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PROOF OF INSURANCE (2020 - 2021) CLOSEDA� I DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 3/10/2020 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(les) must 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 I UUN I At: i Western Republic Insurance Services NAME. I n//CiNNo, Ext): 714.536.0500 I (A/C, Na): 19900 Beach Blvd I ADDR dustin(�wrinsurance.com ADDRESS: Suite Fl I INSURER(S) AFFORDING COVERAGE NAIC # Huntington Beach CA 92648 INSURER A: SECURITY NATL INS CO 19879 INSURED I INSURER B: HOUSTON SPECIALTY INS CO Golden Meters Service, Inc. I INSURER C: AMGUARD INS CO 14812 Hunter Lane I INSURER D: NATIONAL UNION FIRE INS CO OF PITT, PA INSURER E: Midway City CA 92655 I INSURER F: 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 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. INUK AuuL'U6H LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER YULIGY thF YULIGY hXP (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE 7 OCCUR I PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 B Y Y TEN -23796 09/09/2019 09/09/2020 I PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ 2,000,000 PRO - POLICY X JECT 7 LOC I PRODUCTS - COMP/OP AGG $ 2,000,000 OTHER: CGL $ AUTOMOBILE LIABILITY UUMHINtU tiINULL LIMI I $ (Ea accident) 1,000,000 ANY AUTO I BODILY INJURY (Per person) $ ALL SCHED C AUTOS OWNED X AUTOSULED Y Y GOAU047887 08/23/2019 08/23/2020 I BODILY INJURY (Per accident) $ NON -OWNED X HIRED AUTOS X AUTOS NHUFLK I Y UAMAUL $ I (Per accident) X UMBRELLA LIABX OCCUR I EACH OCCURRENCE $ 4,000,000 D EXCESS LIAB H CLAIMS -MADE EBU047705122 09/09/2019 09/09/2020 I AGGREGATE $ 4,000,000 DED I_ I RETENTION $ $ WORKERS COMPENSATION I H- X I I I AND EMPLOYERS' LIABILITY Y / PROPRIETOR/PARTNER/EXECUTIVE SIK STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBERANY ❑ N / AI EXCLUDED? Y SWC1283428 (Mandatory in NH) 03/07/2020 03/07/2021 I E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the insured's operations. A blanket additional insured and blanket waiver of subrogation are included with the general liability and commercial auto policies. Additional insured status is automatically granted where required by written contract. A Waiver of Subrogation applies in favor of Owners Parties for Workers Compensation, General Liability, Auto and Umbrella policies where required by written contract. The certificate holder is named as additional insured where required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St. AUTHORIZED REPRESENTATIVE EI Segundo, CA 90245 I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Policy #TEN -23796 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 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): Only those parties required to be named as an Addi- ALL tional Insured in a written contract with the Named Insured under this policy, entered into prior to loss or "occurrence". Location(s) Of Covered Operations 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) desig- nated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment 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 in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) PN11IF/=1 X91 �1�J 7_:3_Cr7._t0 i ii[0 _1.I_: 4*L1I_%9:11�I:I"hdwoa_I&IazI_/1 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 as required by written contract. 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 3/7/2020 Policy No. SWC1283428 Endorsement No. 0 Insured Golden Meters Service, Inc. Premium $ 8,087 Insurance Company Security National Insurance Company Countersigned by WC 04 03 06 (Ed. 04-84)