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PROOF OF INSURANCE (2021 - 2021) CLOSED'--as 0 � DATE(MMIDDIYYW) ACCO'Ra CERTIFICATE OF LIABILITY INSURANCE o2120 /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 pollcy(les) must have ADDITIONAL INSURED pro'vi'sions 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 �101'A'1AT BobbyTruong t'''10 Risk Insurance Services, LLC rIE,,dI,(949)679.3700 �iC, Nek,('949M 6r°t1.;'tWf)t 225 N Bush Street f�E55' btruongrU7D igrisk com INSURERISI AFFORDING COVERAGE NAIC p 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: INSURER F'.. ' COVERAGE'S CERTIFICATE NUMBER: CL20'22006213 REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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 ADDINSRR �'wWVptl POLICY EXP „ LIMITS POLICY NUMBER rMrPlrm='(YYY OF INSURANCE IINSDL Y'w'Y4_ fMMIDD/YYYYl ,TYPE X' COMMERCIAL GENERAL LIABILITY IIs4 EACH OCCURRENCE S 1,000,000 1 CLAIMS -MADE OCCUR t)AMAUk', IQ IftN 0l:0 100,000 PFYEPr4wSE.E YEa'vcCu,n^p,w:eS S IVIED EXP IAnV one Dersarl S lmmluaed . A Y 010061552-2 02/01/2020 02/01/2021 I PERSONAL& ADV INJURY 5 1,000,000 I' GEPJERALAGGREGATE 5 2,000,000 r=FhC'Y„CI,3liREl;';A`vE UMITAPPLIES PER JECT LOG X POLICY,,,,,,,, O AG PRODUCTS - COMPIOP O __... 5 2,000,000 s 0,11 -ER arM,tarNED SRXG,l'k 1, Ir11 r s AUTOMOBILE LIABILITY IE�a �ccodonti - I ANYAUTO BOD6LY INJURY(Per person) 3 OWNED SCHE'17{.JI-ED BODILY INJURY (Pcr accidartt) S AUTOS ONLY HIRED AUTOS OWNEDR1'u' L"'A hMArd rc S ,„„.....,„ AUTOS ONLY AUTOS ONLY lPcr mr 6d'mr.tl , S X UMBRELLA LIAR OCCUR EACH OCCURRENCE S 2,000,000 I A EXCESpSLIAIIR Hcl.AIMS,MADE 0100061562-2 02101/2020 02/01/2021 AGGREGATE s 2,000'`f1O DED II U RETENTIONS S WORKERS COMPENSATION BAER t"r"pH- %Cp S'rA'rL7.TE- 11,11 AND EMPLOYERS'LIABILITY ANDYIN 1,000,000 B ANY PROPRIMB RtPAftTNERIEXECu7ivE l N fA FLA008293-02 02/01/2020 02(01/2021 J C,l AC GIDE:N'r 5 OFFICEory In NH) EXCLUDED? (Mandatory In NH) E L DISEASE= - EA EMPLOYEE 5 1'000'000 Ir yes, dt!Iu'! re under1,000,000 DE.SCRiP, ,ON OF OPERATIONS below EL DISEASE POLICY !LIMIT 5 ....,......M DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) °1'0 gays N011ce'DfCareellation for Non-Payr'nent of Premium RE Covered CA Operations Performed By 0'l On Behalf of Che Named Insured The City of 'Ell Segundo„ its oEf)CVS, 01110411S, employees, agents. and volunteer's are named additlonad 'insured as respects general Ilabll.1y and lauds Insurance vs primary and rlonconlrNb,afory with any o!h'ei Insurance of the additional insured; and warwr of subrogation apples as respects workers comperlsallon as requrred' by wvritlen Contract. per end'orsernents attached Joseph LlhhlO +,w4xxavnear x,rv,w,dry,,r.,�uui,IliwrmwipmyunJo or9, ,pub A9<xx bh,AAMnM a'l,AkfYd4P'M1%G' CE'RTI'FICATE HOLDER City of EI Segundo 350 Main Street El Segundo I ACORD 25 (2016103) i7 ',Tg4llW;.T1l 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 ©1888-2015 ACORD CORPORATION. All rights reserved. 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 I Attached To and Farming Part of Policy Effective Date of Named Insured Endorsement Named Ins r ed 0100061552-2 02/01/2020 12*01AM at the Named Insured C C Layne & Sons Inc address shown on the Declarations Additional Premium: Return Premium i �... $0-..m.�.�..�.._.. .,�e. .. ,�.,x:��. �...�..._.... 50��«�.«,�::.M���-,,«..n��..,.,,.,.....�rvw��.,w"a,,«.,«.�,� 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 start of 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 B. With respect to the insurance afforded to these as an additional insured the person(s) or additional insureds, the following additional exclusions organization(s) shown in the Schedule, but only with apply: respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage" or "personal and advertising injury" caused, "property damage" occurring after: in whole or in part, by: 1. All work, including materials, parts or equipment 1. Your acts or omissions; or furnished in connection with such work, on the 2. The acts or omissions of those acting on your project (other than service, maintenance or behalf; repairs) to be performed by or on behalf of the in the performance of your ongoing operations for the additional insured(s) at the location of the covered additional insured(s) at the location(s) designated operations has been completed; or above. 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 O ISO Properties, Inc., 2004 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, V` WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US -BLANKET Attached ToAand Forming Part of Policy I fjective Date of Endorsement Nomed )nsured 0100061552-2 02/01/2020 12:01AM at the Named Insured C C Layne & Sons Inc address shown on the Declarations Additional Premium: Return Premium: I $0 $0 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 AC CERTIFICATE OF LIABILITY INSURANCE ( DATE(MMIDD/YYYY) � 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(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 CONTACT Tom Brundidge .,.., ... Ei .. ., g PHONE ) l✓ No�! 20831 214 Standard St. Ste B E-MAIL tom@tombrundidge.comAM 10 32 a r Tom Brundid a License 0479986 (310 322-5840 3 EI Segundo CA 90245 INSURERS) AFFORDING COVERAGE NAIC # INSUR ERA :State Farm Mutual ut Automobile Insurance Company 25178 INSURED INSURER B C C LAYNE & SONS INC INSURER C 216 STANDARD ST INSURER D: EL SEGUNDO CA 90245 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: W............ _ .........................m 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. TR, ..TYPE OF INSURANCE ! N WVn ... POLICV NUMBER WMRDD'IYYYYY (FF MNMIDD/ E. .. . ppryyyy) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ry�MAGE1''CSktNcER CLAIMS -MADE OCCUR PRFMISSS(Eapp._q_en,g$ �) ., I I,.,MED EXP (Any one person) $ ,... „. PERSONAL & ADV INJURY $ GEN -LL AGGREGATE LIMIT APPLIES PER: RO- i , JPECT ,. LOC I GENERAL AGGREGATE $ PRODUCTS -COMP/OP AGG J $ OTHER $ AUTOMOBILE IILE LIABILITY Y Y 639 1212-608-75 08/08/2020 02/08/2021 COMBINd. ANSINGLE L.1 IIT $ BODILY (Per person) $ 1,000,000 A OWNED SCHEDULED BODILY INJURY (Per accident) $„ 0,000 , AUTOS ONLY 1 066.. ',�" HIRED NON -OWNED P&"tOPERTY DAMAt'aE Q ,000 /''^�, AUTOS AUTOS ONLY AUTOS ONLY �CPe? «acrgroki $ UMBRELLA LIAB I OCCUR I EACH OCCURRENCE $ EXCESS LI AB CLAIMS -MADE AGGREGATE $ DEDRETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE F7OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E,T, TUTE......... E(iH ACH ... .. DISEASE ACCIDENT EA EMPLO .........�.,..,..�, YETI(( $ E L. DISEASE -POLICY LIMIT I $ I I DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) 2006 FORD F350 SD CREW CAB VIN 1FTWW31P46EA08216 Additional Insured: The City of EI Segundo, its officers, officials, employees, agents, and volunteers. 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 St AUTHORIZED REPRESENTATIVE EI Segundo CA 90245 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849,12 03-16-2016 3 - 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.