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PROOF OF INSURANCE (2020) CLOSEDPALP, INC. JEA
ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
1129/2020
.............. .......
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 %NTACT
a/c"N . ExSI.;...949)....................9800 �.�nic...N.l 1949)..................._............
553
553-0670
SS: �. ......
The Park
Plaza,
CompanyInsurance Services, Inc. INsuRER(siAPPORDI Nuc ............._
1 Park Plaza, Shite 400
Irvine, CA 92614 NG COVERAGE
INSURER .,A..,..Starr Indemnity & Liability Co ............ _,,,,„,,,I�38318
INSURED .-_ ................................................ .......... INSURE.R..E..S.......................... �................................
Palp, Inc. DBA Excel Paving Company; GAP Equipment, LLC INSURER C ..
2230 Lemon Avenue INSURER D: uG
Long Beach, CA 90806 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 ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH 3OLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY 'AID CLAIMS.
LIMITS
....................
�A ..L..X.......COMMERCIAOF INSURANCE ...... POLICY NUMBE R ................. ..__.Y..-. _......... ...ITS_.
TYPE....
ADDL SUBR POLICY EFF POLICY EXP
J2.. INSD wV0 R MDDIVVYYI 1'MMfDDf'9fY'YYI
L LIABILITY 1,000,000
CLAIMS -MADE l.. X.. X X Q.';zs'L�2. ndJd” 24... .................
GENERA
OCCUR 1000025506191 611/2019 61112020 DAMAGC TO RENTED 100,000
GEmN'L AGGREGATE LIMIT APPLIES PER:
POLICY X JET F_� LOC
OTHERa m ....................._..
A AUTOMOBILE LIABILITY
X ANY AUTO X
OWNED 11
AUTOS ONLY �,AUTOSULED
X HIRED X I NON -OWNED
AUTOS ONLY7 I AUTOS ONLY
UMBRELLA LIAB OCCUR
EXCESS LIAB CLAIMS -MADE
_ ( RETENTION $
A WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE F '
MaD?
FICER/MEMBER EXCLUDEN / A
ndatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below w,
,MED EXP (Any one person)
$ 5'000
..
1.'. 00
00,000
000
PERSONAL 8 ADV INJURY
$ ,
00
__
$2,000 . ,0 ..,._
m,GE,N,E;,RAIAGGREGATE
..
2,0,COMP/OP
00,0„0000MBINED
PRODUCTS - AGG
$ „
SINGLE LIMIT
1,000,000
$................
X 1000198549191 6/112019 6/1/2020 BODILY INJURY (Pe p_wson),,,,,,,,,,_,,,,,Y,,,,,,,,,,,,,,,,,,,,,,,,
INJURY (Per accident).,
„Y,.......... ..............
PORDILY
P.? raccidpnIDAMAGE
$.......................................,,,_
.......-� ...............
$
_.EACH OCCURRENCE
$
$
E orH-
...X 5T.AT.U1.9 F, R.
X' 1000002214 6/112019 611/2020
.EL EAUH
,g
0 0
1,000,000
1,000,000
ESL._DISEAS„g,: EA„E,M,P,LOYEE
r...... E...
$
....$
..E
1'000'000
E.L. DISEASE -POLICY LIMIT
$
................. _.
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached It more space is required)
RE: Excel Job 95727; City of El Segundo Job #PW 19-09; Walnut Avenue Drainage and Street Improvements. glaipwv/auaiwv/wcwv
City of EI Segundo, its officers, officials, employees, agents, and volunteers are included as Additional Insureds as respects General Liability and Auto
Liability per attached endorsements.
This insurance shall apply as Primary and Non -Contributory per attached endorsement.
Waiver of Subrogation for General Liability, Auto Liability and Workers' Compensation: See Attached Endorsements.
CERTIFICATEHOLDER
City of EI Segundo
City Clerk
350 Main Street
EI Segundo, CA 90245
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
©1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: PALP, INC. JEANA
........._.. .............._ ...................._................................
LOC #: 1 ........... — ....
._
CCOROe ADDITIONAL REMARKS SCHEDULE
Page 1 of 1
AGENCY NAMED INSURED
Palp, Inc. DBA Excel Paving Company; GAP Equipment, LLC
2230 Lemon Avenue
POLICY NUMBER Long Beach, CA 90806
SEE PAGE 1
C A
RIER
N A I C CODE
SE
EPAG E 1 SEE P 1 EFFECTIVE......
DATE: SEE PAGE 1
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER:.?wP!C RD 2525 FORM TITLE: CeFgflpate of Liability Ins ur9nce,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Cancellation:
*Except 10 days notice of Cancellation for non-payment of premium.
*Should this policy be cancelled before the expiration date, The Wooditch Company will mail 30 (thirty) days written notice to those
Certificate Holders which require such action per contract or agreement.*
ACORD 101 (2008/01) C 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
*Starr Indemnity & Liability Company
Dallas, TX 1-866-519-2522
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
Policy Number: 1000198549191 Effective Date: 06/01/2019
Named Insured: Palp, Inc. DBA Excel Paving Company; GAP Equipment, LLC
ADDITIONAL INSURED - WHERE REQUIRED UNDER
CONTRACT OR AGREEMENT
This policy is amended as follows:
BUSINESS AUTO COVERAGE FORM
SCHEDULE
ADDITIONAL INSURED
ANY PERSON OR ORGANIZATION FOR WHOM YOU ARE CONTRACTUALLY BOUND TO PROVIDE
ADDITIONAL INSURED STATUS BUT ONLY TO THE EXTENT OF SUCH PERSON OR
ORGANIZATIONS LIABILITY ARISING OUT OF THE USE OF A COVERED "AUTO"
SECTION II — LIABILITY COVERAGE A. Coverage, 1. Who is Insured, is amended
to add:
d. Any person or organization, shown in the schedule above, to whom you become obligated to
include as an additional insured under this policy, as a result of any contract or agreement
you enter into which requires you to furnish insurance to that person or organization of the
type provided by this policy, but only with respect to liability arising out of use of a covered
"auto". However, the insurance provided will not exceed the lesser of:
(1) The coverage and/or limits of this policy, or
(2) The coverage and/or limits required by said contract or agreement.
SICA 1016 (02/12) Page 1 of 2
Copyright © C. V. Starr & Company and Starr Indemnity & Liability Company. All rights reserved.
Includes copyrighted material of ISO Properties, Inc., used with its permission.
Starr Indemnity & Liability Company
Dallas, TX 1-866-519-2522
Signed for STARR INDEMNITY & LIABILITY COMPANY
�P,V6 ; " /'
Charles IH. Dangelo,19President
Nehemiah E. Ginsburg, General" .ounsel
SICA 1016 (02/12) Page 2 of 2
Copyright © C. V. Starr & Company and Starr Indemnity & Liability Company. All rights reserved.
Includes copyrighted material of ISO Properties, Inc., used with its permission.
POLICY NUMBER: 1000198549191 COMMERCIAL AUTO
CA 04 44 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US (WAIVER OF SUBROGATION)
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless
modified by the endorsement.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated
below.
Named Insured: Palp, Inc. DBA Excel Paving Company; GAP Equipment, LLC
Endorsement Effective Date: 6/1/2019
SCHEDULE
Name(s) Of Person(s) Or Organization(s):
Any person or organization to whom you become obligated to waive your rights of recovery against,
under any contract or agreement you enter into prior to the occurrence of loss.
-information required to complete this Schedule, if not shown above, will be shown in the Dectarations.
The Transfer Of Rights Of Recovery Against
Others To Us condition does not apply to the
person(s) or organization(s) shown in the Schedule,
but only to the extent that subrogation is waived prior
to the "accident' or the 'loss" under a contract with
that person or organization.
CA 04 4410 13 © Insurance Services Office, Inc., 2011 Page 1 of 1
POLICY NUMBER: 1000025506191
COMMERCIAL GENERAL LIABILITY
CG 20 37 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) Or Location And Description Of Completed
Organization(s): Operations
Where Required By Written Contract Where Required By Written Contract
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" 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 additional 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 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1
POLICY NUMBER: 1000025506191
COMMERCIAL GENERAL LIABILITY
CG 20 10 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY,
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following;
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) Or
Organization(s): Location(s) Of Covered Operations
li Where Required By Written Contract Where Required By Written Contract
V 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:
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 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1
*Starr Indemnity & Liability Company
Dallas, TX 1-866-519-2522
Primary and Non -Contributory Condition
Policy Number: 1000025506191 Effective Date: 06/01/19 at 12:01 A.M.
Named Insured: Palp, Inc. DBA Excel Paving Company
This endorsement modifies insurance provided under the:
Commercial General Liability Coverage Part
A. SECTION IV — CONDITIONS, condition 4. Other Insurance is amended as follows:
1. The following is added to paragraph 4.a. of the Other Insurance condition:
This insurance is primary insurance as respects our coverage to the additional insured, where the written
contract or written agreement requires that this insurance be primary and non-contributory. In that event,
we will not seek contribution from any other insurance policy available to the additional insured on which
the additional insured is a Named Insured.
All other terms and conditions of this Policy remain unchanged.
Signed for STARR INDEMNITY & LIABILITY COMPANY
Charles H. Diaf°igelo, President
Nehemiah E. Ginsburg, GeneraCounsel
OG 107 (04111) Page 1 of 1
Copyright© C. V. Starr & Company and Starr Indemnity & Liability Company. All rights reserved.
Includes copyrighted material of ISO Properties, Inc., used with Its permission.
POLICY NUMBER: 1000025506191
COMMERCIAL GENERAL LIABILITY
CG 24 04 05 09
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Person Or Organization:
Any person or organization to whom you become obligated to waive your rights of recovery against, under any
contract or agreement you enter into prior to the occurrence of loss.
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 © Insurance Services Office, Inc., 2008 Page 1 of 1
Policy No: 1000002214
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06
(Ed. 04-84)
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.
The additional premium for this endorsement shall be 2 .0 % of the California workers' compensation premium
otherwise due on such remuneration.
Schedule
Person or Organization Job Description
Where required by contract
Any person or organization to whom you become obligated to waive
your rights of recovery against, under any contract or agreement you
enter into prior to the occurrence of loss.
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: 06/01/19 Policy No.: 1000002214 Endorsement No.: N/A
Insured: Palp, Inc. DBA Excel Paving Company Premium:
Insurance Company: Starr Indemnity & Liability Company Countersigned by:
WC 04 03 06
(Ed. 04-84) Page 1 of 1