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PROOF OF INSURANCE (2020 - 2021) CLOSEDaI DATE (MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 02,20,2020 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 Bobby Truong NAME: IQ Risk Insurance Services, LLCPHONE (949) 679-3700 AX' (949} 679-3701 AIC' No,mC• N.Y: 225 N Bush Street "MAIL. btruong@igrisk com ADDRESS: - ..... .. .................. ........... _ INSURER(S) AFFORDING COVERAGE NAIC # Santa Ana CA 92701 INSURERA: Kinsale Insurance Company 38920 INSURED INSURER B: Falls Lake Fire and Casualty Company 15884 CC LAYNE & SONS INC, INSURER C: 216 Standard Street INSURER D: EI Segundo, CA 90245 I INSURER E. I' INSURER F: COVERAGES CERTIFICATE NUMBER: CL2022006213 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, INSIR " AV OL'SU'BR ....... POLICY EFF LIMITS POLICY'ER LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDDIYYYY) IMM/DDIYYYYI X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000.000 1)AIMAV,;.E WHENNED 100,000 CLAIMS -MADE ❑OCCUR Pk� MISES (Ea ac-urrence'I S AMED EXP (Any one person) S Excluded A Y I 010061552-2 02/01/2020 02/01/2021 PERSONAL &ADV INJURY S 110001000 GEN'LAGGREGATE LIMITAPPLIES PER: POLICY ❑tJo" ❑ LOC OTHER: AUTOMOBILE LIABILITY ANYAUTO OWNEDSCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY X UMBRELLA LIAB OCCUR A EXCESS LIAB 0100061562-2 02/01/2020 02/01/2021 HCLAIMS-MADEmm DED RETENTION S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE B OFFICER/MEMBER EXCLUDED? NIA FLA008293-02 02/01/2020 02/01/2021 (Mandatory In NH) .••••••••••• If yes, describe under DESCRIPTION OF OPERATIONS below _...m ........._.......... ............................. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) GENERALAGGREGATE $ "i", 56,000 ............ PRODUCTS-COMP/OPAGG S 2;000,000 S COM8tNECV SINGLE Lll I S dEa accnden0 ................. it BODILY INJURY (Per person) S BODILY INJURY (Per accident) $ ....$......... P'�n6`Pi��L;'R"6'a' !7A?uRAGE I Pfir ac6deal0 5 s 2,000,000 $ 2,000,000 EACH OCCURRENCE AGGREGATE O X1 STATUTE I ERHm E L EACH ACCIDENT E L DISEASE - EA EMPLOYEE E L DISEASE - POLICY LIMIT '10 Days Notice of Cancellation for Non -Payment of Premium RE: Covered CA Operations Performed By Or On Behalf of the Named Insured The City of EI Segundo, its officers, officials, employees, agents, and volunteers are named additional insured as respects general liability and this insurance is primary and noncontributory with any other insurance of the additional insured; and waiver of subrogation applies as respects workers compensation as required by written contract, per endorsements attached Digitally signedb h Lillio Joseph L i l l i o --ph hlliah.,— o=Gty of EI Segundo Oa -D-d., of Finance, email=,Iillm�melsegundo.Org, c=US Date 202006.151):52:09-0)b0 CERTIFICATE. HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street AUTHORIZED REPRESENTATIVE f o EI Segundo CA 90245 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS SCHEDULED PERSON OR ORGANIZATION Attached To and Forming Part of Policy Effective Date of Endorsement . ................w....._... rc, 0100061552-2 02/01/2020 12:OlAM at the Named Insured C Layne & Sons Inc address shown on the Declarations Additional Premium: p ReturnPPremium: 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 Blanket, as required by written contract, executed prior to Locations as required and specified by written contract, the startof work on the project. executed prior to the start of work on the project, 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. 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. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 p THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO LIS -BLANKET Attached To and Forming Fart of Policy I 0100061552-2 Additional Premiums Sa Effective Date of Endorsement Named Insured 02/01/2020 12:01AM at the Named Insured C C Layne & Sons Inc address shown an the Declarations Return Premium: This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE SECTION IV — CONDITIONS, 8. Transfer of Rights of Recovery against Others to Us is amended by the addition of the following: We waive any right of recovery we may have against persons or organizations because of payments we make for injury or damage arising out of "your work" done under a written contract with that person or organization wherein you have agreed to provide this waiver. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. CAS4002 0110 Page 1 of 1 91- AC7i;Rt':)* CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDWYM 02120/2020 F—THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS -NO RIGHTS UPON I THE C - ERTI - FICATE H . OLDER. 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. R TRTANT� It the ertificate holder s an ADITINAINSUED, the policy(ios) m st have ADIOAL INURED provisions or 'be endorsed. It SMPUBROGATiONOIScWAIVED, subjectiD to the termsOandL conditions of the policy, cerutain policiesDmaTIN y requireSan endorsement A statement on this coilificate does not confer rights to the certificate holder In lieu of such endorsenient(s). PRODUCER CONTACT ,Aq: _ rom Brunuidw Tom Brundidge License 0479986 PHONE (310) 322-5840 (310)37-2-0831 914StandardSt Ste EAWL lorn@lornbrundidge,com El Segundo CA 90245 IN F QNO WYERAGE NAIC 0 . . . ..... INSURER A State Farm Mutual Automobile Insurance Company 1 25178 INSURED C C LAYNE & SONS INC f REfi C 216 STANDARD ST INSURER r: EL SEGUNDO CA 90245 INSURER E. COVERAGE$ CERTIFICATE NUMBER'. REVISION NUMBER: IS TO CERTIFY 'niAl THE POLICIES OF INSURANCE LISTED RELOW HAVE BEEN ISSUED To THE INSURED NX-M—FO A13OVE FOR THE POGF� PE6—D INDICATED, NOTVIATHSTANDING ANY REQUIREMENT, TERM OP. CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT THICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLOT HE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH PCX ICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. N Sk 7 L TA TYPE Of INSURANCE —1U5riwW1 POLICY NUMBER POLIC F,FF POLICY EXP IMWDUNYYY� tMMj0OFYYYYJ, LIMITS COMMERCIAL GENERAL LIABILITY CUIMS-MADF ()C�:LIR t VUL: EXP rApV OAC. inqrgW _,a a Apr', PER JCII: PU)T, q AUTOMOBILE LIABILITY y Y 16391212-B08.75 02JOB12020 08/08/2020 ANYALIF0 DILY INjURY (PeT persw) 1.0,00,000 A owNL-1) SCHEDULED X AJTD8 k -%4'r' ,u ros SoolLY IN;URY (Per acudent) s Ixosiol) HiREID NCIIN-OWNED �AJTGSOW� AUTOS ONLY 1"EITY DIIIIAQ41 s UMBRELLA LIAR OCCJR ii EXCESS LIAR .. 7 ... . ....... . GORLQA1[, NION$ WORKERS COMP FNSATION I'VE q OTPi S1L7—qTR AND EMPLOYERS'LJARRATY Y fl,%'y IkPFI�Ip�jrrLl — QR, P 4 R, N � R1r Kt,, � - 11)F;11-1 EVF�P QNIA Im"11114tory in NH) E L DISE SF - E�, rM EE 4 t, yes, "esallbe uoyjw r.L DESCRIPTION OF OPERATIONS P LOCATIONS 0 VEHICLES (ACORD 191, Additional Remarks Schedule, may be attached if more space is required) 2006 FORD F350 SID CREW CAB VIN 1 FTVVW31 P46F-A08216 Additional Insured: The City of EI Segundo, its officers, officials, employees. agents, and volunteers. CERTIFICATE HOLDER City of EI Segundo 350 Main St El Segundo CA 90245 • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL SE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1988.2015 ACORD CORPORAT18N. All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD IfN)1488 132649.12 03-1E-2016 it JZ_ WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) 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 25% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Blanket Waiver of Subrogation As respects to all CA jobs performed by the named insured during the policy period where by written contract a waiver of subrogation is required prior to the commencement of work. 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 02-01-2020 Policy No. FLA008293-02 Endorsement No. Insured Insurance Company CC Layne & Sons, Inc (a Corp) Falls Lake Fire & Casualty Company Countersigned By ©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved.