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PROOF OF INSURANCE (2020 - 2021) CLOSEDACC 4�M ... .. DATE (MM/Y) CERTIFICATE OF LIABILITY INSURANCE 02„1,202°2020 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 CO'NTA'CT Elizabeth Flinders (NAME. Flinders/DePalma Insurance AgencyINnEpe. Ertl„ (818) 843-8600 I CIX FANe) (818) 566-9841 4t ;. License # 0447329E"MAIL liz@flindersins,com ADDRESS:, P.O Box 510 INSURER(S) AFFORDING COVERAGE .............. Burbank CA 91503 INSURERA: Mesa Underwriters Specialty Insurance Company INSURED wsURER B: United Financial Company (Progressive) ..........m ................. Clean Scene Services, Inc INSU RER C: PO Box 500103 INSURER D: IIINSURER E: Palmdale CA 93591 INSURER F: COVERAGES CERTIFICATE NUMBER: Feb 2020 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, INSR ADUL5U81,1' POSY EFF POLICY EXP LTR TYPE OF INSURANCE INSD 4MlO. POLICY NUMBER (MM/DD/YYYY) IMM/DD/YYYY1I LIMITS X COMMERCIAL GENERAL LIABILITY $ 1,000,000 CLAIMS -MADE ❑OCCUR s 100,000 A Y GEN'LAGGREGATE LIMITAPPLIES PER: POLICY PRO LOC JEOT OTHER AUTOMOBILE LIABILITY ANYAUTO B OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAR d OCCUR --I EXCESS LIAB CLAIMS -MADE u, DED n I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE N I A OFFICER/MEMBER EXCLUDED El (Mandatory in NH) IF yes, describe under DESCRIPTION OF OPERATIONS below I EACH OCCURRENCE DAMAGE TO RENTED PREMISES (Ea NAIC # 36838 11770 occurrence) MED EXP (Any one Derson) MP0004018004877 02/06/2020 02/06/2021 PERSONAL &ADV INJURY GENERAL AGGREGATE I PRODUCTS - COMP/OP AGG $ 5,000 $ 1,000,000 $ 2,000,000 $ included $ �. .-......... COMBINED S.Ild'CdLELIMIT s 1,000,000 IEa accrrlerrl) BODILY INJURY (Per person) $ 06342952-2 11/22/2019 11/22/2020 BODILY INJURY (Per accident) $ 5.. PROPERTY DAMAGE Mer ayu; Idanftl $ EACH OCCURRENCE $ AGGREGATE $ _.W... .. ...........$ PER STATUTE ERH E L EACH ACCIDENT $ E DISEASE -EA EMPLOYEE $ E L DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of EI Segundo is named as an additional insured on the General Liability policy as per written contract Endorsement attached 10 day notice of cancellation for non payment of premium. CERTIFICATE HOLDER City of EI Segundo 348 Main Street EI Segundo I ACORD 25 (2016103) 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 CA 90245 ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Policy # MP0004018004877 MESA UNDERWRITERS SPECIALTY INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, LIMITED Al - PRIMARY NON-CONTRIBUTORY - WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM Blanket Additional Insureds - As Required By Contract A. Subject to the Primary and Non -Contributory provision set forth in this endorsement, SECTION II - WHO IS AN INSURED is amended to include as an additional insured any person or organization whom you have agreed in a written contract, written agreement or written permit that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability for "bodily injury" or "property damage" or, to the extent applicable under the Coverage Part to which this endorsement applies, "personal and advertising injury" caused, in whole or in part, by: 1. Your ongoing operations, "your product", or premises owned or used by you; With respect to the insurance afforded to these additional insureds, the following additional exclusion applies: This insurance does not apply to "bodily injury", "property damage" or, to the extent applicable under the Coverage Part to which this endorsement applies, "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services by or for you, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrong -doing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or, to the extent applicable under the Coverage Part to which this endorsement applies, the offense which caused the "personal and advertising injury", involved the rendering of, or failure to render, any professional architectural, engineering or surveying services. Your maintenance, operation or use of equipment, other than aircraft, "auto" or watercraft, rented or leased to you by such person or organization. A person or organization's status as an additional insured under this endorsement ends when their contract, or agreement with you for such rented or leased equipment ends. With respect to the insurance afforded to these additional insureds, this insurance does not apply to any "occurrence" which takes place after the rental agreement or equipment lease expires. The provisions of this coverage extension do not apply unless the written contract or written agreement has been executed (executed means signed by the named insured) or written permit issued prior to the "bodily injury" or "property damage" or, to the extent applicable under the Coverage Part to which this endorsement applies, "personal and advertising injury". MUS 01 01 20127 0316 INSURED Page 1 of 2 Primary and Non -Contributory Provision The following is added to Paragraph 4. Other Insurance, b. Excess Insurance under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS: This insurance shall be excess with respect to any person or organization included as an additional insured under this policy, any other insurance that person or organization has shall be primary with respect to this insurance, unless: 1) The additional insured is a Named Insured under such other insurance; 2) You have agreed in a written contract, written agreement or written permit to include that additional insured on your General Liability policy on a primary and/or non-contributory basis; 3) The written contract or written agreement has been executed (executed means signed by the named insured) or written permit issued prior to the "bodily injury" or "property damage" or, to the extent applicable under the Coverage Part to which this endorsement applies, "personal and advertising injury"; and 4) With respect to indemnity, you have been adjudicated liable in full for the "bodily injury" or "property damage" or, to the extent applicable under the Coverage Part to which this endorsement applies, "personal and advertising injury". Waiver Of Transfer Of Rights Of Recovery The following is added to Paragraph 8. Transfer of Rights Of Recovery Against Others To Us under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS: We will waive any right of recovery we may have against a person or organization because of payments we make for "bodily injury" or "property damage" arising out of your ongoing operations or "your work" done under a written contract or written agreement and included in the "products -completed operations hazard", if: 1. You have agreed to waive any right of recovery against that person or organization in a written contract or written agreement; 2. Such person or organization is an additional insured on your policy; or 3.. You have assumed the liability of that person or organization in that same contract, and it is an "insured contract". The section above only applies to that person or organization identified above, and only if the "bodily injury" or "property damage" occurs subsequent to the execution of the written contract or written agreement. All other terms and conditions of this policy remain unchanged. MUS 0101 20127 0316 Page 2 of 2 Policy # MP0004018004877 COMMERCIAL GENERAL LIABILITY CG 20 33 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT' ITH YOU This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured 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. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: 1. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. However, the insurance afforded to such This exclusion applies even if the claims against additional insured: any insured allege negligence or other wrongdoing 1. Only applies to the extent permitted by law; in the supervision, hiring, employment, training or and monitoring of others by that insured, if the 2. Will not be broader than that which you are "occurrence" which caused the "bodily injury" or required by the contract or agreement to "property damage", or the offense which caused provide for such additional insured. the "personal and advertising injury", involved the rendering of or the failure to render any A person's or organization's status as an professional architectural, engineering or additional insured under this endorsement ends surveying services. when your operations for that additional insured are completed. CG 20 33 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 2. 'Bodily injury" or "property damage" occurring after: a. 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 b. 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: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement you have entered into with the additional insured; 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. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 33 0413 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL 'AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 37016, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: (__) I have and will maintain a certificate of consent of self -insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code §3700 for the performance of the work set forth the agreement with the City of EI Segundo. Policy No. (_) I have and will maintain workera° compensation insurance as required by Labor Code § 3700 for the performance of the work for which the agreementwith the City of EI Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Name of Agent Policy Number Expiration Date phone # W I certify that, In the performance of the work set forth In the agreement with the City of EI Segundo, I will not employ any person In any manner so as to become subject to the workers' compensation laws of California„ and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those provisigns or the agreement will automatically become vont. Signature of Applicant / ? ; : ,„ �, f �, ;" _ bate Agreement for: Dated: Reviewed by: w__