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PROOF OF INSURANCE (2021 - 2021) CLOSEDDATE (MM/DDr"YY) AC4 RVQ CERTIFICATE OF LIABILITY INSURANCE Ill 1 10/23/2020 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 pol(cy(ies) 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 CONTACT Rhonda Scow, CISR NAME: Landscape Contractors (Lic#0755906) PHONE H E Ent):(559) 650-3555 FAX, Nary. (559)650-3558 (AJInsurance Services, Inc. L"MAIL rscow@lcisinc.com 1835 N. NG RAGE Fresno Fine Avenue CA 93727 NSURERA:Clear INSURER(S) )Insurlance ECompany N I28 AIC # 860 „D. ...., . , ,,. ... INSURER B ...,..,, .. INSURE Oliver Holt INSURERC; 8611 Amestoy Avenue INSURER D; INSURER E: Sherwood Forest CA 91325 INSURER F: COVERAGES CER'T'IFICATE NUMBER:20/21 Pkg & Auto 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. .INSR_ AN,SO ISWVD� P.. POLICYEFF.F, , TYPE ..���I POLICY fMMfDDJY LIMITS LTR, YY6 !M'C1LIC'Y EXP MIDDIYYW) X COMMERCIAL GENERAL LIABILITYEACH $ 1, 000 OAMAGE R � P+Y'I EIJ 0 A CLAIMS-MADE I X I OCCUR PRIM SES o gcgWe9rpl 100,00 X LCOI-00698-2001 7/16/2020 7/16/2021 MED EXP (Any one person) $ 5,000 $1,000 Pd 00 g,�d PERSONAL &ADV INJURY $ . I ----- 1, 000 0........ G'EN'L AGGREGATE LIMIT APPLIES PER:$ 2, 000, 000 GENERAL AGGREGATE .................,,,, .. POLICY PH LOC /OP AGG $ 2,000,000 X.. Employee BenefOMP„ OTHER $ 1,000,000 AUTOMOBILE LIABILITY � mBINED�1)� SINGLE Ia I $ 1,000,000 BODILY INJURY Perl %�ANY AUTO BODILY INJURY Per accident) n $ A ALL OWNED i SCHEDULED ( person) ,,. AUTOS L._ . } A $ HIRED AUTOS I, X..,,, X AUTOS Poor Parc 'YY DAMAGE � $ LCOl-00698-2001 7/16/2020 7/16/2021 NON-OWNED Medical pavmenls is 51000 UMBRELLA OCCUR EACH OCCURRENCE s EXCESS L DED RETENTION $ CLAIMS-MADE AGGREGATE $ Is WORKERS COMPENSATION IPER „ ST�ATI„1TF ,�OTH- AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N NIA (Mandatory in Ni"""""' $ If yes, describe under E.L DISEASE - POLICY LIMIT I $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: All landscape operations performed by or on behalf of the named insured. Blanket Additional insured per attached DBLC0434005012519 City of E1 Segundo and its officers, elected officials, and employees (Excluding ofessional Liability) are named as additional insured per attached endorsement. This revises certificate dated 7/20/2020** CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Clerk ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street Room 5 El Segundo, CA 90245-3813 AUTHORIZED REPRESENTATIVE R Scow, CISR/ACOMBE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (tot 401) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM A. The following is added to Paragraph 2. In SECTION II -WHO IS AN INSURED: Any person or organization you are required by written contract or agreement to name as an additional insured subject to the following: Any such person or organization must be approved in writing by us as an additional insured. Coverage for such person or organization will begin on the date of our approval. a. No such person or organization is an additional insured for your acts, errors or omissions if such acts, errors or omissions are not also covered under such person or organization's liability insurance. b. No such person or organization is an additional insured for "bodily injury" or "property damage" for acts errors or omissions of any additional insured. B. With respect to the insurance afforded to the additional insureds under Paragraph A. above, the following is added to SECTION III - LIMITS OF INSURANCE: The most we will pay on behalf of the additional insured is the amount of insurance: a. Required by the contract or agreement; or b. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement does not increase the applicable Limits of Insurance shown in the Declarations. C. With respect to the insurance afforded to the additional insureds under Paragraph A. above, Paragraph I. Damage to Your Work in Paragraph 2. Exclusions of COVERAGE A - BODILIY INJURY AND PROPERTY DAMAGE LIABILITY in SECTION I- COVERAGES is replaced by the following This insurance does not apply to: I. Damage to Your Work "Property damage" to "your work" arising out of it or any part of it and included in the "products - completed operations hazard". D. With respect to the insurance afforded to the additional insureds under Paragraph A, above, the following is added to Paragraph 4. Other Insurance in SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS: Page 1 of 2 DB LC 0434-005 0125 19 Includes copyrighted material of Insurance Services Office, Inc. with its permission This insurance is primary if required by the contract or agreement. If there is no such requirement, this insurance will be excess and paragraph b. Excess Insurance applies. E. With respect to the insurance afforded to the additional insureds under Paragraph A. above, the following is added to Paragraph 8. Transfer of Rights of Recovery Against Others to Us, in SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS However, we will waive our rights to recover against any additional insured for payments we make for injury or damage arising out of: a. Your ongoing operations; or b. "Your work" done under the contract or agreement and included in the "products completed operations hazard" if such waiver is required by the contract or agreement. All other terms and conditions of this Policy remain unchanged. Policy Number: LC01-00698-2001 Named Insured: Oliver Holt Landscape This endorsement is effective on the inception date of this policy unless otherwise stated herein. Endorsement Effective Date: 7/16/2020 Page 2 of 2 DB LC 0434-005 0125 19 Includes copyrighted material of Insurance Services Office, Inc. with its permission DATE (MM/DD/YYYY) ACC>R" " CERTIFICATE OF LIABILITY INSURANCE ice,,✓ 10/23/2020 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 CONTACT Victoria Mitchell, CSR NAMIE, Landscape Contractors (Lic#0755906) PHONE (559)650-3555 Atc, No)! (559)650-3558 Insurance Services, Inc. E-MAIL ADDRESS: vmitchell@lcisinc.com 1835 N. Fine Avenue INSURER(S) AFFORDING COVERAGE NAIC# Fresno CA 93727 INSURERA:State Compensation Insurance Fund 35076 INSURED INSURER B Oliver Holt Landscape INSURER C: 8 611 Ames toy Avenue INSURER D INSURER E ; Sherwood Forest CA 91325 INSURER F: COVERAGES CERTIFICATE NUMBER:20-21 WC 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. LTR TYPE OF INSURANCE ,ADDL ,,,,,, MM/DDIYYYYI l � ...... . &J�I'R .... POLICY EFF POLICY EXP .. INSR �, I� POLICY NUMBER ( MMBDDiYYYY'I 1 LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I I OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY' JRO "C LOC I OTHER, AUTOMOBILE LIABILITY ANY AUTO ALL OWNED „I SCHEDULED AUTOS IAUTOS HIRED AUTOS I NON -OWNED I AUTOS UMBRELLA LIAB OCCUR EXCESSLIAB MSCU... DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER A (Mandatory in NH) EXCLUDED? NIA Y 91297 06-2 020 If yes, describe under DESCRIPTION OF OPERATIONS below EACHCURRENCE $ AMAGE fb kiLNT1=G................... ERPMl �.S,.(Ee,gnp,urrence) $...... MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERALAGGREGATE I$ . PRODUCTS. -.. COMP/OP. AGG..L..$............. $ BD (ODILYI�SRNG'LE' iLRL^Orson) 1 $ INJURY (Per person) BODILY INJURY (Per accident) $ PROPERTY DAMAGE .,,(Per acnidenl) EACH OCCURRENCE $ AGGREGATE $ $ S PER OTH- .'TAT.4!TP FR E.L, EACH ACCIDENT 4/1/2020 4/1/2021 E.L. DISEASE- EA EMPLOYEE, $ 11000,000 E.L. DISEASE - POLICY LIMIT � $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: All landscape operations performed by or on behalf of the named insured. ((// ***** WC Waiver of Subrogation on Order****** Waiver of subrogation in favor of City of E1 Segundo and its officers, elected officials, and employees Waiver of Subrgation attached 10/27/2020 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of E1 Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Clerk ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street Room 5 El Segundo, CA 90245-3813 AUTHORIZED REPRESENTATIVE V Mitchell/ARUIZ © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) ENDORSEMENT AGREEMENT simislol WAIVER OF SUBROGATION INSURANCE 9129706-20 FUND RENEWAL NE HOME OFFICE 1-53-82-86 SAN FRANCISCO PAGE 1 OF 1 ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC EFFECTIVE OCTOBER 26, 2020 AT 12.01 A.M. STANDARD TIME OR THE TIME INDICATED AT AND EXPIRING APRIL 1, 2021 AT 12.01 A.M. PACIFIC STANDARD TIME OLIVER HOLT LANDSCAPE 8611 AMESTOY AVE SHERWOOD FOREST, CA 91325 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF EL SEGUNDO WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, OLIVER HOLT LANDSCAPE IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03%. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: OCTOBER 28, x,22✓020 AUTHORIZED REPRESENT IVE PRESIDENT AND CEO SCIF FORM 10217 (REV.7-2014) 2570 OLD DP 217