No preview available
PROOF OF INSURANCE (2022 - 2022) CLOSEDACC)R& CERTIFICATE OF LIABILITY INSURANCE DATE (MWDDrfYYY) 0612412021 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: 81 the certificate holder is an ADDITIONAL INSURED, the poi cy(ies) ust 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 ant on this certificate does rrot confer rIr hts to the oertll'Icate holder In lieu of such erudorsmn�ent('), NAI�q� Carol i�noX Crgr Butler or Debbie Waller KNOX GENERAL INSURANCE BROKERS _E MAIL . . . . . . . .......... .............. 1744 6537 A AR90.,, Caror,%k9ibine.com, Kory@kqih�nc.com' Dwa�ler@kgfbinc.com 226 SOUTH GLASSELL STREET . . .. .. ..... . C_0k1j!ACE .... . . . . ........... MIDI# ORANGE CA 92866 INSUREA A CM VANTAGE SPECIALTY INSURANCE CO. 15872 uN'soar. ..... . . ... ......... . . . ......... ............... . ........ .. ... . ........ INSURER S.:1 CALIFORNIA AUTOMOBILE INSURANCE CO 38342 . ............. R.E. SCHULTZ CONSTRUCTION, INC INSuRER c: ACCEPTANCE CASUALTY INSURANCE CO 10349 1767 N BATAVIA sTREET INSURER D : WESTCHESTER SURPLUS LINES INS. COMPAN'r 10172 ORANGE CA 92865-4103 A!;Rkut fo�u DO CE COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY_ THATTHEPOLICIES OF INSURANCE LISTED BELOW HAVE BEEN IS -SUED 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. ..... . . ........ . TYPE OF INSURANCE X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE L XI OCCUR A _Grr_VL AGGREGArC LIMITAPPLIES PER: POLICY PCT O. JERLOD 'OTHER:: AUTOMOBILE LIABILITY X ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NCNB OV4N80 AUTOS ONLY AUTOS ONLY X X CMV-PLI-0025237-01 x BAG40000046316 UMBRELLA LIAB X, OCCUR C X EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YPN ANY I1ROPPJET0RLn`ARTNER4'X5C1 71 IV- OFFICER4AEMHER FEXCLUO6? NIA (Mandatory In NH) I ves cdy nclihn 4 rvd­ XL00020086 Z 10 ff-I W EACH OCCURRENCE ra 10 Oar Cr ExpiMy one prm E EXCLUDED 04122/2021 04/22J2022'PERsONAL&AOV%A)RY S 1,000,000 GENERA AGGREGATE s 2,000,000 FROD14T$-COIA?iCPAGG s 2,000,000 . .. . . . ................. --35MB I _NLD S dGLELIMI` BODILY INJURY (Per person) S 06/19/2021 06/19/2022 BODILY INJURY (Par acdclant) $ ­� . ...... ....... ... PROPERTY D,iMAGE - - ---------- --- EACH OCC UR PENCEe. s $3,000,0010 04/22/2021 04/2212022 AGOREGA $ 3,000,000 CIDENT - � _5L _ .............. ... E 1- nuS-_A$F - CA EMPLOYEE 5 E�LL DiSEASE -POLICY WAT S CONTRACTORS POLLUTION Each Occurrence $2,000,000 D LIABILITY G71802152002 0412212021 0412212022 General Aggregate $4,000.000 $2500 each Pollution Condition DESCRIPTION OF OPERATIONS d LOCATIONS d VEHICLES (ACORD IDII, Additional Remarks Schedule, maybe attached If more space is required) Project: Sycamore Park, Sycamore Avenue and California Street, El Segundo, CA 90245 The City of Ei Segundo, its officers, officials, employees, agents and volunteers is named as additional insured on a primary and non contributory basis per form PLI5240 06 16, CG 2010 04 13 for on going operations, CG2037 04 13 for completed operations and Waiver of Subrogation per form CG2404 05 09 with respect to General Liability and Auto Liability additional insured per form MCA85100817-CA as required by written contract. * 30 Day Notice of Cancellation will be provided to the Certificate Holder. 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 AUTHORIZED REPRESENTATIVE ELSEGUNDO CA 90245 rc 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Policy number: CMV-PLI-0025237-01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AMENDMENT - ADDITIONAL INSURED - PRIMARY AND NONCONTRIBUTORY OTHER INSURANCE CONDITION SCHEDULE Additional Insured: Any Person or Organization who are required to add as an additional insured on this policy under a written contract or written agreement in effect prior to any loss or damage, but only to the extent required in the written contract or written agreement, including any amounts or limits specified. A. Information to complete the Schedule, if not shown above, will be shown in the Declarations. The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary and Noncontributory Insurance As respects the Additional Insured shown in the Schedule above, this insurance is primary to and will not seek contribution from any other insurance available to the Additional Insured, provided that: B. The Additional Insured is a Named Insured under such other insurance; and C. 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. All other terms and conditions of the policy remain unchanged. PLI 52 40 06 16 Page 1 of 1 Copyright 2016, CM Vantage Specialty Insurance Company POLICY NUMBER: CMV-PLI-0025237-01 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY CG 20 10 0413 SCHEDULE Name Of Additional Insured Pemon(s) Or Organizations Location(s) Of Covered O erations Any Person or Organization who your are required to add as an Locations as specified by written contract. Additional Insured on this policy under a written contract or written agreement in effect prior to any loss or damage, but only to the extent required in the written contract or agreement, including any amounts or limits specified. Information re wired to com lete 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 persons) 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 notbe 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 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 C Insurance Services Office, Inc., 2012 Pagel 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 behaH of the addifiona� insured is the amount of insurance: 2. Available under the appficabie Limits of Insurance shown in the Declarations; whichever is less. This endorsement applicable Limits of Declarations, shall not increase the Insurance shown in the Page 2 of 2 Q Insurance Services Office, Inc., 2012 CG 20 10 04 13 POLICY NUMBER: CMv-PLI-0025237.01 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE F e Of Additional Insured Person(s) Or Or anization s Location And Descri !ion Of Com leted O erations Organization who your are required to add as an Locations as specified by written contract. ed on this policy under a written contract or written ect prior to any loss or damage, but only to the in the written contract or agreement, including any amounts or Ilmlts specified. Information re faired to com lete 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 organizations) 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 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER; CMV-PLI-25237-01 COMMERCIAL GENERAL LIABILITY CG24 04 05 09 '4AIVER OF TRANSFER OF RIGHTS OF RECOVER' 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: Any person or organization who you are required to waive the rights of recovery against under this policy under a written contract or written agreement in effect prior to any loss or damage, but only to the extent required in the written contract or written agreement, including any amounts of limits specified. The following is added to Paragraph S. Transfer of Rights of Recovery Against Others To Us of Section IV- Conditions: We waive any rights 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 operation 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 Service Office, Inc, 2008 Page 1 of 1 POLICY NUMBER: BA040000046316 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Business Auto Broadening Endorsement This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM I. NEWLY ACQUIRED OR FORMED ENTITY (BROAD FORM NAMED INSURED) II. EMPLOYEES AS INSUREDS III, AUTOMATIC ADDITIONAL INSURED IV. EMPLOYEE HIRED AUTO LIABILITY V. SUPPLEMENTARY PAYMENTS VI. FELLOW EMPLOYEE COVERAGE VII. ADDITIONAL TRANSPORTATION EXPENSE Vill. HIRED AUTO PHYSICAL DAMAGE COVERAGE IX. ACCIDENTAL AIRBAG DEPLOYMENT COVERAGE X. LOAN/LEASE GAP COVERAGE XI, GLASS REPAIR — DEDUCTIBLE WAIVER XII. TWO OR MORE DEDUCTIBLES XIII. AMENDED DUTIES IN EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS XIV. WAIVER OF SUBROGATION XV. UNINTENTIONAL ERROR, OMISSION, OR FAILURE TO DISCLOSE HAZARDS XVI. EMPLOYEE HIRED AUTO PHYSICAL DAMAGE XVII, PRIMARY AND NONCONTRIBUTORY IF REQUIRED BY CONTRACT XVIII. HIRED AUTO — COVERAGE TERRITORY XIX. BODILY INJURY REDEFINED TO INCLUDE RESULTANT MENTAL ANGUISH Copyright 2017 Mercury Insurance Services, I.I.C. All rights reserved. MCAS5100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 1 of 6 BUSINESS AUTO COVERAGE FORM NEWLY ACQUIRED OR FORMED ENTITY (Broad Form Named Insured) SECTION I I - LIABILITY COVERAGE, A. Coverage, 1. Who Is An Insured, the following is added; d. Any business entity newly acquired or formed by you during the policy period provided you own 50% or more of the business entity and the business entity Is not separately insured for Business Auto Coverage. Coverage Is extended up to a maximum of 180 days following acquisition or formation of the business entity. Coverage under this provision is afforded only until the end of the policy period. Coverage does not apply to an "accident" which occurred before you acquired or formed the organization. 11. EMPLOYEES AS INSUREDS SECTION If - LIABILITY COVERAGE, A. Coverage, 1. Who is An Insured, the following is added: e. Any "employee" of yours is an "insured" while using a covered "auto" you don't own, hire or borrow in your business or your personal affairs. III. AUTOMATIC ADDITIONAL INSURED SECTION II - LIABILITY COVERAGE, A. Coverage, 1. Who Is An Insured, the following Is added: f. Any person or organization that you are required to include as additional insured on the Coverage Form in a written contract or agreement that is signed and executed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period is an "insured" for Liability Coverage, but only for damages to which this insurance applies and only to the extent that person or organization quallfles as an "insured" under the Who Is An Insured provision contained in Section II. IV. EMPLOYEE HIRED AUTO LIABILITY SECTION II - LIABILITY COVERAGE, A. Coverage, 1. Who Is An Insured, the following is added: g. An "employee" of yours Is an "Insured" while operating an "auto" hired or rented under a contract or agreement in that "employee's" name, with your permission, while performing duties related to the conduct of your business. V. SUPPLEMENTARY PAYMENTS SECTION II — LIABILITY COVERAGE, A. Coverage, 2. Coverage Extensions, a. Supplementary Payments, Subparagraphs (2) and (4) are replaced by the following, (2) Up to $3,000 for cost of bail bonds (including bonds for related traffic law violations) required because of an "accident" we cover. We are not obligated to furnish these bonds. (4) All reasonable expenses incurred by the "insured" at our request, including actual loss of earnings up to $500 a day because of time off from work. Copyright 2017 Mercury Insurance Services, LLC, All rights reserved. MCASS100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 2 of 6 V1. FELLOW EMPLOYEE COVERAGE; SECTION 11 — LIABILITY COVERAGE, B, Exclusions, 5. Fellow Employee This exclusion does not apply if you have workers' compensation insurance in -force covering all of your "employees". Coverage is excess over any other collectible insurance, VIL ADDITIONAL TRANSPORTATION EXPENSE SECTION III - PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage Extensions, a, Transportation Expenses, is replaced with the following: We will pay up to $50 per day to a maximum of $1000 for temporary transportation expense incurred by you because of the total theft of a covered "auto" of the private passenger type. We will pay only for those covered "autos" for which you carry either Comprehensive or Specified Causes of Loss Coverage. We will pay for temporary transportation expenses Incurred during the period beginning 48 hours after the theft and ending, regardless of the policy's expiration, when the covered "auto" Is returned to use or we pay for Its "loss". If your business shown in the Declarations is other than an auto dealership, we will also pay up to $1,000 for reasonable and necessary costs incurred by you to return a stolen covered auto from the place where it is recovered to Its usual garaging location, VIII. HIRED AUTO PHYSICAL DAMAGE COVERAGE SECTION III — PHYSICAL DAMAGE COVERAGE, A. Coverage, 4. Coverage Extensions, the following is added: C. If Liability Coverage is provided in this policy on a Symbol 1 or a Symbol 8 basis and Comprehensive, Specified Causes of Loss, or Collision coverages are provided under this coverage form for any "auto" you own, then the Physical Damage Coverages provided are extended to "autos" you hire, subject to the following limit: (1) The most we will pay for "loss" to any hired "auto" Is $50,000 or Actual Cash Value or Cost of Repair, whichever is less (2) $500 deductible will apply to any loss under this coverage extension, except that no deductible shall apply to 'loss" caused by fire or lightning Subject to the above limit and deductible we will provide coverage equal to the broadest coverage applicable to any covered "auto" you own of similar size and type, This coverage extension is excess coverage over any other collectible Insurance. IX. ACCIDENTAL AIRBAG DEPLOYMENT COVERAGE SECTION III - PHYSICAL DAMAGE COVERAGE, B. Exclusions, 3.a., is amended to add the following: This exclusion does not apply to the accidental discharge of an airbag. Copyright 2017 Mercury Insurance Services, LI.C. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with Its Permission Page 3 of 6 X. LOAN/LEASE GAP COVERAGE SECTION III - PHYSICAL DAMAGE COVERAGE C. Limit of Insurance, the following is added; 4. In the event of a "total loss" to a covered "auto" shown in the schedule or declarations for which Collision and Comprehensive Coverage apply, we will pay any unpaid amount due on the lease or loan for that covered "auto," less; a. The amount paid under the Physical Damage Coverage Section of the policy; and b. Any: (1) Overdue lease/loan payments at the time of the "loss"; (2) Financial penalties imposed under a lease for excessive use, abnormal wear and tear or high mileage. (3) Security deposits not returned by the lessor; (4) Costs for extended warranties, Credit Life Insurance, Health, Accident or Disability Insurance purchased with the loan or lease; and (5) Carry-over balances from previous loans or leases. The most we will pay under Auto Loan/Lease Gap Coverage for an Insured auto is 25% of the actual cash value of that insured auto at the time of the loss. XI. GLASS REPAIR — DEDUCTIBLE WAIVER SECTION III - PHYSICAL DAMAGE COVERAGE, D. Deductible, the following is added; No deductible applies to glass damage if the glass is repaired rather than replaced. XII. TWO OR MORE DEDUCTIBLES SECTION III -PHYSICAL DAMAGE COVERAGE, D. Deductible, the following is added: If two or more "company" policies or coverage forms apply to the same accident: 1. If the applicable Business Auto deductible is the smallest, it will be waived; or 2. If the applicable Business Auto deductible is not the smallest, it will be reduced by the amount of the smallest deductible; or 3. If the loss involves two or more Business Auto coverage forms or policies the smallest deductible will be waived. For the purpose of this endorsement "company" means the company providing this insurance and any of the affiliated members of the Mercury Insurance Group of companies. XIII. AMENDED DUTIES IN EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS The requirement in SECTION IV, BUSINESS AUTO CONDITIONS, A. Loss Conditions, 2. Duties In The Event Of Accident, Claim, Suit, Or Loss, a., In the event of "accident", you must notify us of an "accident" applies only when the "accident" is known to: (1) You, if you are an individual; (2) A partner, if you are a partnership; (3) A member, if you are a limited liability company; or (4) An executive officer or insurance manager, if you are a corporation. Copyright 2017 Mercury Insurance Services, LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 4 of 6 XIV, WAIVER OF SUBROGATION SECTION IV - BUSINESS AUTO CONDITIONS, A. Loss Conditions, S. Transfer of Rights Of Recovery Against Others To Us, section is replaced by the following: 5. Transfer Of Rights Of Recovery Against Others To Us We waive any right of recovery we may have against any person or organization to the extent required of you by a written contract executed prior to any "accident" or "loss", provided that the "accident" or "loss" arises out of the operations contemplated by such contract. The waiver applies only to the person or organization designated in such contract. XV. UNINTENTIONAL ERROR, OMISSION, OR FAILURE TO DISCLOSE HAZARDS SECTION IV - BUSINESS AUTO CONDITIONS, B. General Conditions, 2. Concealment, Misrepresentation, or Fraud, the following is added: Any unintentional omission of or error in information given by you, or unintentional failure to disclose all exposures or hazards existing as of the effective date or at any time during the policy period shall not invalidate or adversely affect the coverage for such exposure or hazard or prejudice your rights under this insurance. However, you must report the undisclosed exposure or hazard to us as soon as reasonably possible after its discovery. This provision does not affect our right to collect additional premium or exercise our right of cancellation or non -renewal. XVI. EMPLOYEE HIRED AUTO PHYSICAL DAMAGE SECTION IV— BUSINESS AUTO CONDITIONS, B. General Conditions, 5. Other Insurance, b. For Hired Auto Physical Damage Coverage, Is replaced by the following: b. For Hired Auto Physical Damage Coverage, the following are deemed to be covered' "autos" you own: 1. Any covered "auto" you lease, hire, rent or borrow; and 2. Any covered "auto" hired or rented by your "employee" under a contract in that individual "employee's" name, with your permission, while performing duties related to the conduct of your business. However, any "auto" that is leased, hired, rented or borrowed with a driver is not a covered "auto". XVII. PRIMARY AND NONCONTRIBUTORY IF REQUIRED BY CONTRACT SECTION IV — BUSINESS AUTO CONDITIONS, B. General Conditions, S, Other Insurance, the following is added and supersedes any provision to the contrary: e. 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. Copyright 2017 Mercury Insurance Services, LLC. All rights reserved. MCA85100817-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 5 of 6 XVIII. HIRED AUTO - COVERAGE TERRITORY SECTION IV- BUSINESS AUTO CONDITION'S, B. General Conditions, 7. Policy Period, Coverage Territory, e. Anywhere in the world if:, is replaced by the following: e. Anywhere in the world if: (1) A covered "auto" is leased, hired, rented or borrowed without a driver for a period of 30 days or less; and (2) The "insured's" responsibility to pay damages is determined in a "suit" on the merits, in the United States of America, the territories and possessions of the United States of America, Puerto Rico, or Canada or in a settlement we agree to. XIX, BODILY INJURY REDEFINED TO INCLUDE RESULTANT MENTAL ANGUISH SECTION V — DEFINITIONS, C. "Bodily Injury" is amended by adding the following. "Bodily injury" also includes mental anguish but only when the mental anguish arises from other bodily injury, sickness, or disease. Copyright 2017 Mercury Insurance Services, I.I.C. All rights reserved. MCA95100917-CA Includes copyrighted material of Insurance Services Office, Inc., with its Permission Page 6 of 6 we Policy Number: Date Entered: 04/14/2021 R R DATE (MM/DD/YYYY) A'1..> f...r" CERTIFICATE OF LIABILITY INSURANCE 6/24/2021 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 The Hulett Agency 13959 Saddlewood Drive CONTACT N PHO NMC 1a Ex : (858) 618-5442 AAX I (858) 618 5944 ADDRESS:hulettagency@sbcglobal.net Poway, CA 92064 INSURER(S)AFFORDING ........................ COVERAGE NAIC # INSURERA: State Compensation Insurance Fund 35076 INSURED R E Schultz Construction, Inc. INSURER B: INSURER C : INSURER D: 1767 N. Batavia St INSURER E: Orange, CA 92865 INSURER F r. f'.r1Vr_PAf.P_q,. f:FRTIFICATF NIIMHFR' K.tV1h&L1N NL1MIftK: 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. 9L LTR TYPE OF INSURANCE ADDOLICY IN SUBRIS POLICY NUMBER P M/DDfYYXY MMIOp/YXXX LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE 0 OCCUR PfEM9aES "Eaaaocurr`,$ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO- LOG PRODUCTS $ OTHER; $ AUTOMOBILE. LIABILITY JE.&d ISCx^dd0nt $.... ANY AUTO BODILY INJURY (Per person) ............OWNED _...._.... SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ Per Oderm $ "--- HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ A OR'.KE:RS COMPENSATION AND E MPLOYERS'LIABILITY ANY PRO PRIETOR/PARTNER/EXECUTIVE YIN orFpcERdMEr�uBElaExctupeD? NL� lMSndatorya in (fig) N/A X 9274424 p4/19/zou 04/14/2022 STATUTE ER EL EACH ACCIDENT $1,000,000 E.L. DISEASE EA EMPLOYEE $ 1,000,000 Idq . de�rltme U11 O C1S'Si"pJpi4CYF+.IOP°f'JPERA"I^pCi,beipw E..L.DISEASE -POLICY LIMIT $1,000,000 I DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Project: Sycamore Park Project Address:Sycamore Ave 6 California Street,El Segundo, CA 90245 Blanket Waiver of Subrogation Attached. CERTIFICATE HOLDER t:ANc:tLLAIIUN City of E1 Segundo 350 Main Street El Segundo, CA 90245 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 AUTHORIZEED REPRESENTA7NE(j LyJt� �//�//,��- I \ �,i \ �J "d V ©1988-2015 ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS HOME OFFICE SAN FRANCISCO EFFECTIVE APRIL 14, 2021 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING APRIL 14, 2022 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME R E SCHULTZ CONSTRUCTION, INC 1767 N BATAVIA ST ORANGE, CA 92865 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. THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 2.00% OF THE TOTAL POLICY PREMIUM. s criF nmv. PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER JOB DESCRIPTION BLANKET WAIVER OF SUBROGATION REP D1 9274424-21 RENEWAL SP 4-22-35-07 PAGE 1 OF NOTHING IN THIS ENDORSEMENT SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS ABOVE STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS IN THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 2572 AUTHORIZED REPRESPNT NVE SCIF FORM 10217 (REV.4-2018) APRIL 13, 2021 A.""'..' �v" * PRESIDENT AND CEO 1 OLD DP 217