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PROOF OF INSURANCE (2021) CLOSEDTRIASER-01 TLOVELL HC (JKL! CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `.� 2/17/2020 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 (CONTACT Theresa Lovell NAME: Alliant Insurance Services, Inc. PHONE FAX 353 N Clark St 11th Floor (A/C, No, Ext): (A/C, No): Chicago, IL 60654 E-MAIL g ADDRESS: Theresa.LovelI@alIiant.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Everest National Insurance Companv 10120 INSURED INSURER B: AXIS Surplus Insurance Companv 26620 Shelter Clean Services, Inc. INSURER C: Lexington Insurance Company 19437 11065 Penrose St. INSURER D : Westchester Surplus Lines Insurance Company 10172 Sun Valley, CA 91352 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: ABN 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 CONTRA:T OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLIC ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH DOLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY RAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYYI (MM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE OCCUR X RM8GL00008201 GEN'L AGGREGATE LIMIT APPLIES PER: PRO � LOC POLICY � JECT OTHER A AUTOMOBILE LIABILITY X ANY AUTO RM8CA00016201 OWNEDSCHEDULED AUTOS ONLY AUTOS HIREDNON-OWNED ONLY AUTOS ONLY CCAUTOS X $3,Ogb Ded X Coll. Ded. $3,000 B UMBRELLA LIABX OCCUR X EXCESS LIAB CLAIMS -MADE P00100008343102 DED I I RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y ANY PROPRIETOR/PARTNER/EXECUTIVE X WC8WC00031201 A OFFICER/MEMBER EXCLUDED? ❑ NIA (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below C Excess Liab - 5Mx3M 023627617 D Excess Liab - 5Mx8M G71785518001 2/2$/2020 2/2$/2021 DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Anv one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OPAGG $ COMBINED SINGLE LIMIT (Ea accident) $ 2/28/2020 2/28/2021 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ I EACH OCCURRENCE $ 2/28/2020 2/28/2021 (AGGREGATE $ X STATUTE EERH 2/28/2020 2/28/2021 E.L EACH ACCIDENT $ 2/28/2020 2/28/2021 2/28/2020 2/28/2021 E.L DISEASE - EA EMPLOYEE $ E.L DISEASE -POLICY LIMIT $ Each Occ./Aggregate Each Occ./Aggregate 500,000 10,000 2,000,000 6,000,000 2,000,000 2,000,000 3,000,000 3,000,000 2,000,000 2,000,000 2,000,000 3,000,000 5,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: City of EI Segundo. City of EI Segundo, its officials, officers, agents and employees are included as Additional Insured in accordance with the policy provisions of the General Liability policy. A Waiver of Subrogation is granted in favor of Certificate Holder in accordance with the policy provisions of the Workers' Compensation policy. CERTIFICATE HOLDER City of EI Segundo Attn: PW Dept. 350 Main Street EI Segundo, CA 90245 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 w. © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: TRIASER-01 LOC #: ACRO ADDITIONAL REMARKS SCHEDULE AGENCY Alliant Insurance Services, Inc. POLICY NUMBER SEE PAGE 1 CARRIER NAIC CODE SEE PAGE 1 SEE P 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance 2020 Excess Liability Excess Liability - 4th Layer $10,000,000 Excess $13,000,000 Policy # 100036107 Term: 2/28/2020 to 2/28/2021 Carrier: QBE Insurance Corporation Limits: $10,000,000 Occurrence / $10,000,000 Aggregate NAMED INSURED Shelter Clean Services, Inc. 11065 Penrose St. oun Valley, CA 91352 EFFECTIVE DATE: SEE PAGE 1 TLOVELL Page 1 of 1 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: RM8GL00008201 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 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) ALL ORGANIZATIONS WHERE REQUIRED BY WRITTEN CONTRACT AND EXECUTED PRIOR TO LOSS 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. Location(s) Of Covered Operations YOUR LOCATIONS 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. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 INSURED COPY 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. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13 INSURED COPY POLICY NUMBER:RM8GL00008201 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 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 Organization(s) Location And Description Of Completed Operations ALL ORGANIZATION WHERE YOUR LOCATIONS AND COMPLETED REQUIRED BY WRITTEN CONTRACT OPERATIONS. AND EXECUTED PRIOR TO LOSS. lInformation 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. CG 20 37 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 INSURED COPY 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. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 37 04 13 ❑ INSURED COPY WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 76 (Ed. 04-11) NOTICE OF CANCELLATION TO DESIGNATED PERSON OR ORGANIZATION If we cancel this policy for any statutorily permitted reason other than nonpayment of premium, we shall endeavor to mail or deliver a written notice in accordance with state law to the person or organization shown in the Schedule below. Proof of mailing will be sufficient proof of such notice. This endorsement shall not operate directly or indirectly to benefit any person or organization not named in the schedule below. SCHEDULE Designated Person or Organization: ANY PERSON OR ORGANIZATION WITH WHOM YOU HAVE AGREED IN A WRITTEN CONTRACT THAT NOTICE OF CANCELLATION OF THIS POLICY WILL BE GIVEN Designated Person or Organization Address: Contract, Permit or Job Number: Number of Days Notice: 30 All other terms and conditions of this policy remain unchanged. 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 02/28/2020 Policy No. RM8WC00031201 Endorsement No. Insured TRIANGLE SERVICES INC. Premium $ INCL. Insurance Company EVEREST NATIONAL INSURANCE COMPANY Countersigned By WC 99 06 76 (Ed. 04-11) Copyright, Everest Reinsurance Company, 2011 Includes copyrighted material of National Council on Compensation Insurance, Inc. used with its permission. INSURED COPY