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PROOF OF INSURANCE (2021 - 2021) CLOSED
A 0 DATE (MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 06/09/2020 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 P Othis DU ERrtcertificate does not confer ri hts to the certificate holder in lieu of such endorsements). NAME:CarolCarol Knox, Debbie S. Taylor or Debbie Waller KGIB, INC. PHONE �i.......714#,744-3300(T14 744-6537 KNOX GENERAL INSURANCE BROKERS -ADDRESS:Carodk gobinc.Com, de bbiei g c,coor dwaller@kglbinc.com ExMAUL k i'bdn m 226 SOUTH GLASSELL STREET INSURER(S) AFFORDING COVERAGE NAIC # ORANGE CA 92866 INSURERA: SCOTTSDALE INSURANCE COMPANY 41297 ..............................WW................................_w......._...._....__..._.........._................................—..........._.........._...................... INSURED INSURERB; CALIFORNIA AUTOMOBILE INS. CO, 38342 _.......................... R.E. SCHULTZ CONSTRUCTION, INC INSURER C: WESTCHESTER SURPLUS LINES INS. CO. 10172 1767 N BATAVIA STREET INSURER D: INSURER E:** UPDATING AUTO LIABILITY COVERAGE ONLY' ORANGE CA 92865-4103 INSURER.-................_.......................................................................................................................................... _... 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 O'rHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY 'ERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH DOLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IIN.TR TYPE OF INSURANCE ADDL SUBR............._................�....POLICDYfYYFF f I CMPO SOY/yyV"Y1__........................ .............._............... .._.....................- ........_. I POLICY NUMBER IM LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR ,........... _ A ryry $ 100,000 GEN'L AGGREGATE LIMIT APPLIES PER: 04/22/2021 PERSONAL&ADV INJURY X 'JE F—] $ 2,000,000 POLICY LOC OTHER: COMBINED SINGLE LIMIT IEa no ddentY AUTOMOBILE LIABILITY BODILY INJURY (Per person) X ANY AUTO 06/19/2021 BODILY INJURY (Per accident) $ B OWNED . �. SCHEDULED AUTOS ONLY AUTOS HIRED $ 3,000,000 NON -OWNED _ AUTOS ONLY AUTOS ONLY X X BCS0038628 X BA040000046316 UMBRELLA LIAB X OCCUR A X EXCESSSLIAB CLAIMS -MADE DED jRETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED' ❑ N / A (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below CONTRACTORS POLLUTION C LIABILITY XLS0113602 --N/A— G71802152001 04/22/2020 06/19/2020 04/22/2020 EACH OCCURRENCE q $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea cccurrenceY ryry $ 100,000 MED EXP (Any one person) $ EXCLUDED 04/22/2021 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 COMBINED SINGLE LIMIT IEa no ddentY $ 1,000,000 BODILY INJURY (Per person) $ 06/19/2021 BODILY INJURY (Per accident) $ d��iCTPERTY DAMAGE _._._._._.__.$ . �. EACH OCCURRENCE _ $ 3,000,000 04/22/2021 AGGREGATE $ 3,000,000 PER '', OTH- STATUTE ER E.L. EACH ACCIDENT Is E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ $4,000,000 Aggregate $2500 Deduct. 04/22/2020 04/22/2021 $2,000,000 Per Occul DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) PROJECT NO. PW 18-33, HOLLY VALLEY PLAYGROUND PROJECT, HOLLY AVENUE & VALLEY STREET, EL SEGUNDO, CA The City of EI Segundo, its officers, officials, employees, agents and volunteers is named as additional insured on a primary and non contributory basis per form CG2001 12 19, CG 2010 12 19 for on going operations, CG2037 12 19 for completed operations and Waiver of Subrogation per form CG2404 12 19 with respect to General Liability and Auto Liability additional insured per form MCA85100817-CA as required by written contract CERTIFICATE HOLDER CITY OF EL SEGUNDO 350 MAIN STREET EL SEGUNDO 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 CA 90245 ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: BCS0038628 COMMERCIAL GENERAL LIABILITY CG 20 10 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWE NEH.S, 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) ANY PERSON OR ORGANIZATION WHEN REQUIRED BY WRITTEN CONTRACT OR AGREEMENT, EXECUTED PRIOR TO THE OCCURRENCE TO WHICH THIS INSURANCE APPLIES, THAT SUCH PERSON OR ORGANIZATION BE ADDED AS AN ADDITIONAL INSURED ON YOUR POLICY Location(s) Of Covered Operations ALL LOCATIONS I 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. CG 20 10 12 19 0 Insurance Services Office, Inc., 2018 Page 1 of 2 C. With respect to the insurance afforded to these 2. Available under the applicable limits of additional insureds, the following is added to insurance; Section III — Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the applicable required by a contract or agreement, the most we limits of insurance. will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or Page 2 of 2 0 Insurance Services Office, Inc., 2018 CG 20 10 12 19 POLICY NUMBER: BCS0038628 COMMERCIAL GENERAL LIABILITY CG 20 37 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSPIRED - 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 Organizations) ANY PERSON OR ORGANIZATION WHEN REQUIRED BY WRITTEN CONTRACT OR AGREEMENT, EXECUTED PRIOR TO THE OCCURRENCE TO WHICH THIS INSURANCE APPLIES, THAT SUCH PERSON OR ORGANIZATION BE ADDED AS AN ADDITIONAL INSURED ON YOUR POLICY Location And Description Of Completed Operations ALL LOCATIONS 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; whichever is less. This endorsement shall not increase the applicable limits of insurance. CG 20 37 12 19 0 Insurance Services Office, Inc., 2018 Page 1 of 1 POLICY #BCS0038628 COMMERCIAL GENERAL LIABILITY CG 20 01 1219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the This insurance is primary to and will not seek additional insured. 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 CG 20 01 1219 C Insurance Services Office, Inc., 2018 Page 1 of 1 POLICY NUMBER: BCS0038628 COMMERCIAL GENERAL LIABILITY CG 24 04 12 19 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: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS Name Of Person(s) Or Organization(s): ANY PERSON OR ORGANIZATION FOR WHOM THE INSURED HAS AGREED TO WAIVE RIGHTS OF RECOVERY, PROVIDED SUCH AGREEMENT IS MADE IN WRITING AND PRIOR TO THE 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 against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 04 12 19 0 Insurance Services Office, Inc., 2018 Page 1 of 1 POLICY NUMBER: BA040000046316 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Business Auto Broadening Endorsement This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM I. NEWLY ACQUIRED OR FORMED ENTITY (BROAD FORM NAMED INSURED) li. EMPLOYEES AS INSUREDS 111. AUTOMATIC ADDITIONAL INSURED IV. EMPLOYEE HIRED AUTO LIABILITY V. SUPPLEMENTARY PAYMENTS VI, FELLOW EMPLOYEE COVERAGE VII. ADDITIONAL TRANSPORTATION EXPENSE Vlll. HIRED AUTO PHYSICAL DAMAGE COVERAGE IX. ACCIDENTAL AIRBAG DEPLOYMENT COVERAGE X. LOAN/LEASE GAP COVERAGE XI, GLASS REPAIR — DEDUCTIBLE WAIVER X11. TWO OR MORE DEDUCTIBLES XIII. AMENDED DUTIES IN EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS XIV. WAIVER OF SUBROGATION XV. UNINTENTIONAL ERROR, OMISSION, OR FAILURE TO DISCLOSE HAZARDS XVI. EMPLOYEE HIRED AUTO PHYSICAL DAMAGE XVII. PRIMARY AND NONCONTRIBUTORY IF REQUIRED BY CONTRACT XVIII. HIRED AUTO — COVERAGE TERRITORY XIX. BODILY INJURY REDEFINED TO INCLUDE RESULTANT MENTAL ANGUISH Copyright 2017 Mercury Insurance Services, I.I.C. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with Its Permission Page 1 of 6 NEWLY ACQUIRED OR FORMED ENTITY (Broad Form Named SECTION ||- LIABILITY COVERAGE, A^Coverage, 1.Who |uAnInsured, the following is added: d. Any business entity newly acquired orformed 6vyou during the policy period provided you own 50% or more of the business entity and the business entity is not separately insured for Business Auto Coverage. Coverage is extended up to a maximum of1Q0 days following acquisition u,formation ufthe business entity. Coverage under this provision is afforded only until the end of the policy period. Coverage does not apply to an "accident' which occurred before you acquired or formed the organization. Ill. EMPLOYEES AS INSUREDS SECTION H - LIABILITY COVERAGE, A.Coverage, 1.Who IsAnInsured, the following is added: e. Any "employee" of yours is an "insured" while using a covered "auto" you don't own, hire nrborrow |nyour business pryour personal affairs, Ill. AUTOMATIC ADDITIONAL INSURED SECTION U -LIABILITY COVERAGE, A.Coverage, 1.Who IsAnInsured, the following is added: t Any person or organization that you are required to include as additional insured onthe Coverage Form inawritten contract oragreement that |osigned and executed by you before the "bodily Injury" or "property damage" occurs and that is in effect during the policy period is an "Insured" for Liability Coverage, but only for damages towhich this insurance applies and only tothe extent that person nr organization qualifies as an "insured" under the Who Is An Insured provision contained in Section II. IV. EMPLOYEE HIRED AUTO LIABILITY SECTION U'LIABILITY COVERAGE, A.Coverage, 2.Who |sAninsured, the following is added: Q. An"emplovee"ofyours Is an"\nmured°while operating an»outm"hired orrented under a contract or agreement in that "employee's" name, with your permission, while performing duties related tothe conduct mfyour business. V. SUPPLEMENTARY PAYMENTS SECTION U—LIABILITY COVERAGE, A.Coverage, 2.Coverage Extensions, a.Supplementary Payments, Subparagraphs (2)and (4) are replaced bythe following: (2) Upto$3,D0Ofor cost ofball bonds (including bonds for related traffic law violations) required because ufan"acc|dent"vxecover. VVeare not obligated to furnish these bonds, /4\ All reasonable expenses incurred bythe "inmunnd"atour request, including actual loss ofearnings upto$5OUaday because oftime off from work. Copyright 2017 Mercury Insurance Services, U.C.All rights reserved. KxCA851001117-CA includes copyrighted material ofInsurance Services Office |nc.,with its Permission Page %of6 VI. FELLOW EMPLOYEE COVERAGE. SECTION II — LIABILITY COVERAGE, B. Exclusions, 5. Fellow Employee This exclusion does not apply if you have workers' compensation insurance in -force covering all of your "employees". Coverage is excess over any other collectible insurance. VII. ADDITIONAL TRANSPORTATION EXPENSE SECTION III - PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage Extensions, a. Transportation Expenses, is replaced with the following: We will pay up to $50 per day to a maximum of $1000 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. 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". If your business shown in the Declarations is other than an auto dealership, we will also pay up to $1,000 for reasonable and necessary costs Incurred by you to return a stolen covered auto from the place where it is recovered to its usual garaging location. VIII. HIRED AUTO PHYSICAL DAMAGE COVERAGE SECTION III — PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage Extensions, the following is added: C. If Liability Coverage is provided in this policy on a Symbol 1 or a Symbol 8 basis and Comprehensive, Specified Causes of Loss, or Collision coverages are provided under this coverage form for any "auto" you own, then the Physical Damage Coverages provided are extended to "autos" you hire, subject to the following limit: (1) The most we will pay for "loss" to any hired "auto" is $50,000 or Actual Cash Value or Cost of Repair, whichever is less (2) $500 deductible will apply to any loss under this coverage extension, except that no deductible shall apply to "loss" caused by fire or lightning Subject to the above limit and deductible we will provide coverage equal to the broadest coverage applicable to any covered "auto" you own of similar size and type. This coverage extension is excess coverage over any other collectible Insurance. IX. ACCIDENTAL AIRBAG DEPLOYMENT COVERAGE SECTION III - PHYSICAL DAMAGE COVERAGE, B. Exclusions, 3.a., is amended to add the following: This exclusion does not apply to the accidental discharge of an airbag. Copyright 2017 Mercury Insurance Services, I.I.C. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 3 of 6 X. LOAN/LEASE GAP COVERAGE SECTION III - PHYSICAL DAMAGE COVERAGE C. Limit of Insurance, the following is added; 4 in the event of a "total loss" to a covered "auto" shown in the schedule or declarations for which Collision and Comprehensive Coverage apply, we will pay any unpaid amount due on the lease or loan for that covered "auto," less: a. The amount paid under the Physical Damage Coverage Section of the policy; and b. Any: (1) Overdue lease/loan 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) Security deposits not returned by the lessor; (4) Costs for extended warranties, Credit Life Insurance, Health, Accident or Disability Insurance purchased with the loan or lease; and (5) Carry-over balances from previous loans or leases. The most we will pay under Auto Loan/Lease Gap Coverage for an Insured auto is 25% of the actual cash value of that insured auto at the time of the loss. X1. GLASS REPAIR — DEDUCTIBLE WAIVER SECTION III - PHYSICAL DAMAGE COVERAGE, D. Deductible, the following Is added: No deductible applies to glass damage if the glass is repaired rather than replaced. X111 TWO OR MORE DEDUCTIBLES SECTION III -PHYSICAL DAMAGE COVERAGE, D. Deductible, the following is added: If two or more "company" policies or coverage forms apply to the same accident: 1. If the applicable Business Auto deductible is the smallest, it will be waived; or 2. If the applicable Business Auto deductible is not the smallest, it will be reduced by the amount of the smallest deductible; or 3. If the loss involves two or more Business Auto coverage forms or policies the smallest deductible will be waived, For the purpose of this endorsement "company" means the company providing this insurance and any of the affiliated members of the Mercury Insurance Group of companies. XIII. AMENDED DUTIES IN EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS The requirement in SECTION IV, BUSINESS AUTO CONDITIONS, A. Loss Conditions, 2. Duties In The Event Of Accident, Claim, Suit, Or Loss, a., in the event of "accident", you must notify us of an "accident" applies only when the "accident" is known to: (1) You, if you are an individual; (2) A partner, if you are a partnership; (3) A member, If you are a limited liability company; or (4) An executive officer or insurance manager, if you are a corporation. Copyright 2017 Mercury Insurance Services, LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 4 of 6 XIV. WAIVER OF SUBROGATION SECTION IV - BUSINESS AUTO CONDITIONS, A. Loss Conditions, 5. Transfer of Rights Of Recovery Against Others To Us, section is replaced by the following: 5. Transfer Of Rights Of Recovery Against Others To Us We waive any right of recovery we may have against any person or organization to the extent required of you by a written contract executed prior to any "accident" or "loss", provided that the "accident" or "loss" arises out of the operations contemplated by such contract. The waiver applies only to the person or organization designated in such contract. XV. UNINTENTIONAL ERROR, OMISSION, OR FAILURE TO DISCLOSE HAZARDS SECTION IV - BUSINESS AUTO CONDITIONS, B. General Conditions, 2. Concealment, Misrepresentation, or Fraud, the following is added: Any unintentional omission of or error in information given by you, or unintentional failure to disclose all exposures or hazards existing as of the effective date or at any time during the policy period shall not invalidate or adversely affect the coverage for such exposure or hazard or prejudice your rights under this insurance. However, you must report the undisclosed exposure or hazard to us as soon as reasonably possible after its discovery. This provision does not affect our right to collect additional premium or exercise our right of cancellation or non -renewal. XVI. EMPLOYEE HIRED AUTO PHYSICAL DAMAGE SECTION IV — BUSINESS AUTO CONDITIONS, B. General Conditions, 5. Other Insurance, b. For Hired Auto Physical Damage Coverage, is replaced by the following: b. For Hired Auto Physical Damage Coverage, the following are deemed to be covered' "autos" you own: 1. Any covered "auto" you lease, hire, rent or borrow; and 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". XVII. PRIMARY AND NONCONTRIBUTORY IF REQUIRED BY CONTRACT SECTION IV — BUSINESS AUTO CONDITIONS, B. General Conditions, 5, Other Insurance, the following is added and supersedes any provision to the contrary: e. 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. Copyright 2017 Mercury Insurance Services, LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 5 of 6 XVIII. HIRED AUTO - COVERAGE TERRITORY SECTION IV - BUSINESS AUTO CONDITIONS, B. General Conditions, 7. Policy Period, Coverage Territory, e. Anywhere In the world If:, is replaced by the following: e. Anywhere in the world if: (1) A covered "auto" is leased, hired, rented or borrowed without a driver for a period of 30 days or less; and (2) The "insured's" responsibility to pay damages is determined in a "suit" on the merits, in the United States of America, the territories and possessions of the United States of America, Puerto Rico, or Canada or in a settlement we agree to. XIX. BODILY INJURY REDEFINED TO INCLUDE RESULTANT MENTAL ANGUISH SECTION V— DEFINITIONS, C. "Bodily Injury" is amended by adding the following: "Bodily injury" also includes mental anguish but only when the mental anguish arises from other bodily injury, sickness, or disease. Copyright 2017 Mercury Insurance Services, LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 6 of 6 Policy Number Date Entered: 04/14/2020 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIOOIYVVY( (yam, r 4/30/2020 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 11 CONTACT The Hulett Agency NA��Mi PHONE hulett (858)618-5442 ecIg I F (858) 618-5444 13959 Saddlewood Drive Poor RMess�r g y@ @sbc lobal , ne tlA u Nop Poway, CA 92064 INSURER(S) AFFORDING COVERAGE NAI.........., INSURER A: State Corlpmsation Insurance Fund INSURED R E Schultz Construction, Inc. INSURER B: J II INSURER C 1767 N. Batavia St INS. RIR D: Orange, CA 92865 INSURER E;. C INSURER F COVERAGES CERTIFICATE NUMBER: REVI'a(ION 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 AODL. SUSP POLICY EFF POLICY E%P I LIMITS LTR TYPE OF INSURANCE INSO WVO POLICY NUMBER (Aro ry1PDOpYYYYM IMMIDDIYYYV) COMMERCIAL GENERAL LIABILITY CLAWS -MADE = OCCUR GENT AGGREGATE LIMIT APPLIES PER POLICY D PRC} JECT LOC OTHER AUTOMOBILE LIABILITY ANY AUTO OWNED " SCHEDULED � AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB oc•c(IR ,,........, C'IF�VIASAAAI)E EXCESS LIAB DEG I ( RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIErORrpp,R'rldERIEXECUTIVE NIA A OFFICEP.IMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below 9274424 04/14,'2020 04!14"2021 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required( Project: Sycamore Park Location: 1414 E. Sycamore Ave.El Segundo, CA 90245 Blanket Waiver of Subrogation Attached CERTIFICATE HOLDER CANCELLATION I:ACI I CCCUdiY(IENO..:: S k.Y�APdkWY.rk;:1LA'�Ck•.°.aV k q•.I..I P REWSE"°a i'r,a rccuuer:oM S MED EXP (Any one person) 5 PERSONAL & ADV INJURY S GENERAL AGGREGATE S PRODUCTS - C'OMPIOP AGO S 1�B111L41 PNP.:'Jet ;alPWt„L'. C.. Y.,Jugtl�l I 5 WEadoodavin _ BODILY INJURY (Per person) $ BODILY INJURY (Per acudent) S ^'I'd4�7h"E H 1 Y' JkMAL"t S Wel ar Cr47enl t S EACH OCCURRENCE S AGGREGATE S S h�rr< U I s.k. ScTATUTE I FR E L EACH ACCIDENIT 5 1'000 , 000 E L DISEASE - EA EMPLOYEE $ 1,000,000 EL DISEASE -POLICY LIMIT $ 1,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of E1 Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St., Room 5 El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE tskamrrat IJ Kn 01988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS ROME OFFICE SAN FRANCISCO EFFECTIVE APRIL 14, 2020 AT 12.01 A.M. ALL EFFECTIVE DATESARE AND EXPIRING APRIL 14, 2021 AT 12.01 A.M. AT 1201 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME R E SCHULTZ CONSTRUCTION, INC 1767 N BATAVIA ST ORANGE, CA 92865 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, TRIS AGREEMENT APPLIES ONLY TO THE EXTENT THAT YOU PERFORM WORK UNDER A WRITTEN CONTRACT THAT REQUIRES YOU TO OBTAIN THIS AGREEMENT FROM US. THE ADDITIONAL PREMIUM FOR THIS ENDORSNT SHALL BE 2.00% OF THE TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION FOR WHOM THE NAND INSURED AAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER JOB DESCRIPTION BIAtMT WAIVER OF SUBROGATION 9274424-20 NEW SP 4-22-35-07 PAGE 1 OF NOTHING IN THIS ENDORSEMENT CONTAINED SHALL SE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED, NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT, COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: SCIF FORM W2T7 IREV.7-20141 APRIL 15, 2020 1 PRESIDENT ANO CEO 2572 OLD DP 217