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PROOF OF INSURANCE (2021) CLOSED�VCERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDmYY) � 07/22/2020 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 4' CONTACT' Kathy Macias -Ramirez NAME: Millennium Risk Management & Insurance Services PHONE (818) 844-4100 FAX (818) 638-7920 ItIC No. Ex1Ir IAIC', No): An ISD Network Member #OM93299 •l�1AIL kath m mcsins,com - ADDRESS: Y @ 550 N Brand Blvd #1100 INSURER(S) AFFORDING COVERAGE NAIC # Glendale CA 91203 INSURER A • Mt Hawley Insurance Co 37974 INSURED Trueline INSURERB: West American Insurance Company INSURERC: RSUI Indemnity Company INSURER D : Everest National Ins Co 1651 Market St Ste B INSURER E: Corona CA 92880-1710 INSURER F: COVERAGES CERTIFICATE NUMBER: 2020-2021 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. INSR AUOL'SUUR[ POLICY EFF I POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDD/YYYY) (MMlDDfYYYY) LIMITS 44393 22314 10120 X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ CLAIMS -MADE � OCCUR DAMAGE TO RLN IED 50,000 $5,000 Ded -Per Occ I PREMISES (Ea occurrence) $ MED EXP (Any one person) $ 5,000 A Y MGLO192713 G,,E,�N'LAGGREGATE LIMITAPPLIES PER: 0 F__1 PRO - X POLICYJECT LOC �I OTHER: AUTOMOBILE LIABILITY X ANYAUTO B _ OWNEDSCHEDULED BAS (21) 56945605 — AUTOS ONLY AUTOS X HIRED NON -OWNED AUTOS ONLY AUTOS ONLY X, COMP -$1K X' COLL-$1K X,I UMBRELLA LIAB X OCCUR C EXCESS LIAB CLAIMS -MADE NHA249918 ... DED I X1 RETENTION $ '0` - - WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N D ANY PROPRIETOR/PARTNER/EXECUTIVE N I A OFFICER/MEMBER EXCLUDED? 7600016618201 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below 07/25/2020 07/25/2021 PERSONAL &ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COM P/OPAGG $ 2,000,000 Employee Benefits $ 1,000,000 C'OMMNED SINGLE LIMIT I''E'aawdenn $ -1,000,000 BODILY INJURY (Per person) $ 07/25/2020 07/25/2021 BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ PR)r accmdarrtlY EACH OCCURRENCE $ 4,000,000 07/25/2020 07/25/2021 AGGREGATE $ 4,000,000 X' STATUTE O ERH 07/25/2020 07/25/2021 E.L EACH ACCIDENT $ 1,000,000 EL,DISEASE- EAEMPLOYEE $ 1,000,000 E,L DISEASE -POLICY LIMIT $ 1,000,000 a i DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: 350 Main Street. The City of EI Segundo, its officers, officials, employees, agents, and volunteers are included as additional insureds with for General Liability as respects to the insureds operations and only if required by written contract per the attached endorsement. Waiver of subrogation applies to the Workers Compensation. Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. CERTIFICATE HOLDER City of EI Segundo 350 Main Street EI Segundo I ACORD 25 (2016103) [riTT:rC�'f, 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: MGLO192713 Mt. Hawley Insurance Company 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 Name Of Additional Insured Person(s) Or Organization(s): All persons or organizations where required by written contract executed prior to the commencement of your work. SCHEDULE Location(s) Of Covered 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 in- not be broader than that which you are required clude as an additional insured the person(s) or organi- by the contract or agreement to provide for such zation(s) shown in the Schedule, but only with respect additional insured. to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or B. With respect to the insurance afforded to these in part, by: additional insureds, the following additional exclusions apply: 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: 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 re- pairs) to be performed by or on behalf of the addi- tional insured(s) at the location of the covered operations has been completed; or 1. The insurance afforded to such additional insured 2. That portion of "your work" out of which the injury only applies to the extent permitted by law; and or damage arises has been put to its intended use by any person or organization other than another 2. If coverage provided to the additional insured is contractor or subcontractor engaged in performing required by a contract or agreement, the in- operations for a principal as a part of the same surance afforded to such additional insured will project. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 Insured 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. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 2 of 2 Insured Policy Number: MGLO192713 Mt. Hawley Insurance Company 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) Location and Description of or Organization(s) Completed Operations All persons or organizations where required by written All Locations and All Projects contract executed prior to the commencement of your work. 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 dam- age" 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 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 re- quired 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. 2. If coverage provided to the additional insured is required by a contract or agreement, the insur- This endorsement shall not increase the applicable ance afforded to such additional insured will not Limits of Insurance shown in the Declarations. 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 1 Insured 5 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 2% of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOM THE BLANKET WAIVER OF SUBROGATION NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER 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: 07/25/2020 Policy No. 7600016618201 Endorsement No. 001 Insured: Trueline Construction & Surfacing, 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.