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PROOF OF INSURANCE (2021 - 2021) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 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 CONTACT Jeannine Tuvesson Insurance Brokers West, Inc NAME ., - 233 E High St, Ste 200 EMAIL to 5)299ONE .150n c, Na); (80)239 216 Moorpark, CA 93021D.��.e j vessonibwins.com License #: OF95189 INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURERB. California Automobile InsuranceGO,se.s4Z Pacific Tennis Courts, Inc. , 530 W Los Angeles Ave INSURER c : Scottsdale , Ste 115-320 INSURER.D: Weseo Insurance.Company ,. Moorpark, CA 93021-1746 INSURERS INSURER F : nrwcDwrccroDYICW AM NUIRnDCD• nnn49Qna_40A4an9 RFVICI(1N NIIMRFR• 11 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, ILTR ., ... ... AODL t6ak MM/DDPdbOY BF' F TYPE OF INSURANCE POLICY NUMBER POLICY EXP LIMITS MMlO ryyyy , A X COMMERCIAL GENERAL LIABILITY Y Y -.. 600GL0032022-01 10/28/2020 10/28/2021 EACH OCCURRENCE $ 1,000,000 $ 50,000 CLAIMS -MADE 4 OCCUR . ......: .,,,. P;REiMI ES(�,anrar,Gkgerq�zc,,a�y '', '...... 1 MED EXP (An)one person} : $ PERSONAL & ADV INJURY $ 1,000,000 1 APPLIES I GEN'LAGGREGATE LIMIT APPLIE GENERAL $ 2r000a0O0 X POLICY D PLR T Ll LOC PRODUCTS -COMP/OP AGG $ .. 2,900,000 „ OTHER1111111-11— .' { $ B ' AUTOMOBILE LIABILITY Y Y BA040000023313 08/14/2020 08/14/2021 M5NEIS'N :,Lr iIMlI $ 1,00,00011, ANY AUTO '.. BODILY INJURY (Per person) $ OWNED : SCHEDULED BODILY INJURY (Per accident) $ _._ AUTOS ONLY ; AUTOSHIRED p 4'.�P E'hA�ACL $ - AUTOS ONLY AUTOS ONLDY Mr ak0darr9m�r1'i),. ,,,,�.,.. Medical a ment $ 1000 X UMBRELLA LIAB X OCCUR Y Y XBS0139827 10/28/2020 10/28/2021 EACH OCCURRENCE 2,000,000 EXCESS LIAB MADE CLAIMS...... .�.,........... ..... .. ..—. AGGREGATE ,�,,.., ,,,,,,, ,. $ 000,000 DED I X RETENTION $ 10.000 $ 1 WORKERS COMPENSATION p Y WWC3492287 08/27/2020 08/27/2021 X sT�TUrE H � YIN EACH ACCIDENT $ 1,000/OOO ANYDEMPLOEERS' ARBILIaa(ar uarlVE Y 10FRCER/tl�mFM5ER EXC.IR.UDkD7 N / A (Mandatary In NH) .L �. L DISEASE EA EMPLOYEE" $ _ 1,000,000 -.... Po4 yes. darzsrt "rvaa'�ro�r .. DESCRIPTION OF OPERATIONS below . EL, DISEAS.... E - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached if more space is required) RE: Roller Hockey Rink Improvments Project NO. PW19-13; The City of EL Segundo, its officers, officials, employees, agents, and volunteers are named as additional insured as required by written contract. a,__, 1:1 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 Street El Segundo, CA 90245 I AUTHORIZED REPRESENTATIVE — © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Printed by JMT on December 30, 2020 at 09:03AM POLICY NUMBER: 103 GL 0032022-00 COMMERCIAL GENERAL LIABILITY CG20100413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.. ADDITIONAL INSURED OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON O 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 All persons or organizations as required by written As designated in written contract with the Named contract with the Named Insured Insured 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 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 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 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 POLICY NUMBER: 103 GL 0032022-00 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OIL CONTRACTORS - COMPLETED OPERATIONS ATIONS 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) Or Organization(s) I Location And Description Of Completed Operations All persons or organizations as required by written As designated in written contract with the Named Insured contract with the Named Insured 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 damage" 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 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. 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 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 37 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following; COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY 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: All persons or organizations as requested by written contract with the Named Insured, 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 © Insurance Services Office, Inc., 2008 Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) 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 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 8/27/2020 Policy No. WWC3492287 Endorsement No. 0 Insured Pacific Tennis Courts, Inc. Premium $ 20,124 Insurance Company Wesco Insurance Company Countersigned by WC 04 03 06 (Ed. 04-84)