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PROOF OF INSURANCE (2021 - 2022) (2) CLOSEDBRUBCON-01 CPECKH .4<""RD' DATE (MMIDDIYYYY) `� CERTIFICATE OF LIABILITY INSURANCE 5/6/2021 ....................._......_ ........ ........_ _. 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 ri Ns to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Rock 10 Insurance Services, Inc. NI�MI Arc N 866 376 2 P O Box 15608 HONE , c6 376 2510 FAX ) ( ) vc No EXser�rb....e roCk101nsu 86 51 San Diego, CA 92175 ," rance.com INSUR€RMA. Security National,lnsurance Co _— ,,,1987,8 INSURED �j"JNSUKER.q, NSURER B a .... _. ..------ .. 1.... .. ......... Brubec Construction Co.I'll C.., P.O. BOX 987 [PIS—UREIR-4 NSURER n ....... ___------- t .. Moreno Valley, CA 92556 I INSURERF. COVERAGE CERTIFICATE NUMBER _ REVISION NUMP BER: 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, —. _ _.. . - - -.... .......,. _. .. NUMBER ._ .---- -- ... ... ............ ......-- INS. TYPE OF INSURANCE ADDL, R POLICYPOLICY EFF 1 POLICY EXP DDfYYYYI I LIMITS A X COMMERCIAL GENERAL LIAB ! ............... SUBR ..... POLI ,I!!YY il. I CLAIMS -MADE LIABILITY EACH OCCURRENCE., 1,000,000 X OCCUR NA168353100 7/312020 7/3/2021 MED PTO RENTED $ 6,000 X X DAMAGE TO S _ 1 , _ _� _ ...... PERSONAL&ADV,INJURY $ __ 1,000,000 X Jw .000 000 QENLAGGRDAT APPLIES � POLICY ` PR ❑LOC PRQDUCTSGGOMP COMP/OP AGG $ 2000 000 OTHER' AUTOMOBILE LIABILITY COMBINED $GNOLE LIMIT` $ IEA 0;44 �11 ...... j ANY AUTO BODILY INJURY (Per person) $ OWNED- SCHEDULED f 1� gg• POPERTYtDAMAGI .... � $, AUTOS ONLY AUTOS BODILY INJURY Per accident $ V& ONLY RUM G. 7 _.......... _ UMBRELLA LIAB OCCUR EACH OCCURRENCE Is EXCESSLIAB CLAIMS MADE I, AGGREGATE „'. $ DED RETENTION $ __. _ I $ ®........._..... YIN. ..........-. WORKERS COMPENSATION PER OTH AND EMPLOYERS' LIABILITY .................. -.. STAT.U.T.E .. ER.................. _, ... ANY PROPRIETOR/PARTNER/EXECUTIVE E. L EACH ACCIDENT I $ C FICiRd'M9MBER EXCLUDED? ❑ N I A � tandata5ry n NH)DISEASE EA EMPLOYEE,i.-__, If yes, describe under 1 DESCRIPTION OF OPERATIONS below ,,,,,,,,„„„„„„„„ __ ,, E L_L11SE.ASEITITPQLfCY I IMIT $ �....-.-.. _.. ......... _ _........... ...�.......................... ..........�.. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,. Additional Remarks Schedule, may be attached it more space is required) Re: Hilltop Park, 400 Maryland Street, EL Segundo, CA 90246 ,Additional Insured status applies to City of EL Segundo under the Commercial General Liability Policy subject to attached endorsements. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of EL Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN tY 9 ACCORDANCE WITH THE POLICY PROVISIONS. 400 Maryland Street El Segundo, CA 90245 ._.. -- •••• AUTHORIZED REPRESENTATIVE a &"q L, ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY BLANKET ADDITIONAL INSUREDS OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Policy Number: NA168353100 Endorsement Effective: 07/03/20 12:01 a.m. .................. .... Named Insured DOUGLAS HAIG BRUCE BRUBEC CONSTRUCTION CO SCHEDULE Name of Person or Organization: Any person or organization that the named insured is obligated by virtue of a written contract or agreement to provide insurance such as is afforded by this policy, Location (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section II — Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization shown in the Schedule is held liable for your acts or omissions arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions 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 site 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. C. The words "you" and "your" refer to the Named Insured shown in the Declarations. D. "Your work" means work or operations performed by you or on your behalf; and materials, parts or equipment furnished in connection with such work or operations. Primary Wording If required by written contract or agreement: Such insurance as is afforded by this policy shall be primary insurance, and any insurance or self-insurance maintained by the above additional insured(s) shall be excess of the insurance afforded to the named insured and shall not contribute to it. Waiver of Subrogation If required by written contract or agreement: We waive any right of recovery we may have against an entity that is an additional insured per the terms of this endorsement because of payments we make for injury or damage arising out of "your work" done under a contract with that person or organization. 49-0108 07 11 May Include Copyrighted Material of Insurance Services Offices, Inc. Page 1 of 1 Used with permission Important information i AIILU11.2 UMURMIUC WCIWIR:A MU lNQ1U geico.com 1�00-Aar -4nnn GEICO CASUALTY COMPANY P.O. Box 509090 - San Diego, CA 9215D-9090 ADOT Code: 0880 Policy Number Effective Date Expiration Date 4590-02-44-38 04-21-21 10-21-21 Year Make Model Vehicle ID No. 2013 FORD EXPLORER Insured: Douglas Haig Bruce Arizona Insurance Identification Card geico.com 1400441-3000 GEICO CASUALTY COMPANY P.O. Box 509090 • San Diego, CA 9215D-9090 ADOT Code: 0880 Policy Number Effective Date Expiration Date 4590-02-44-38 04-21-21 10-21-21 Year Make Model Vehicle ID No. 2013 FORD EXPLORER Insured: Douglas Haig Bruce Here are your Policy Identification Cards. Two cards have been provided for each vehicle insured. Please destroy your old cards when the new cards become effective. Due to space limitations on the ID card, only the Named Insured and the Co-insured are listed. For a full list of drivers covered under this policy, please reference the Drivers section of your Declarations Page (page 9). Please notify us promptly of any change in your address to be sure you receive all important policy documents. Prompt notification will enable us to service you better. Your policy is recorded under the name and policy number shown on the card. If you would like additional ID cards, you can go online to geico.com or call us at 1-800-841-3000. DOUGLAS HAIG BRUCE X ....., _. '........................ Ar.onaInce Identification Cardgannn g1ai�. 1"M7i GEICO CASUALTY COMPANY P.O. Box 509090 • San Diego, CA 92150-9090 ADOT Code: 0880 Arizona Insurance Identification Card geico.com 140o.Aai-tnnn GEICO CASUALTY COMPANY P.O. Box 509090 - San Diego, CA 92150-090 ADOT Code: 0880 Policy Number Effective Date Expiration Date Policy Number Effective Date Expiration Date 4590-02-44-38 04-21-21 10-21-21 4590-02-44-38 04-21-21 10-21-21 Year Make Model Vehicle ID No. w Year Make Model Vehicle ID No. 0 2013 FORD F-150 12012 FORD F-250 Insured: insured: Douglas Haig Bruce Douglas Haig Bruce Arizona Insurance Identification Card Arizona Insurance Identification Card gaiewi.com 1.800-841-3000 gisiccocom 1400441-3000 ° WOO CASUALTY COMPANY GEICO CASUALTY COMPANY o j PO. Box 5MSO • Sam Diego, CA 921M9090 RO. Box W9090 - San Diego, CA 92150.9090 0 lV � ADOT Code: 0880 ADOT Code: 0880 c N Expiration Date Policy Number Effective Date Expiration Date Policy Number Effective Date N 4590-0244-38 04-21-21 10-21-21 + 4590-0244-M 04-21-21 10-21-21 g Year Make Model Vehicle ID No. Year Make Model Vehicle ID No. Q; 2013 FORD F-150 2012 FORD F-250 N?Insured: Insured: § Douglas Haig Bruce v N Douglas Haig Bruce , JES #3015 'I— -1 9 DATE (MMIDDIYYYY) ""f> CERTIFICATE OF LIABILITY INSURANCE ,. 05/27/2021 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 ALEJANDRO DIAZ w N1�..N as�1: J, N � GWgI _.. 12625 FREDERICK ST SUITE B3 -242 4411 951 530 3092� tL'dPHONE SARATH HERNANDS STATE FARM AGENCY E-MAILE MANL 951 FA ........... ......... AIC # MORENO VALLEY ,CA 92553 INSURER,tS) AFFORDING COVERAGE N INsuRe�Afate Farm and Casual riCom Company 25143 ...... .....------ .-- INSURED INSURER B ERIC GLEN LONGORIA INSURERC DBA LONGORIA PAINT & WALL COVERING INSURER D 9210 BOX SPRINGS MOUNTAIN RD , MORNEO VALLEY CA INsuRERE 92557-0708 INSURERF: 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. - — ...... �R r....... TYPE OF INSURANCE .. CAC%DL SUa 'j----- POLICY NUM.BER........ .._.. POLICY�Y MMdC17CD,NYYY L............ T ... LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ . ME EXP �fiiN ...� CLAIMS -MADE^ OCCUR accurren,9p) $ _ .._ .. (Anyone one person) . $ ...____ .,_, _ .. L AGGREGATE LIMIT APPLIES PER: ....,POLICY - PRO- LOC ... JECT ......, AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED .... AUTOS ONLY .—� AUTOS ONLY UMBRELLA LIAB �pp, OCCUR EXCESS LIAB 7 CLAIMS -MADE DED l I RETENTION $ N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNERIEXECUTIVE rr�� OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) If Ves, describe under PERSONAL & ADV INJURY S GENERAL AGGREGATES PRODUCTS - COMPIOP AGG S $ I`a �CCd9ru ...41 7$ 05M ING1 E OMIT; . BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ 0RO("(1-1R_TY L -m- AGE EACH OCCU,RR,E,NCE AGGREGATE E L EACH ACCIDENT $ .1,000,000 E L DISEASE _ 92-G8-B392-5 04/13 202 0 3 20 1 00 E EA EMPLOYEES $ 1 000 000 E L.. DISEASE POLICY LIMIT $ 0,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CITY OF EL SEGUNDO 400 MARYLAND ST AUTHORIZED REPRESENTATIVE EL SEGUNDO , CA 90245 Completed by an authorized State Farm representative. If signature is required, please contact a State Farm agent. ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 1001486 132849,13 04-22-2020