsements
as per attached Schedule of Endorsernerits form SISTRJXS SFE 01 '1118,
ITEM 10. MINIMUM EARNED PREWUM: 2�5%
SISTRIXS DEC of a 119 Page I of I
Tr,sura Spe6alry Irsuilance Corri,,nany; 2r„0 Park Menue, Suite 14001,; 046ir�orra C4, OK 73102
DATE (MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE
�,,,.•• 10/08/2019
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(les) 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 Pacific Pro's insurance Agency
HONE 1Y: A % _......_.
NAME: Y
Pacific Pro's Insurance AgencyArC N,n 714-909-0755 MIC. Nol:
MA� ...........................
8700 Wa rner Ave, Ste. 220 ADDREs kim@pacificprosins.com
IPIINSURER(S) AFFORDING COVERAGE NAIC •
_....................................................................................p IT. �............_
Fountain ValleyCA 92708 Preferred Professional Insurance Company339950
INSURED INSURER B
Ruiz Concrete & Paving, Inc. I INSURER C :
DBA: Ruiz Engineering I INsuRERD:
...........................................................................
1344 Temple Ave I INSURER E:
...............................................
Long Beach CA 90804-2423 I INSURER F:
COVERAGES CERTIFICATE NUMBER: 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.
�........................... __.__r. _ .._........_r ___.........................................
INSR TYPE OF INSURANCE IA,DOL SUBIR POLICY EFF POLICY EXP LIMITS
LTR INSn WVn POLICY NUMBER (MMIDDryY'YYI WMIDO(YYYY)
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
.• IU&RLNILU
CLAIMS -MADE ..•.•.• ]OCCUR Air r13,_ fE'r1_2r,; ,tigrrnnreeI $
MED EXP (Anyone person) $
_ ...................
PERSONAL & ADV INJURY $
_.._....... . ____................. __m .........................
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $
POLICY ❑ PRO ❑LOC
JEC7
OTHER
AUTOMOBILE LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLYAUTOS
HIRED _.M. NON -OWNED
AUTOS ONLY AUTOS ONLY
UMBRELLALIABOCCUR
T EXCESS LIAB CLAIMS. MADE
DED I RETENTION$p
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y I N
ANYPR OPRI ETORIPARTNERIEXECUTI VE
A OFFICERIMEMBER EXCLUDE D7 Y NIA X
(Mandatory In NH)
I f yyes, dro � rrlb o under
DESCRIPTflON OF OPERATIONS below
PRODUCTS - COMP/OP AGG
COMBINED SINGLE LIMIT $
fEn a(vdonl)
BODILY INJURY (Per person) $
................................
BODIlPeraLY nAMA� E .......$...................
INJURY (Per ar�ident,•,•• „X ^•................
.............__m
EACH OCCURRENCE $
AGGREGATE $
X..L.cM.. AT UTE......L.___-„L EF H.�
E L EACH ACCIDENT
ON08918-01 04/01/2019 04/01/2020 -•.•••••••••••-• $ 1,000,000••••••
EL DISEASE-EAEMPLOYEE', $ 1,000,000
.---..•.•.•.•.•.•.•.•...._......•.•.•.•.•.•.•.•._.__..._.... ........_.......... ...................... I
EL DISEASE -POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required)
Proofof Insurance
CSLB # 966395
"Subject to policy terms, conditions and exclusions.”
CERTIFICATE HOLDER
City of EI Segundo
Frivera@elsegundo.org
350 Main Street
EI Segundo
ACORD 25 (2016/03)
MAHMARETUDO 11,
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
CA 90245 AUTHORIZED REPRESENTATIVE
Rhonda Holt
O 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC ON 04WSA
(Ed. 01-19)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA
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 the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work
under a written contract that requires you to obtain this agreement from us.)
You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work
described in the Schedule.
Blanket Waiver: The additional premium for this endorsement shall be 2% of the California workers' compensation premium
otherwise due on such remuneration, subject to a $ 250 minimum charge.
Specific Waiver: The additional premium for this endorsement shall be 5% of the California workers' compensation premium
otherwise due on such remuneration, subjectto a $ 100 minimum charge.
Schedule
Person or Organization Job Description
Blanket Waiver of Subrogation As respects to all CAjobs performed by the named insured during the
policy period where by written contract a waiver of subrogation is
required prior to the commencement of work.
I,
�
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective: 04/01/2019
Insured Ruiz Concrete & Paving, Inc.
dba Ruiz Engineering
Print Date: 4/29/2019
Policy No.: ON08918 - 01 Endorsement No.:
Insurance Company Preferred Professional Insurance Company
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Countersigned By