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PROOF OF INSURANCE (2021 - 2021) CLOSED� P CERTIFICATE OF LIABILITY INSURANCE D06E(M2�DDlYYYY) 06/1612020 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 pollcy(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 NAME: Next First Insurance Agency, Inc. PHONE 855 222-5919 FAx DDP PO Box 60787 tAlC NV Fx6! support@nextinsurance c Palo Alto, CA 94306 E-MAIL om INSURERS) AFFORDING COVERAGE �, NAIC # INSURER A : National Insurance Company, Inc ..._...._..r............ 12831 mm I .... ..........� Slate Nat.......... ......... ...... INSURED INSURER B _...,,.... Horacio Delatorre Nata Construction, Inc. INSURER c.............m...._..... 32564 Cullen Ct JNSuERD_ Winchester, CA 92596 .. _..-,...,...._.___..................._..,....,. INSURER E: ,,, INSURER F; COVERAGES CERTIFICATE NUMBER: 4402477 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. _ .__.. ..... ..-.._. ,,. n. Y ... i .,,..LIMITSIT.... IC b�'DDgp+E.,,dC.PT t MIDDI' -' �I �r'YV f TYPE OF INSURANCE WVD � POLICY NUMBER LTRTYPEJ 1 NSn I MM.FDDFYi dN1' YYYI GENERAL LIABILITY � COMMERCIALGENE � � Fr4CH OCCURRENCE $1 000,000.00 .. ..— X _pgtvUCG� iCJf"Y�NY6R5 ..... $100 000.00 CLAIMS -MADE .,I OCCUR REMISES {Ep nccur'MPEeI,,,, ME D F�(P !Any one personl $15,000.00 A P X X NXT36SLQ22-00•GL 0611612020 05116 ?021 PERSONAL B ADV INJ URY „ S1,00000000 ...... GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $2,000,00000 .,tl POLICY �� JECTPRO- ; I LOG PRODUCTS - COMP/OP ASG $2,000,000.00 I OTHER' $ R AUTOMOBILE LIABILITY I,'Nta'u,E �"OhBINED St R.,IN"pT $ r ANY AUTO k BODILY INJURY (Per person) S .............._._,_,.,...,___. Y OWNED ... LED'l BODILYE INJURY Per accident) $ AUTOS ONLY HIRED UTOS,. AUTOS A NON -OWNED ,......... d 71"DXA�i61"T ._._,.denQ '^. .......... h ' AUTOS ONLY W ..... AUTOS ONLY td n crlaGetuCt . .5_..-...,._—__ ._ R.-.._....o.._ UMBRELLALIABI1 OCCUR I H URR ENCE_.....$5 CLAIMS-ApXESS J DE ` V. AGGREGATE ....,,.... ___...................._.-..._......_,_..,-.. EpRETENTIONS ' WORKERS COMPENSATION - PER 1 OTW UTE.. I, F AND EMPLOYERS'LLABILITY$ YIN N ...-- .. -STA . ANyyYPROPRIETORIPARTNERIEXECUTIVEE.L. I CHA m ^ n m ,_-....._...,.,. OMFFIICERIry In NH) E CLUDED9 F__] N 1 A E.L. DISEASE C„'EA,EMPmmm $ ,.._ . '. ,'.".. _..-.-_......... describe under - MIT � 5 EL. DISEASE POLICY LIMIT DESS, CRtPTION OF OPERATIONS below a Each Occurrence: $25,000.00 A Contractors Errors and Omissions IX �NXT38SLQ22-00-Gl_ 06/1612020 06/16/2021 Aggregate: 1$50,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule" may be attached it more space is required) The City of EI Segundo, its officials, employees, agents and volunteers are Additional Insureds on the General Liability policy for ongoing operations, on a primary and non- corRBPlbuRORYbasis if required by writter. a Ireement wilh the insured. A General liability Waiver of Subrogation applies in favor of this Additional Insured if required by written agreement with the insured. CERTIFICATE HOLDER CANCELLATION City of ED Sundo I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The City Ov Segundo, its officials, employees, agents and volunteers THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main St EI Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - AUTOMATIC STATUS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SECTION 11 - WHO IS AN INSURED is amended to include as an additional insured any person or organization when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. A. Such person or organization is an additional insured 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 with respect to: a. Premises you own, rent, lease, or occupy; or 41 b. Your ongoing operations performed for that insured. B. The insurance afforded to such additional insured; 1. Only applies to the extent permitted by law; and 2. Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. C. The Limits of Insurance applicable to the additional insured are the lesser of those specified in; 1. The written contract or agreement; or 2. The Declarations for this policy, whichever is less. Such are included in, and not in addition to, the Limits of Insurance shown in the Declarations. D. Regardless of whether other insurance is available to an additional insured on a primary basis, this insurance will be primary and noncontributory if a written contract between you and the additional insured specifically requires that this insurance be primary. All other terms and conditions of the policy remain unchanged. NXT-0308 BM GL 0619 Includes material copyrighted by Insurance Services Office, Inc. used with its Page 1 of 1 permission COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED ADDITIONAL INSURED - PRIMARY INSURANCE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person or Organization: The City of EI Segundo, its officials, employees, agents and volunteers 350 Main St El Segundo, CA 90245 SECTION 11 - WHO IS AN INSURED is amended to include the person or organization 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 your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. 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. 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. Ill. Coverage provided to the additional insured shown in the SCHEDULE is afforded on i) a primary basis, ii) a noncontributory basis, or iii) a primary and noncontributory basis in accordance with the applicable written contract between you and the additional insured. All other terms and conditions of the policy remain unchanged. NXT-0064 BM GL 0218 Includes material copyrighted by Insurance Services Office, Inc. used with its Page 1 of 1 permission POLICY NUMBER: NXT38SLQ22-00-GL COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 RIVER OF TRANSFER OF RIGHTS OFR COVER' 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 against whom you have agreed to waive such right of recovery in a written contract or agreement 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 O Insurance Services Office, Inc., 2008 Page 1 of 1 11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY NUMBER NXT38SL022-00-GL NAMED INSURED Horacio Delatorre Nata Construction, Inc. 32564 Cullen Ct Winchester, CA 92596 COVERAGE PARTS AFFECTED POLICY CHANGES POLICY CHANGES EFFECTIVE 06/16/2020 Commercial General Liability Coverage Part CHANGES SEE ATTACHED SCHEDULE Additional Total Policy Change Number 01 COMPANY State National Insurance Company, Inc. AUTHORIZED REPRESENTATIVE Ann Ryan Authorized Representative Signature IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1963 Page 1 of 2 O Copyright, ISO Commercial Risk Services, Inc., 1983 SCHEDULE OF POLICY CHANGES It is understood and agreed that the policy is amended as follows: The following; forms are added. Designated Additional Insured - primary Insurance NXT-0084 SM GL 0218 Additional Insured — Owners, Lessees or Contractors — Scheduled Person or Organization CG 20 10 04 13 All other terms and conditions remain unchanged. IL 12 01 1185 Copyright, Insurance Services Office, Inc., 1983 Page 2 of 2 ❑ Copyright, ISO Commercial Risk Services, Inc., 1983 POLICY NUMBER: NXT38SLQ22-00-GL COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURE® - 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 The City of EI Segundo, its officials, employees, agents and volunteers 350 Main St EI Segundo, CA 90245 California Information required to complete this Schedule, if not shown above, will be shown in the Declarations, J A. Section II — Who Is An Insured is amended to B 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. 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 2010 0413 0 Insurance Services Office, Inc., 2012 Pagel of 2 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 0413 NATACON-01 KOULIN� .ICOR® CERTIFICATE OF LIABILITY INSURANCE DATE iMMroDIYYYYI6/17120 'll n_..., 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)._ PRODUCER License # OFB2764 CRp TACT Laurie Graves Inszone Insurance Services, Inc. I FAX 2721 Citrus Road IIrNitraves.ins..8.........ei......_......._......_........._...._rC Ner: 916) 636-D734 W 3-4 13 SURER 8 ,AFFOR�ING,CQVE I N1s u Suite A zon ns.com AIC �..�__.., ... mm. .. Rancho Cordova, CA 95742 INsuR�l�nr Guard Insurance Companies INSURED INSURER a: Everest Premier Insurance NataConstruction, Inc. �NsuRE�zµc..;....__.._........._...w._..._............._................................................................_...._.. p . _............_ ....W..._ 32564 Cullen CourtINSURER D Winchester, CA 92596 INS,UREIq E INSURER F -- " COVERAGE'S CERTIFICATE NUMBER: _..._.___.._... F1a15I97N hit MBER: 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. p INSR AODLISUeR _._........ ............ _.„ .... _, _,....m__ POLICY EFF POLICY EXP POLICY NUMBER LIMITS 9 TYPE OF INSURANCE I INSO WVD �' J�(0 P COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE �_ ....._. .. ' ...._.�....._..�.. _....... ......� CLAIMS -MADE �..DAMAGE TORENTED ............� OCCUR RMgpS A De„p.e Rvl .....$ _ ...�..... ._..�............ �......i n A V IN.�URV S KEN"LAGGREATEPROT APPLIES . � � PROnUGTS...„.COMPIOPAGG $ __, POLICY �E OC OTHER: COMBINED SINGLE LIMIT1 ODD 000 A AUTOMOBILE LIABILITY -. ................. $ ANY AUTO X� NAAU109747 619/2020 6/9/2021 ?Lr$ ,S Rfu...W p. I.cN.mnmmI _ ......._ ... OWNED ULED AUT030NLY XAUTO. UUI.IRRYY„ i r,a.m,r, .i.d.., NOTOWN UNODS ONLY LLL— LY I AMACE 48P4e.r.a' cYt �!. ............................, $ UMBRELLA OCCUR R.. _.............. �..__.._..... EXCESS RAB. CLAIMS -MADE A GREGA .. . .., ........DED .�......... $ _ ,_ 13 WORKERS COMPENSATION S.7AZ1dTAw i�LL..N �N.........._$ X U PER H AND EMPLOYERLEWH1LiTYN Y f N 7600021486201 4/15/2020 4115/ZD21 'WE.L. EACH ACCIDENT � 1,000,000 OR ANY PROPRIETOR/PARTNERIEXECUTIVE FFICERIM M ER EXCLUDED NIA � .,.,.._,.._�.,_ ... .._,.. (fNYPROP In Y . DIS EA EE $ ^ 11000,000 I[ es, descnbo under E.L. DISEASE POLICY LI, UT S 1,000,000 D SCRIPTION OF OPERATIONS .. RATIONS below - �„— DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES IACORD 161, Ad'dMonal Remarks Schedule, may be attached If more spaces reuired) City of EI Segundo is Included as Additional Insured In regards to Commercial Auto per attached endorsement City of EI Segundo 350 Main Street EI Segundo, CA 90245 A 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 POI ICY PROVISIONS. AUTHORIZED R++`EPRESENTATIVE 1988-2015 ACORD�mm.�� CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: NAAU109747 COMMERCIAL AUTO BA 99 04 06 18 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED WHEN REQUIRED BY CONTRACT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This provision does not apply in regard to any ownership, maintenance or use of the additional insured's "autos." Additional Insured When Required by Contract (1) Paragraph A.1. — WHO IS AN INSURED — of Section II — Liability Coverage is amended to add: d. When you have agreed, in a written contract or written agreement, that a person or organization be added as an additional insured on your business auto policy, such person or organization is an "insured", but only to the extent such person or organization is liable for "bodily injury" or "property damage" caused by the conduct of an "insured" under paragraphs a. or b. of Who Is An Insured with regard to the ownership, maintenance or use of a covered "auto." The insurance afforded to any such additional insured applies only if the "bodily injury" or "property damage" occurs: (1) During the policy period, and (2) Subsequent to the execution of such written contract, and (3) Prior to the expiration of the period of time that the written contract requires such insurance be provided to the additional insured. (2) How Limits Apply If you have agreed in a written contract or written agreement that another person or organization be added as an additional insured on your policy, the most we will pay on behalf of such additional insured is the lesser of: (a) The limits of insurance specified in the written contract or written agreement; or (b) The Limits of Insurance shown in the Declarations. Such amount shall be a part of and not in addition to Limits of Insurance shown in the Declarations and described in this Section. (3) Additional Insureds Other Insurance If we cover a claim or "suit" under this Coverage Part that may also be covered by other insurance available to an additional insured, such additional insured must submit such claim or "suit" to the other insurer for defense and indemnity. However, this provision does not apply to the extent that you have agreed in a written contract or written agreement that the insurance is primary and non- contributory with the additional insured's own insurance. (4) Duties in The Event Of Accident, Claim, Suit or Loss If another person or organization is added as an additional insured on your policy, the additional insured shall be required to comply with the provisions in A. Loss Conditions 2. — Duties In The Event Of Accident, Claim, Suit Or Loss — of SECTION IV — BUSINESS AUTO CONDITIONS, in the same manner as the Named Insured. BA 99 04 06 18 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 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 5 % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION CITY OF EL SEGUNDO 350 MAIN STREET EL SEGUNDO CA 90245 JOB DESCRIPTION SITE IMPROVEMENTS AND CONCRETE REPAIRS. JOB # PW 20-03 JOB LOCATION: RECREATION PARK SOFTBALL FIELD AREA IMPROVEMENTS PROJECT 342-362 EUCALYPTUS DR EL SEGUNDO CA 90245 V% 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 07/06/2020 Policy No. 7600021486201 Endorsement No. 001 Insured NATA CONSTRUCTION INC Premium $ INCL. Insurance Company EVEREST PREMIER INSURANCE COMPANY Countersigned By -1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual - 1999. INSURED COPY