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PROOF OF INSURANCE (2020 - 2021) CLOSED
0 DATE (MM/DD/YYYY) AC"Rf> CERTIFICATE OF LIABILITY INSURANCE 314/2020 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(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). CONTACT PRODUCER IA/r`. Ed eWood Partners Insurance Center (EPIC) i"� �� Eo¢tl. (s4si 263-0606 � FAX Nai: 19000 MacArthur Blvd. PH Floor Irvine, CA 92612 -EMAIL -'49" 263-oso6 JADDRESS: INSURERS) AFFORDING COVERAGE NAIC # www.edgewoodins.com f INSURER A: GuideOne National Insurance ComDanv14167 INSURED INSURER B: Robert's Liquid Disposal Inc. 140"18 Carmenita Rd. GENERALAGGREGATE $2,000,000 Fe Springs CA 90670 kINURERtSanta 11RERP: ,,„,,,,,,,,URER OTHER: E: ...................m._.........._......._.. AUTOMOBILE LIABILITY INSURER F: COVERAGES CERTIFICATE NUMBER: 54450787 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 AMD l� POLICY NUMBER (MMIDD/YYYY) (MMFF IDD1Y ICY Y LTR Y) LIMITS A �p COMMERCIAL GENERAL LIABILITY ENV562000053-02 3/5/2020 3/5/2021 EACH OCCURRENCE $1,000,000 CLAIMS -MADE ✓ 1 OCCUR -DAMAGE IS TORENIED $ 50,000 _EBh.... F'S JEa orcurrence) Certificate holder is named as additional insured as respects the general liability, but only if required by written contract with the named insured, prior to an occurrence, per form CG 2010 07/04 & CG2037 07/04 subject to all policy terms and conditions. CERTIFICATE HOLDER City of El Segundo Deartment of Public Works 150 Illinois Street EI Segundo CA 902453813 ACORD 25 (2016/03) 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 r Anthony D'Asaro ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 54450787 1 20-21 GL/UMB AI MAIN MASTER I Tina Coleman 1 3/4/2020 10:51:53 AM (PST) I Page 1 of 4 MED EXP (Any one person) $ 5,000 .........................w.............................................— PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $2,000,000 POLICYEI F1 PrdO- LOC JEOT' PRODUCTS -COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ iEa accldem) ___.. _................. ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON -OWNED PROPERTYDAMAGE' $ AUTOS ONLY AUTOS ONLY IPer' accidentl $ A UMBRELLA LIAOOCCUR ENV562000054-02 3/5/2020 3/5/2021 EACH OCCURRENCE $4.00Q 000 I✓ EXCESSLIAB CLAIMS -MADE AGGREGATE $4.0001099 DED ✓ RETENTION $10,000 $ WORKERS COMPENSATION R STAI E” STATUTE AND EMPLOYERS' LIABILITY Y / ANYPROPRIETOR/PARTNER/EXECUTIVE NIA I E,L, EACH ACCIDENT $ ....""'""""" �-N OFFICER/M EMBER EXCLUDED? I (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A Pollution Liability ENV562000053-02 3/5/2020 3/5/2021 $5,000,000 per Occurrence/Aggregate Limit Transportation Pollution Liability $5,000,000 per Occurrence/Aggregate Limit DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder is named as additional insured as respects the general liability, but only if required by written contract with the named insured, prior to an occurrence, per form CG 2010 07/04 & CG2037 07/04 subject to all policy terms and conditions. CERTIFICATE HOLDER City of El Segundo Deartment of Public Works 150 Illinois Street EI Segundo CA 902453813 ACORD 25 (2016/03) 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 r Anthony D'Asaro ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 54450787 1 20-21 GL/UMB AI MAIN MASTER I Tina Coleman 1 3/4/2020 10:51:53 AM (PST) I Page 1 of 4 AGENCY CUSTOMER ID: LOC #: ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED Edgewood Partners Insurance Center (EPIC) 14018Ys Liquid Dis osal Inc. 14018 Carmenita Rd. POLICY NUMBER Santa Fe Springs CA 90670 CARRIER 11 NAIC CODE U I EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability (03/16) HOLDER: City of EI Segundo Department of Public Works ADDRESS: 150 Illinois Street EI Segundo CA 902453813 City of E1 Segundo, its officials, and employee as "additional insureds" with respects to general liability ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ADDENDUM 54450787 1 20-21 GL/UMB AI MAIN MASTER I Tina Coleman 1 3/4/2020 10:51:53 AM (PST) I Page 2 of 4 Robert's Liquid Disposal Inc. POLICY NUMBER: ENV562000053-02 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 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 Any person or organization for whom you are performing In respect to any location where the named insured is operations when you and such person or organization have performing "your work agreed in writing in a contract or agreement, effected prior to the date your operations for that person or organization commenced, that such person or organization be added as an additional insured on your policy. Information re ulreq to carnplete thise Schedule, If not shown, will be shown In the Declarations. A. Section It — 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 iocation(s) designated above. CG 20 10 07 04 B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment 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. © ISO Properties, Inc., That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part cif the same project. 2004 Page 1 of 1 54450707 120-21 GL/UME AI MAIN MASTER I Tina Coleman 1 3/4/2020 10:51:53 AM (PST) I Page 3 of 4 Robert's Liquid Disposal Inc. POLICY NUMBER: ENV562000053-02 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 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 SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operations Any person or organization for whom you are performing In respect to any location where the Named Insured is operations when you and such person or organization have performing "your work." agreed in writing in a contract or agreement, effected prior to the date your operations for that person or organization commenced, that such person or organization be added as an additional insured on your policy Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section 11 - 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 dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sched- ule of this endorsement performed for that additional insured and included in the 'products -completed operations hazard". CG 20 37 07 04 ® ISO Properties, Inc., 2004 Page 1 of 1 54450787 1 20-21 GL/UMB AI MAIN MASTER I Tina Coleman 1 3/4/2020 10:51:53 AM (PST) I Page 4 of 4 DATE (MMMIYYYY) AC40RU CERTIFICATE 4F LIABILITY INSURANCE � 02/27/2020 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) 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(a). li AC PRODUCER .. .... , Edgar Beth Bettger Insurance Agency, Inc. PHONE .562-496-1000 I VAA 2.809.9559 SlateFarm 20220 State Road ADDRESS:Edgar,Pare4es.Esgo@stalefarm,corn Cerritos, CA. 90703 INSURER(S) AFFORDING COVERAGE NAIC a INSURERA:State Farm Mutual Automobile insurance Company 2ti178 INSURED Robert & Peggy Herricks INSURER B: DBA Roberts Liquid Disposal I INSURERC; 14018 Carmenita Rd INSURER D: h Santa Fe Springs, CA 90670-4919 INSURER E: I INSURER F, COVERAGE$ 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 WTH 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. I li"_.- AWOULIUK POLICY 91`* POUOYzXP LIMITS LTR TYPE OF IN$URANCE Imo„ POLICY NUMBER IMMIOWYYYYI IMWDDfrf" COMMERCIAL GENERAL UABILITY EACH OCCURRENCE S CLAIMS -MADE � OCCUR PREMISESM, a--„ onoaI $ AMA 'E LI HI: l 9+1P �v DESCRIPTION OF OPERATIONS 1 LOCATIONS /VEHICLES (ACORD 101, Addidonsl Remarks SchedWa, may be attached N mon apace la requlmd) 100% Replacement Cost up to the Palm Limits 2018 Ford Tank Truck Policy EFF: 011'0712020 Policy EXP: 07/07/2020 Polley nu'mbe'r: 603-2869 296 5590-E20.75T EFF: 11/20/2019 EXP: 05/20/2020 2003 Ford F250 2020 Freightliner M2 106 Flat Bed Truck EFF:12r0612019 EXP: 0610612020- COMBINED SINGLE LIMITA,000,000 This insurance is Primary and Non -Contributory with the respects to Balms arising out of the operation of the described vehicle. CERTIFICATE HOLDER CITY OF EL SEGUNDO DEPARTMENT OF PUBLIC WORKS EL SEGUNDO, CA 90246 CANCELLATION SHOULD ANY OF TH BO DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO' DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCOACIAN'C'E TH' TH LICY PROVISIONS. 1988.2014 ACO'RD CORPORATION. All rl" reserved. ACORD 25 {2014101) The ACORD name and logo d marks of ACORD 1001466 132849.9 02-04-2014 MED EXP (,Any one paraoral T PERSONAL b ADV INJURY i I GEE'N'LAGGREGATE ,LIMIT APPLIES PER: GENE'RALAGCR6CATE I .POLICY' f JECT F—]LOCI PRODUCTS . COM PROPAGG $ $ OTHER' AUTOMOBILE LIABILITYY 244054.801-75 02/01/2020 COMaINEOSINLILELIMV'I 08101!2020 � rE>�av^.c�dsnll $ 2,000,000 ' ANY ALTO P73 -6662 -AOS -75 01/0612020 07/0612020 BODILY INJURY(Perpereon) $ I ALL OWNED SCHEDULED BODILY INJURY (PeraodderN) E I AUTOS AUTOS NON -OWNED x 413$508-BO3-75 02/03/2020 08103/2020 PROPERTY CIAMA%E $ X HIRED AUTOS AUTOS 244-3052-801-75 02/01/2020 08101/2020 1Psrawrfidc, h $ - UMBRELLA LMB OCCUR �CLAIMSWADE - i EACH OCCURRENCES , S EXCESS LMB AGGREGATE i I RETENTION $ $ DED COMPS' A p STATUTE__ N 1 ha R AND EMPLERIIIOYERS' LI ILII AND EMPLOYERS' LIABILITY YIN II _ I ZANY PROPMETOR!'PARTNERtEXECUTIVE E,L. EACH ACCIDENT $ �OlFFICERNEMSEREXCLUDED? N f A (MendatoryIn NH) E.L. DISEASE - EA EMPLOYEE $ I Mes, dewfte underPOLICY...... j SCRIPT ION OF OPERATIONS 121HOW E L DISEASE . LIMIT $ ' DESCRIPTION OF OPERATIONS 1 LOCATIONS /VEHICLES (ACORD 101, Addidonsl Remarks SchedWa, may be attached N mon apace la requlmd) 100% Replacement Cost up to the Palm Limits 2018 Ford Tank Truck Policy EFF: 011'0712020 Policy EXP: 07/07/2020 Polley nu'mbe'r: 603-2869 296 5590-E20.75T EFF: 11/20/2019 EXP: 05/20/2020 2003 Ford F250 2020 Freightliner M2 106 Flat Bed Truck EFF:12r0612019 EXP: 0610612020- COMBINED SINGLE LIMITA,000,000 This insurance is Primary and Non -Contributory with the respects to Balms arising out of the operation of the described vehicle. CERTIFICATE HOLDER CITY OF EL SEGUNDO DEPARTMENT OF PUBLIC WORKS EL SEGUNDO, CA 90246 CANCELLATION SHOULD ANY OF TH BO DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO' DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCOACIAN'C'E TH' TH LICY PROVISIONS. 1988.2014 ACO'RD CORPORATION. All rl" reserved. ACORD 25 {2014101) The ACORD name and logo d marks of ACORD 1001466 132849.9 02-04-2014 POLICYHOLDER COPY Sc P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 02-28-2020 CITY OF EL SEGUNDO Sc DEPT OF PUBLIC WORKS 150 ILLINOIS ST EL SEGUNDO CA 90245-4311 GROUP: POLICY NUMBER: 1446891-2019 CERTIFICATE ID: 370 CERTIFICATE EXPIRES: 12-31-2020 12-31-2019/12-31-2020 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. ell Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 12-31-1998 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2020-02-28 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO EMPLOYER ROBERT'S LIQUID DISPOSAL INC DBA: ROBERT'S LIQUID DISPOSAL 14018 CARMENITA RD SANTA FE SPRINGS CA 90670 [ND7,CNj (REV.7-2014) PRINTED : 02-28-2020 WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation: 1. Please be advised that a waiver of subrogation requires that a 3% surcharge will be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certificate holder who requested the waiver. (Note: if you have no employee payroll on that job, then there is no charge.) 2. To apply the 3% surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work on job/s for the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. Example: Payroll for job: Sample Rate: Regular Premium equals: Surcharge: Additional Waiver charge: Total premium equals $5,000.00 13.300 $ 665.00 3.00% $ 19.95 $ 684.95 (665.00 + 19.95) ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION REP 02 1446891-19 RENEWAL SC 1-37-56-44 PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE FEBRUARY 28, 2020 AT 12.01 A.M. AND EXPIRING DECEMBER 31, 2020 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME ROBERT'S LIQUID DISPOSAL 14018 CARMENITA RD SANTA FE SPRINGS, CA 90670 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF EL SEGUNDO WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, ROBERT'S LIQUID DISPOSAL IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03%. NOTHING IN THIS ENDORSEMENT SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS ABOVE STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS IN THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: MARCH 3, 2020 An.,N'TI—HORNED REP'RESECwNT IVE PRESIDENT AND CEO SCIF FORM 10217 (REV.4-2018) 2570 OLD DP 217