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PROOF OF INSURANCE (2021) CLOSEDPage 1 of 1 yr-.�.�y DATE (MMIDD/YYYYI L..C..J' CERTIFICATE OF LIABILITY INSURANCE 11/03/202D 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 3ELOW. 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 Willis Towers Watson Certificate Center NAM£;. Willis Towers Watson Midwest, Inc, `" ""' c/o 26 Century Blvd 4 NO.CIIk} 1-877 945-7378 LT FAX 1-888467-2378 0 Na). EpAIL celctificates8willis.com P.O. Box 305191 A, CD&�E5" ." „.. ."... f Nashville, TN 372305191 USA INSURERISI AFFORDING COVFRAGF NAIC it INSURED United Site Services of California, Inc. 118 Flanders Road Westborough, MA 01581 CAVFRAnFR CFRTIFICOTF NIIMRFR- W18644495 INSURERA: Safety National Casualty Corporation 15105 INSURER B s I INSURER C ; I I INSURER D INSURER E ?, RFVISIAN NIIMRFR, 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. ...................................-..rr,..m............_.. .......TYPE INSR A S POLICY' EFF POLICY EXP OF INSURANCE............ LTR, POLICY NUMBER MMIDD M/DD LIMITS X L CO LIABILITY MCLAIMS- EACH OCCURRENCE 2 000 $ 000 ,...... X."' �� CAO� 1'>5""iT6'Y�TI= '', 1 000 000 CLAIMS -MADE OCCUR PREMLSE�S,,..(,�;a occurrrrce).. ,m"..$... A " ."..... "" """" � Y GL4057787 11/03/2020 11/03/2021 pERSONALA&ADV INJURY $ 1 000 000i GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 raR. El POLICY JECT LOC PRODUCTS COMP/OP AGG $ 4,000,0001 OTHER': $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 3,000,000 x '..... ANY AUTO BODILY INJURY (Per person) $ A OWNED ,.......... SCHEDULED CA6675838 11/03/2020 11/03/2021 .._, ,. ._..._._._ ...__._._._, ._.. BODILY INJURY (Per accident) ...,,__._-- ... $ AUTOS ONLY AUTOS -PROPERTY HIRED NON -OWNED DAMAGE $ AUTOS ONLY AUTOS ONLY ... ,,,.------------------------ UMBRELLA.. .. LIAB OCCUR EACH OCCURRENCE EXCESS LIAB AGGREGATE $ --h.j'CLAIMS-MADE DED I_FRETENTION$ I $ WORKERS COMPENSATION OTH PTA AND EMPLOYERS' LIABILITY Y / N T -_ . $ ..0 E _ _ER A ANYPROPRIETOR/PARTNER/EXECUTIVE No Y E.L. EACH ACCIDENT $ 1,000,0001 - -- -- — E.L.DIS_E_A__S__E - EA___EMPLOYEE ... $ 1,000,000 OFFICER/MEMBEREXCLUDED? ,N/A (Mandatory in NH) LDS4047370 11/03/2020 11/03/2021 If yes, describe under . ......... 1,000,000 DESCRIPTION OF OPERATIONS below E.L DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Covered CA Operations Performed By Or On Behalf of the Named Insured. The City of E1 Segundo, its officers, officials, employees, agents, and volunteers are named Additional Insureds as respects General Liability and this insurance is Primary and Noncontributory with any other insurance of the Additional Insureds; and waiver of subrogation applies as respects workers compensation as required by written contract and as permitted by law, per endorsements attached. ME ITY OF EL SEGUNDO 401 SHELDON ST EL SEGUNDO, CA 90245 ACORD 25 (2016/03) 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. '.. AUTHORIZED REPRESENTATIVE ;3,._ l ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID: 20284331 BATCH: 1872680 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. SPECIAL NOTICE OF CANCELLATION SERVICE PROVIDED TO IDENTIFIED THIRD PARTIES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CHANGE The following new provision is added to A. Cancellation of the COMMON POLICY CONDITIONS or such other applicable state cancellation endorsement: As a special service to you, if we cancel this policy for any reason other than non-payment of premium, within thirty (30) days prior to the effective date of cancellation, we will mail a copy of such written notice of cancellation to all third persons whose name and address have, during the applicable policy period, been placed on file with us through your broker of record due to third party contractual requirements relating to such notice. As a special service to you, if we cancel this policy for non-payment of premium, within ten (10) days prior to the effective date of cancellation, we will mail a copy of such written notice of cancellation to all third persons whose name and address have, during the applicable policy period, been placed on file with us through your broker of record due to third party contractual requirements relating to such notice. If we have been provided with an electronic address of such third parties, at our election we may send notice of cancellation to such third parties by electronic mail. Notice of cancellation of coverage provided to a certificate holder is a courtesy only. Failure to provide such notice will not extend the policy cancellation date, negate the cancellation of the policy, nor confer any rights nor expectations upon the certificate holder nor subject us, our agents nor representatives to liability for failure to provide notice. 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 11/03/2020 Policy No. GL 4057787 Endorsement No. Named Insured UNITED SITE SERVICES, INC. Premium $ Included Insurance Company Safety National Casualty Corporation Countersigned By (Countersignature by the Broker or Agent shall only occur in the mailing states that require countersignature) SNGL 047 0514 Safety National Casualty Corporation Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED BY CON�TRACT OR AGREEMEAT - PRIMARY BASIS This endorsement modifies insurance provided under the following Coverage Form.. COMMERCIAL GENERAL LIABILITY PRODUCTS/COMPLETED OPERATIONS LIABILITY LIQUOR LIABILITY POLLUTION LIABILITY This endorsement changes the policy effective on the inception date of the policy unless another endorsement effective date is indicated below. SCHEDULE Name of Additional Insured Persons or Oranization(s:. As required by written contract or agreement when such written contract or agreement is executed prior to an occurrence® offense or loss to which this endorsement applies, but only for the limits agreed to in such contract or the Limits of Liability provided by this policy, whichever is less. Any individually scheduled additional insureds shall not be construed to override nor negate this blanket additional insured. ......... ............................................................ . . . . . . . . . . . . . . . . . . . . . . . Designated Project, Location, or Work of Covered Operations: As per written contract or agreement with the above described person(s) or organization(s). CHANGES SECTION II - WHO IS AN INSURED is amended to include: 4. The person(s) or organization(s) shown in the Schedule above with whom you have agreed in a written contract to provide insurance such as is afforded under this Coverage Form, is included as an Additional Insured subject to the below: a. Insurance for such Additional Insured(s) scheduled above shall be afforded only to the extent that such Additional Insured is liable for "bodily injury", "property damage" or "personal and advertising injury" caused by your acts or omissions while actively engaged in the performance of your ongoing operations involving the project(s), locations(s), or work designated in the Schedule and as specified in the contract between you and the above scheduled Additional Insured(s). b. The insurance afforded under this Coverage Form to such Additional Insured(s) applies only: (1) If the "occurrence" or offense takes place subsequent to the execution and effective date of such written contract: and, (2) While such written contract is in force, or until the end of the policy period, which ever occurs first. c. How Limits Apply to Additional Insured(s) The most we will pay on behalf of the Additional Insured(s) scheduled above is the lesser of: (1) The limits of insurance specified in the written contract or written agreement; or, (2) The Limits of Insurance provided by the Coverage Form. SNGL 023 1209 Safety National Casualty Corporation Page 1 of 2 The amount we will pay on behalf of such Additional Insured(s) shall be a part of, and not in addition to, the Limits of Insurance shown in the Coverage Form Declarations and described in this section. Such amount will thus not increase the Limits of Insurance shown for the Coverage Form. d. Obligations at the Additional Insured's Own Cost No Additional Insured will, except at their own cost, voluntarily make a payment, assume any obligation, or incur any expense, other than for first aid, without our consent. SECTION IV — CONDITIONS is amended by deleting item a. Primary Insurance under 4. Other Insurance and replacing such item by the following, only with respect to insurance provided to the Additional Insured(s) shown in the above Schedule: a. Primary Insurance and/or Primary and Non -Contributory Insurance This insurance is primary if you have agreed in a written contract that this insurance is to be primary. If you have agreed in a written contract that this insurance is primary and non-contributory with the Additional Insured(s) own insurance, this insurance is primary and we will not seek contribution from that other insurance. The Additional Insured(s) scheduled above shall be subject to all other conditions set forth in the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. 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 11/03/2020 Policy No. GL 4057787 Endorsement No. Named Insured UNITED SITE SERVICES, INC. Premium $ Included Insurance Company Safety National Casualty Corporation Countersigned By Page 2 of 2 Safety National Casualty Corporation SNGL 023 1209 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. • • . • . • IIGL • rM r r This endorsement modifies insurance provided under the following: COMMERCIAL AUTOMOBILE COVERAGE PART CHANGE The following new provision is added to A. Cancellation of the COMMON POLICY CONDITIONS or such other applicable state cancellation endorsement: As a special service to you, if we cancel this policy for any reason other than non-payment of premium, within thirty (30) days prior to the effective date of cancellation, we will mail a copy of such written notice of cancellation to all third persons whose name and address have, during the applicable policy period, been placed on file with us through your broker of record due to third party contractual requirements relating to such notice. As a special service to you, if we cancel this policy for non-payment of premium, within ten (10) days prior to the effective date of cancellation, we will mail a copy of such written notice of cancellation to al I th i rd persons whose name and address have, during the applicable policy period, been placed on file with us through your broker of record due to third party contractual requirements relating to such notice. If we have been provided with an electronic address of such third parties, at our election we may send notice of cancellation to such third parties by electronic mail. Notice of cancellation of coverage provided to a certificate holder is a courtesy only. Fa i I u re to provi de such notice will not extend the policy cancellation date, negate the cancellation of the policy, nor confer any rights norexpectations upon the certificate holder nor subject us, our agents nor representatives to liability for failure to provide notice. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherw is stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 11/03/2020 Policy No. CA6675838 Named Insured UNITED SITE SERVICES, INC. Insurance Company Safety National Casualty Corporation Countersigned By Endorsement No. Premium $ Included SNCA 03910 13 Safety National Casualty Corporation Page 1 of 1 POLICY NUMBER: GL 4057787 COMMERCIAL GENERAL LIABILITY CG20100413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES O CONTRACTORS - SCHEDULED PERSON OR M &' Z, • 1► This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Name Of Additional Insured Person(s) Or Or anization s) Locations Of Covered Operations As required by written contract or All Locations of Insured®s Operations agreement when such written contract or agreement is executed prior to an occurrence® offense or loss to which this endorsement applies, but only for the limits agreed to in such contract or the Limits of Liability provided by this policy® whichever is less. Any individually scheduled additional insureds shall not be construed to override nor negate this blanket additional 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. With respect to the insurance afforded to these include as an additional insured the person(s) additional insureds, the following additional or organization(s) shown in the Schedule, but exclusions apply: only with respect to liability for "bodily injury", "property "personal This insurance does not apply to "bodily injury" damage" or and advertising or "property damage" occurring after: injury" caused, in whole or in part, by: 1. Your acts or omissions; or 1. All work, including materials, parts or equipment furnished in connection with such 2. The acts or omissions of those acting on work, on the project (other than service, your behalf; maintenance or repairs) to be performed by in the performance of your ongoing operations or on behalf of the additional insured(s) at for the additional insured(s) at the location(s) the location of the covered operations has designated above. been completed; or However: 2. That portion of "your work" out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted other than another contractor or by law; and subcontractor engaged in performing 2. If coverage provided to the additional operations for a principal as a part of the insured is required by a contract or same project. 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. 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 04 13 COMMERCIAL GENERAL LIABILITY CG 20 370413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ KTCAREFULLY. &00 41k im, 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) Location And Description Of Completed I Or Organization(s) Operations As required by written contract or All Locations of Insured's Operations agreement when such written contract or agreement is executed prior to an occurrence, offense or loss to which this endorsement applies, but only for the limits agreed to in such contract or the Limits of Liability provided by this policy, whichever is less. Any individually scheduled additional - insureds shall not be construed to override nor negate this blanket additional insured. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section U —Who Is An Insured in amended to B. With respect to the insurance afforded to these include as on additional insured the person(s) or additional inounado, the following is added to orgonizaUon(a)shown inthe Schedule, but only Section III — Limits 0fInsurance: with respect to liability for "bodily injury' or If coverage provided to the additional insured is "property dmmage" couoed, in whole or in part, by "your required by o contract or agreement,the most we work" a� the location designated end will pay on behalf of the additional insured is the described in the Schedule of this endorsementn� � performed for that additionalamoun�o�inourance� ono| insured and included inthe ''pnoducto'comp|etedoperations hazand" 1. Required bythe contract oragreement; or However: 2' Aumi|ob|o under the applicable Limits of i' The insurance afforded to such additional|nounonomohovxninthaOodonodono' ono| � insured only applies to the extent permitted by whichever is less. |mw;ond This endorsement shall not increase the 2' |fcoverage provided tothe additional insured io applicable Limits of Insurance shown in the required by a contract or agreement, the Declarations. 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. CG 20 37 04 13 @insurance Services Office, Inc., 2012 Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 99 35 SPECIAL NOTICE OF CANCELLATION SERVICE PROVIDED TO IDENTIFIED THIRD PARTIES ENDORSEMENT As a special service to you, if we cancel this policy for any reason other than non-payment of premium, within thirty (30) days prior to the effective date of cancellation, we will mail a copy of such written notice of cancellation to all third persons whose name and address have, during the applicable policy period, been placed on file with us through your broker of record due to third party contractual requirements relating to such notice. As a special service to you, if we cancel this policy for non-payment of premium, within ten (10) days prior to the effective date of cancellation, we will mail a copy of such written notice of cancellation to all third persons whose name and address have, during the applicable policy period, been placed on file with us through your broker of record due to third party contractual requirements relating to such notice. If we have been provided with an electronic address of such third parties, at our election we may send notice of cancellation to such third parties by electronic mail. Notice of cancellation of coverage provided to a certificate holder is a courtesy only. Failure to provide such notice will not extend the policy cancellation date, negate the cancellation of the policy, nor confer any rights nor expectations upon the certificate holder nor subject us, our agents nor representatives to liability for failure to provide notice. 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 11/03/2020 Policy No. LDS4047370 Endorsement No. Insured UNITED SITE SERVICES, INC. Premium $ Included Insurance Company Safety National Casualty Corporation Countersigned By WC 99 99 35 (07 12) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. SCHEDULE WHERE A WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS IS REQUIRED BY WRITTEN CONTRACT, SUCH ADDITIONAL ENTITIES SHALL BE CONSIDERED AUTOMATICALLY SCHEDULED BY THE COMPANY. INDIVIDUALLY SCHEDULED WAIVERS SHALL NOT BE CONSTRUED TO OVERRIDE NOR NEGATE THIS BLANKET WAIVER. 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 11/03/2020 Policy NO. LDS4047370 Endorsement No. Insured UNITED SITE SERVICES, INC. Insurance Company Safety National Casualty Corporation Countersigned By WC 00 03 13 (04 84) @ 1983 National Council on Compensation Insurance. Premium $ Included Page 1 of 1