PROOF OF INSURANCE (2020 - 2020) CLOSED,-< ----s a DATE (MMIDDNYYY)
C>RE' CERTIFICATE OF LIABILITY INSURANCE 11/11/2019
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 pollcy(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 LICENSE NO. 0637431 CONTACT PATRICK MCRAE
NAME: .. .. mm .-_--.
PATRICK MCRAE INSURANCE SERVICES Elliil: ( t PHONE 7144 779-6999 tFAX AIC.Noi: ( 714 779-6903
i..ilVO,l:ls�..,
E-MAIL mcrae@sbC inb8l.net
1265 N. MANASSERO SUITE 303 ADDRESS: P 9
ANAHEIM HILLS, CA 92807 INSURER(S)AFFORDING COVERAGE .................... NA—1
..........
INSURER A; GEMINI INSURANCE COMPANY 10833
INSURED INSURERB: WESCO INSURANCE COMPANY 25011
INSURER C: FIRST MERCURY INSURANCE 10657 I
CT & T CONCRETE PAVING INC. INSURER D: GREAT AMERICAN INSURANCE CO. OF NY 22136
324 S DIAMOND BAR BLVD, PMB 275 INSURER„E:
DIAMOND BAR CA 91765
F
CATE
SION
OTTHIS ISS TO CERTIFY THAT THE POL G ESTOFI INSURANCEE BL SED BELOW HAVE BEEN ISSUED TO THE INSURED E AIUMBER:
MD 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.
tLT, li �i �. LIMITS ...
AbDL"SUBR POLICY EFF POLICY EX
TYPE OF INSURANCE , POLICY NUMBER f,MMIO014YYY) IMM'IDt (Y)PYr,
RRENCE $
A X...i COMMERCIALCLAIMS-MADE LITY x X VCGP024698 06109x201906I09202G} R-T?5'�6NYYr.._ 1»000,000
50,000,,
1 MED EXP (Ani one �aeraars) $ 5,00.0-111-
.
,00{/
_....._.......... ............. _..._ m .., „_..
PERSONAL & ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2:000,000
POLICY D PR AGG
P ^ ...I LOC PRODUCTS-COMPIO ' _.... 00,000
2x0
EBL $ $10'00,000
OTHER:
�I B AUTOMOBILE LIABILITY X X WPPIS56836 03 0'6123/20190612'3/2020..JCOM
Fta °°tll Ee SINGLELIMIT $ 1,000,000
X ANY AUTO BODILY INJURY (Per person) $
OWNED
AUTOS ONLY
X HIRED
AUTOS ONLY
C UMBRELLA LIAR
q---, SCHEDULED
AUTOS
XNON -OWNED
_.y AUTOS ONLY
_ q IX OCCUR
X EXCESS LIAR m. CLAIMS•MAOE
DED RETENTION $
E WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y I N
ANYPROPRIETOPIPARTiNER!EXECUTIVENIA
OFF uCERBMEMBER EXCLUDED
(Mandatory in NH)
1I es, describe Vander
DESCRIPTION OF OPERATIONS balosw
D INLAND
MARINE/PROPERTY
BODILY INJURY (Per accident) $
Pam
PROIaaERTY DAMAGE
.... .......
......$...111-,,.....__ ........!
CA -EX -0000078856-02 0611612019 06109/2020 _EACH OCCURRENCE $ 5,000,000
AGGREGATE $ 5„000,000
$
XTR'I"U'TE �. ERIOT /,
E.L. EACH ACCIDENT $
E.L. DISEASE . EA EMPLOYEE '$
E.L, DISEASE -POLICY LIMIT , $
MACE2289310200 04/27/20104/271202 $129,692 SCHEDULED EQUIPMENT ,$250.000
BUILDING
9 p
$20,000 BRP
TION OF OPERATIONS I LOCATIONS /VEHICLES, {ACORO 101, Additional Remarks Sctaadurlo may Nae atimobed it mora a ace N required
THE OIRS
TY OF EL SEGUNDO ITS OFFICE, EMPLOYEE S, AND AGENTS ARL NAMED AS ADDITIONAL I'NSU ED WITH RESPECTS TO THE ABOVE
MENTIONED POLICIES PER ATTACHED ENDORSEMENT'('S). COVERAGE IS PRIMARY & NON-CONTRIBUTORY AS REQUIRED BY WRITTEN
CONTRACT„ PER ATTACHED ENDORSEMENT FORMS, WAIVER OF SUBROGATION APPLIES, IF REQUIRED BY WRITTEN CONTRACT.
” SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, A 30 DAY WRITTEN NOTICE WILL
BE ISSUED. 10 DAY FOR NON-PAYMENT.
RE: ALL OPERATIONS
CERTIFICATE HOLDER.
City of EI Segundo
350 Main Street
EI Segundo, Ca 90245
CANCELLATION
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
O 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
Policy: VCGP024698
06/09/2019 to 06/09/2020
CG 20 37 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSENS O
CONTRACTORS - COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
Name Of Additional Insured Person(s)
Or Organization(s)
As required by written contract.
SCHEDULE
Location And Description Of Completed
Operations
Any Location
complete this Scheduleif not shown abovewill be
Information required to , , shown in the Declarations.
A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or
organization(s) shown in the Schedule„ but only with respect to liability for "bodily injury" or "property
damage" caused', in whole or in part, by "your work at the location designated and described in the
Schedule of this endorsement performed for that additional insured and included in the "products -
completed operations hazard".
However:
1. The insurance afforded to such additional insured only applies to the extent permitted by law; and
2. If coverage provided to the additional insured is required by a contract or agreement, the insurance
afforded to such additional insured will not be broader than that which you are required by the
contract or agreement to provide for such addiflonai insured.
B. With respect to the insurance afforded to these additional insureds, the following is added to Section
III — Limits Of Insurance:
If coverage provided to the additional insured is required by a contract or agreement, the most we will
pay on behalf of the additional insured is the amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits of Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.
CG 20 37 04 13 Page 1 of 1
Policy: VCGPO24698
06/09/2019 to 06/09/2020
CG 2010 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the following:
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s) Location(s) Of Covered Operations
As required by written contract.
Any Location
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section ii — Who is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in
the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury"
caused, in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your behalf;
in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above.
However:
1. The insurance afforded to such additional insured only applies to the extent permitted by law; and
2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such
additional insured will not be broader than that which you are required by the contract or agreement to provide for such
additional Insured.
B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply:
This insurance does not apply to "bodily injury" or "property damage" occurring after:
1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than
service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the
covered operations has been completed; or
2. That portion of "your work" out of which the injury 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 principal as a part
of the same project.
C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of
Insurance:
CG 20 10 04 13 1 of 2
If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the
additional insured is the amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits of Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.
CG 20 10 04 13 2 of 2
Policy: VCGP024698
06/09/2019 to 06/09/2020
CG 20 0104 13
Effective Date: 06/09/2018
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
1 ',,,a r FERMI WrogralI
This endorsement modifies insurance provided under the following:
Commercial General Liability Coverage Part
The following is added to the Other Insurance Condition and supersedes any provision to the contrary:
Primary And Noncontributory Insurance
This insurance is primary to and will not seek contribution from any other insurance available to an additional insured
under your policy provided that:
(1) The additional insured is a Named Insured under such other insurance; and
(2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not
seek contribution from any other insurance available to the additional insured.
CG 20 0104 13 1 of 1
Policy: VCGP024698
06/09/2019 to 06/09/2020
CG 24 04 05 09
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF' TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
SCHEDULE
Name Of Person Or Organization:
As required by written contract.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of
Section IV — Conditions:
We waive any right of recovery we may have against the person or organization shown in the Schedule
above because of payments we make for injury or damage arising out of your ongoing operations or "your
work" done under a contract with that person or organization and included in the "products -completed
operations hazard". This waiver applies only to the person or organization shown in the Schedule above.
CG 24 04 05 09 Page 1 of 1
Policy Number: WPP1556836 00
r
COMMERCIAL AUTO
CAN0187 0715
This Endorsement Changes The Polley. Please Read It Carefully
fWSINESS AUTO COVERAGE
ENDORSEMENT
This endorsement modifies insurance provided by the following:
BUSINESS AUTO COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the COVERAGE FORM apply
unless modified by the endorsement.
A. Newly Acquired or Formed e. An 'employee" of yours Is an "insured'
Organizations, Employee Hired Car while operating an 'auto' hired or rented
Llabillty and Blanket Additional Insured under a contract or agreement in that
Status for Certain Entities. 'employee's" name with your
Item 1. Who is an Insured of Paragraph A.
Coverage under SECTION it - COVERED,
AUTOS UABILITY COVERAGE is
amended to add:
d. Any organization you newly acquire or
form, other than a partnership, jolnt
venture or limited liability company, and
over which you maintain ownership of a
majority interest (greater than 50%), will
qualify as a Named Insured; however,
(1) coverage under this provision is
afforded only until the t 800 day
after you acquire or form the
organization or the end of the policy
period, whichever is earlier;
(2) coverage does not apply to "bodily
injury", "property damage' or
'covered pollution cost or expense'
that results from an "accident' which
occurred before you acquired or
formed the organization; and
(3) coverage does not apply if there is
other similar insurance available to
that organization, or lt similar
insurance would have been
available but for its termination or
the exhaustion of its limits of
Insurance.
This insurance does not apply if
coverage for the newly acquired or
formed organization is excluded either
by the provisions of this coverage form
or by endorsement.
permission, while performing duties
related to the conduct of your business,
Any person or organization you are
required by written contract or
agreement to name as an additional
'Insured', but only with respect to
liability created in whole or in part by
such agreement,
B. increase Of loss Earnings Payment
Subpart (4) of a. Supplementary Payments
of hem 2. Coverage Extermlone of
Paragraph A. Coverage under SECTION II
- COVERED AUTOS LIABILITY
COVERAGE is emended to read:
(4) We will pay reasonable expenses
Incurred by the'InsureT at our
request, including actual loss of
earnings up to $1,000 per day
because of time off from work.
C. Fellow Employee Injured By Covered
Auto You Own Or Hire
Item s. Fellow Employee of Paragraph B.
Exclusions under SECTION II - COVERED
AUTOS LIABILITY COVERAGE is
amended to add:
T'"his exclusion does not apply K the "bodily
injury' results from the use of a covered
"auto' you own or hire. Such coverage as
is afforded by this provision is excess over
any other collectible insurance,
CA990187 0716 Includes Copyrighted Material of Insurance Services Offices, Inc, Pago 1 of 5
Used with permission
D. Limited Automatic Towing Coverage
Item 2 Towing, of Paragraph A. Coverage,
under SECTION 111— PHYSICAL DAMAGE
COVERAGE Is amended to read:
2. Towing
We will pay for towing and labor costs
each time that a covered "auto° is
disabled. All labor must be performed at
the place of disablement of the covered
'auto'.
a. The limit for towing and labor for
each disablement to $500;
b. No deductible applies to this cover-
age.
E. Item 3. Glass Breaks — Hitting A Bird
Or Animal — Failing Objects or Missiles of
Paragraph A. Coverage under SECTION Ill
— PHYSICAL DAMAGE COVERAGE, is
amended to add:
Glass Repair Coverage
We will waive the Comprehensive
deductible for Glass, N one Is indicated on
your covered "auto'. for glass repairs. We
will repair at no cost to you, any glass that
can be repaired without replacement,
provided the 'loss' arises from a covered
Comprehenshre'loss'to your'euto".
F. Increase Of Transportation Expense
Coverage
Subpart a. Transportation Expenses of
Item 4. Coverage Exhmslona of Paragraph
A. Coverage under SECTION Ila —
PHYSIICAL DAMAGE COVERAGE Is
amended to read
a. Transportation Expenses
We will pay up to $50 per day to a
maximum of $1,000 for temporary
transportation expense incurred by you
because of the total theft of a covered
"auto' of the private passenger type.
We will pay only for those covered
"autos" for which you carry either
Comprehensive or Specified Causes of
Loss Coverage or Theft Coverage. We
will pay for temporary transportation
expenses Incurred during the period
beginning 48 hours after the theft and
ending, regardless of the policy's
expiration, when the covered "auto" is
returned to use or we pay for its "loss
G. "Personal Effects" Coverage
Item 4. Coverage E. Ions of Paragraph
A. Coverage, under SECTION 111
PHYSICAL DAMAGE COVERAGE" is
amended to add:
"Personal Effects" Coverage
We will pay actual cash value for "loss" to
'personal effects" of the "insured' while in
a covered 'auto" subject to a maximum
Ilmlt of $2,500 per "loss', for that covered
"auto" caused by the same "accident'. No
deductible will apply to this coverage.
H. "Downtime Loss" Coverage
Item 4. Coverage Extensions, of
Paragraph A. Coverage, under SECTION
III. PHYSICAL DAMAGE COVERAGE, is
amended to add:
"Downtime Loss" Coverage
We wHI pay any resulting 'downtime loss'
expenses you sustain as a result of a
covered physical damage `loss" to a
covered °auto" up to a maximum of $100
per day, for a maximum of 30 days for the
same physical damage 'loss", subject to
the following conditions:
a. We will pro "downtime loss* beginning
on the 5s' day after rye have gen you
our agreement to pay for repairs to a
covered "auto" and you have given the
repair facility your authorization.to make
repairs;
b. Co o for time lass' expenses
will end when any of the following occur:
(1) You have a spare or reserve "auto"
available to you to continue your
operation,
(2) You purchase a replacement °auto".
(3) Repairs to your cavered •auto" heye
been completed by the repair facility
and they determine the covered
"auto" Is roadworthy.
(4) You reach the 30 day maximum
coverage.
CA9W187 0715 Includes Copyrighted Material of Insurance Services Offices, Inc. Page 2 of 5
Used with Permission
1. Item 4. Coverage Extensions, of
Paragraph A. Coverage, under SECTION
111, PHYSICAL DAMAGE COVERAGE, is
amended to add:
We will pay any resulting rental
reimbursement expenses incurred by you for
a rental of an 'auto" because of "loss' to a
covered "auto' up to a maximum of $100 per
day, for a maximum of 30 days for the same
physical damage "loss", subject to the
following conditions:
a. We will provide rental reimbursement
Incurred during the policy period
beginning 24 hours after the'loss' and
ending, regardless of the policy
expiration, with the number of days
reasonably required to repair or replace
the covered "auto". If the "loss' is
caused by theft, this number of days Is
the number of days it takes to locate the
covered "auto' and return ft to you or the
number of days it takes for the claim to
be settled, whichever comes first.
b. Our payment is limited to necessary and
actual expenses incurred.
c. This coverage does not apply while
there are spare or reserve 'autos`
available to you for your operations.
d. If a "loss" results from the totes theft of a
covered 'auto' of the private passenger
type, we will pay under this coverage
only that amount of your rental
refmbursemertt expenses which le not
already provided for under the Physical
Damage Coverage 6den3lon.
J. "Personal Effects" Exclusion
Paragraph B. Exclusion* under SECTION
Ill — PHYSICAL DAMAGE COvEP.AOi:, is
amended to add;
"Personal Effects" Exclusion
We will not pay for "loss" to'pemonal
effects' of any of the following:
a. Accounts, bills, currency, deods,
evidence of debt, money, notes,
securities or commercial paper or
other documents of value.
b. Bullion, gold, silver, platinum, or other
precious alloys or metals; furs or fur
garments; jeweiry; watches; precious
or semirpredous stones.
c. Paintings, statuary and other works of
art.
6049MI
d_ Contraband or property In the course
of Illegal transportation or trade.
e. "Loss" caused by theft, unless there is
evidence of forced entry Into the
covered "auto" and a police report is
flied.
K. Accidental Alrbag 01wharge Coverage
item 3.a. of Paragraph B. Excluskma under
SECTION III — PHYSICAL DAMAGE
COVERAGE is amended to read:
a. Wear and tear, freezing, mechanical
or electrical breakdown. The
exclusion relating to mechanical
break -down dose not apply to the
accidental discharge of an air bag.
L, Loan or Losse Gap Coverage
Paragraph C, Limit Of Insurance under
SECTION 111— PHYSICAL DAMAGE
COVERAGE Is amended to add: .
If a covered `auto" Is owned or leased and
if we provide Physical Damage Coverage
on it, we will pay, in the event of a coveMd
total "lose', any unpaid amount due on the
lease or loan for a covered `auto', less:
a. The amount paid under the Physical
Damage Coverage Section of the
policy; and
b. Any.
(1) Overdue lease or loan
payments Including penalties,
interest or other charges
resulting from overdue
payments at the time of the
"loss';
(2) Financial penalties imposed
under a lease for excessive use,
abnormal wear and tear or high
mileage;
(3) Costs for extended warranties,
Credit Life Insurance, Health,
Accident or Disability Insurance
purchased with the loan or
leans;
(4) Security deposits not refund&j
by the lessor, and
(5) Cant' -over balances from
prevlous bans or leases
CA990187 0715 Includes Copyrighted Material of Insurance Services Offices, Inc. Page 9 of 5
Used with permission
M. Aggregate Deduetibte
Paragraph D. Dedue We under SECTION
III — PHYSICAL DAMAGE COVERAGE is
amended to add:
Regardless of the number of covered
`autos" involved in the same 'loss', only
one deducible viii apply to that 'lose. If
the deductible amounts vary by "autos",
then only the highest applicable dedoctible
will apply to that'loss'.
N. Diminishing Deductible
Paragraph D. Deductible under SECTION
Ire — PHYSICAL DAMAGE COVERAGE is
amended to add:
Any deductible will be reduced by the
percentage indicated below on the first
'loss' reported during the corresponding
policy period:
Lorry Free Pollay Periods Dedu0ble
w41h the'Expenaton Reduction an the
Entforermant..._ first "loop'" _.... _..
0%
z z646
3 sm —
4 76%
L. 0,,,, 100%
if we pay a Physical Damage "loss" during
the policy period under any BUSINESS
AUTO COVERAGE FORM you have with
us, your deductible stated in the
Declarations page of each such
COVERAGE FORM will not be reduced on
array subsequent claims during the remainder
of your policy period and your deductible
reduction will revert hack to 0 for each
such COVERAGE FORM If coverage is
renewed.
O. Knowledge of Lose and Notice To Us
Subsection a. of Item 2. Ourtles, In the Event
of Accident, Clstm, Suit or Lxm of
Paragraph A. Loss Conditions under
SECTION IV- BUSINESS AUTO
CONDMONS Is amended to add:
(3) An "executive officer' or director, if
you are a corporation;
(4) A manager or member, If you are a
limited liability company-,
(3) Your Insurance manager, or
(6) Your le ar�,gl
P. waiver Of SubrosiAtIon For Auto Uablft
Looms Assumed Under insured Contract
Item' . Transfer Of Rights Of Recovery
Against Mom To Us of Paragraph A.
Lo as Conditions under SECitON IV «-
BUSINESS AUTO CONDITIONS is
amended to read:
S. Tmnaftr of Rlgtvb of Recovery
Against Others To Us
If any person or organization to or for
wham we make payments ander this
Coverage Form has rights to recover
damages fromanother, those rights are
transferred to us. That person or
organization must dry everything
necessary to secure our rights and must
I do noticing after an 'accideff or "toss"
to Impair them. However, if the Insured
has waived thoatr rights to recover
through a written contract, we will waive
I any right to recovery we may have
under this Coverage Form.
J. Insurance Is Primmy and
Noncontri
Subpart a. of Item S. Other Insurance of
Paragraph B. General Conditions under
SS t""ION IV - BUSINESS Af.iTO
CONDITIONS Is amended to read:
a. This Insurance la primary and
noncontributory, as respects any other
f
insurance, if reqired In a written
contract with you.
F-. Other
sumnos - Hired Auto Physical
csl
Damage
Subpart b, of Item ti.,Other Insumnoe of
Paragraph B. General Conditions under
SECTION IV - BUSINESS AUTO
COWTONS Is amended to read:
However, prompt notice of Ow'accldent', b. For Hired Auto Physical Damage
claim, "suit' or 'loss" to urs or our Coverage, the following are deemed
authorized representative only applies to be co 'autos" you oven:
after the "accident", claim, "suit' or'lose Is (1) Any covered "auto' you lease,
known to: hire, rent or borrow, and
(1) You, li you are an individual;
(2) A partner, if you are a partnership;
C,A090187 0718 Includes Copyrighted Mate " I of Insurance Services Offices, Inc. Page 4 of 5
Used with permission
(2) Any covered 'auto" hired or rented
by your 'employee' under a
contract in that individual
'employee's" name, with your
permission, while performing
duties related to the conduct of
your business.
However, any 'auto" that is leased, hired,
rented or borrowed with a driver Is not a
covered 'auto".
S. Unintentional Failure To Disclose
Hazards
Paragraph B, General Conditions under
SECTION IV — BUSINESS AUTO CONDI-
TIONS Is amended to add:
9. Your failure to disclose all hazards
exleting as of the inception date of this
policy shall not prejudice the coverage
afforded by this policy, provided that
such failure to disclose all hazards is not
intentional. However, you must report
such previously undisclosed hazards to
us as soon as practicable after its
discovery.
T. Additional Deffnitfon
SECTION V — DEFINITIONS is amended to
add:
'Personal effects' means personal
property owned by the "insured".
"Downtime loss" means actual loss of
"business income" for the period of time
that a covered "auto':
1. Is out of service for repair or
replacement as a result of a covered
physical damage "loss" and
2. is in the custody of a repair facility if
not a total 'loss'.
"Business Income" means:
1. Net Income (Net Profit or Loss
before Income taxes) that would
have been earned or incurred; and
2. Continuing normal operating
expenses Incurred, including payroll.
In this endorsement, hjaSfingg Snd TRW4
are Inserted solely for the convenience and
ease of reference. They do not effect the
coverage provided by this endorsernent,
nor do they constitute any pert of the germs
and conditions of this ondorsomwt, All
other policy wording not specifically
changed, modified, or replaced by this
endorsement wording remains In effect.
M CA990167 0716 Includes Copyrighted Material of Insurance Services Offices, Inc. Page 5 of 5
Used with permission
411 0
A+L�"�C3►J►,?L> CERTIFICATE OF LIABILITY INSURANCE DATE(MM11/ 1/20 9
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 be endorsed. If SUBROGRATION 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).
W
PRODUCER illis Towers Wa
tson CONTACT NAME: San Bernardino
12980 Metcalf Ave Suite 500 PHONE (A1C, No, Ext): (909) 890.0100 FAX (A/C, NO): (360) 828-0699
Overland Park KS 66213
EMAIL ADDRESS: Rachael.Budrikabbsihq.com
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A: ACE American Insurance Company 22667
INSURED
INSURER B:
Barrett Business Services, Inc. LIC/F
�$
$
CT & T CONCRETE PAVING INC
INSURER C:
1054 E 3RD ST
INSURER D:
POMONA, CA 91767
$
GENERAL AGGREGATE
INSURER E:
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
ISSUES 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 ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP I LIMITS
LTR INSR WVD (MMIDD/YYYY) (MMIDD/YYYY)
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE ED OCCUR
F
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY -1 ECT
LOC
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS []SCHEDULED AUTOS
HIRED AUTOS NON -OWNED AUTOS
EXCESS UMBRELLALIAB OCCUR
LIAB OCCUR
DED RETENTION $
A WORKERS COMPENSATION AND EMPLOYERS' I C6636950A 10/01/19 10/01/2020
LIABILITY YIN
ANY PROPRIETOR/PARTNER/ EXECUTIVE N / A
OFFICERIMEMBER EXCLUDED? Covered states:
(Mandatory In NH) If yes, describe under CA
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
CERT ..
CERTIFICATE HOLDER
City of EI Segundo
350 Main Street
EI Segundo, Ca 90245
CANCELLATION
EACH OCCURRENCE
DAMAGE TO RENTED PREMISES (Ea
�$
$
occurence)
$
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
$
PRODUCTS - COMPIOP AGG
$
AGGREGATE
$
COMBINED SINGLE LIMIT
(Ea accident)
$
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
$
EACH OCCURRENCE
$
AGGREGATE
$
WCSTATU-
OTH-
TORY LIMITS
ER
E.L. EACH ACCIDENT
$2,000,000
E.L. DISEASE - EA EMPLOYEE
$2,000,000
E.L. DISEASE -POLICY LIMIT
$2,000,000
M
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATA THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Authorized ASRep
31,
c) 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD.
AGENCY CUSTOMER ID:
LOC: :
ADDITIONAL REMARKS SCHEDULE Page 2 of 2
AGENCY NAMED INSURED:
Barrett Business Services, Inc. L/C/F
Lockton Affinity CT & T CONCRETE PAVING INC
1054 E 3RD ST
POLICY NUMBER 1054
CA 91767
C663 6950A
CAR
RIER NAI'C CODE
ACE American Insurance Company 22667 EFFECTIVE DATE: 10/01/19
ADDITIONAL REMARKS
THIS ADDITIONAL'' ..
REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability (01/14)
..
CERTIFICATE HOLDER: City o f EI Segundo
350 Main Street
ADDRESS: EI Segundo, Ca 90245
Waiver of Subrogation in favor of: The City of EI Segundo,its officials and employees
ACORD 101 (2008/01) c) 1988-2010 ACORD CORPORATION. Allri 'ghts reser'v'ed ......
The ACORD name and logo are registered marks of ACORD.
Workers' Compensation and Employers' Liability Policy
Named Insured Endorsement Number
BARRETT BUSINESS SERVICES, INC. IJC/F Policy Number
CT & T CONCRETE PAVING INC
1054 East 3rd St. Symbol: Number: C6636950A
Pomona, CA 91767
Policy Period Effective Date of Endorsement
10/01/2019 TO 10/1/2020 9125/2019
Issued By (Name of the Insurance Company)
Ace American Insurance Co.
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,
I
I CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
This endorsement applies only to the insurance provided by the policy because California is shown in Item
3.A. of the Information Page.
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, but this waiver applies
I
only with respect to bodily injury arising out of the operations described in the Schedule, where you are
required by a written contract to obtain this waiver from us.
You must maintain payroll records accurately segregating the remuneration of your employees while
engaged in the work described in the Schedule.
Schedule
1. Specific Waiver
Name of person or organization:
(x) Blanket Waiver
Any person or organization for whom the Named Insured has agreed by written contract to furnish this
waiver.
2. Operations:
3. Premium:
The premium charge for this endorsement shall be INCLUDED percent of the California premium developed
on payroll in connection with work performed for the above person(s) or organization(s) arising out of the
operations described.
4. Minimum Premium: INCLUDED
WC 99 03 22
�7
Authorized Agent