PROOF OF INSURANCE (2022) CLOSEDCERTIFICATE .N ILIA _...._DATE (MMX) __.._. _.
f)l7
07/01/2021
'THIS CERTIFICATE, IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO R14.;,HT UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NC)"T AFFIRMATWE L.Y 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 INSUREER(S), AUTFIORIZE:D
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICA"rE HOLDER,
µ IIVIPC7F2'TANT: If thD certificate holder is an ADDITIONAL INSURED, the Plicy(ies) rnwlSI 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 <ate holder in hewn of such endorsement(s).
CONTACT"r .. .........,_......., .._......_ .... ..... ..........W.....,.....,..__ w....,.........,�..�,...� ...v, ... ..
r RC)r)tJC„;FF NAME.,. Emily MUrmy
St( -!,wart InSUranc. , Se.rvklr (a, IIIC. PHONIiz, rxt) f -3 4C18-(16P",!7 FAX
AIC Nca) (562) 985-0459
J 715 E': Ama the irn `Strout: �urrAIL tryrraily(17 ,tc wa-ar'tir7c,.crarn
IN UV rwR(S) AFFORDING; COVERAGE NAIL; #
1. oiuIq luloa di CA 90804 1N:'10pE'.RA: I'NAU Ht.US IN.SI,JFANCE:: COMPANY 17310
rNSIIItEU
INSI.IRHR
I.:I'!t(a Con- aand (ra,Iaininq LI.C, INSURERC
2674 1 Poftoia PIky, Suite 1 F Y833 INSURER to
INSURIEIRL:
F a(a(hlill Ran(:;11 GA 9,?610 INSURER F
COVERAGES CERTIFICATE NUMBER:
REVISION NUMBER:
6:A- Y 1hIAf 1 11- PO ICII:I:'.1 01- IIN:°+URAPNC L USII D I3I:i',LOW HAVE BEEN ISSUED 10 11IL, INS URFIJ
NAMEF) ABOVE. FOR III[- F`0I-ICY r E-J-fl D
INDIC;AI E..C') N01 VVI I HS:YTANDINC7 ANY ki-OUII- EMLN 1' "FW ()R CONDITION OF ANY CON'TRAC) r ON O T Hf'.-.R
f-K)C(.)MENF VVII-1-1 RESPECT 'R.) WHICH 'I HIS
G RTIFICATE MAY HI" ISt)(JF;r) OR MAY F'FRIA1N, II -IF INSUIdAN(..,F AFFORD[` 7 BY 'THE=, Poi CIF) I-)IE-C,f;rdlBFD
I -IdI°I.IN IS SUBJEC I TO Atli TFIF_r hE RMS,
F. C':LlJsl(:7Ns; AIVF7 (C)V1:711I(}rNv'7 t:7I °>fJ(;LB ('L )I I(,IES, I IMI IS SHOWN r ' WN MAY HAVE EEN Ri-H)(IC,f.l7 BY PAID CLAIMS,
I kNd F" -. _. ADDi SOBIR. _... _ 4 01 ICY I Fh POLICY Y EX!
..I, y Pt rYFIL OF INSURANCE
_.. -.. _.
�:0
( CImmERCiAL GENERAL L.IABII ITY ', '.
E:.ACH O(,(;IJRRr NCF 1,000,000
4:?hAIME, r1A(.71� 6JUC;IAI)
_. -.
n! t RFVILra
.r(1,O0O
;RE MI >E..",.. QI-,- lSn.l Uriifwo) 3 �
MI I) [-XP OYlyono pwf mvin) Fr' 5,000
A Y Y INN'1262928 0510 1202'1 05/02/2022
PII60NAL&ADVIN,IURY S 1,000,000
Al4'IILS!'L4'. h(: '..,
C'il'N!"fiAL. A<',(,121`I ,/11 tii EI 2,000,000
POLICY_ .)IC„r c)<:
ue,Tst-('OMl,'nlr,A(,! (, IN(A UDED
._.
AUTOMOBILE 4,IAral6„I'r'Y �
COMBINED blid)_,I f.. (JfAl l
ANY ALIrC.7
Pi2C7r)IL.V INJr.112V (!'in ('irar smn) LI
_. AIf1oT (.:)IV(.Y AUTOS
V'bf)IAI), INJURY(Vurs^,t,d,. nk) Li
ri1RH) NONUWNI 1)
PROP[HTY DAMA',f= _. _.._...
AI)FOS;a ONLY AUTOS ONLY
(Pm accident)
UMBRELLA L TAB OG(.;)h
LA(,li O(JCLL.li R NUL S _._ _...
EXCI: SI_IAB (;'L_AIMS MAUI'2
P�U3REGm,TE:
rI lN:,ry 1;
WORKERS Ct7Mph.N3A'a'ION
PE CFYfi.._.__.... ...__.._..._...__ _...,_.._..,_
AND EMPL..CIYERS' t..1AR1L...ITY YIN
`:r'T A FLIT L- I -
IANllI'12))I'ItII Uf )'ARTNIIyrk"Ir::U71W "'
IN f I)::I Ivh11 MfN Z XCd If171'.L>`' �. ..� NdA.
li!.. k/�('fl ('CIIANI _
Mandaztm io NI-i `"
1 Y� )
l:.l 171.,1 A.S, E'. rAI.MPL.t)'r'r.l '��PG
If y � ,, dusr.,riby und(;r
.... ..... -- -.....
IA'CR111"11 oN OF Of'[ HA 1101T':u bolow
t:�� IH YA31ii PUUG)"LIMIT . F'r
---------
DESCRIPTION OF: OPERATIONS ( LOCATIONS I VEHICLES (ACCORD 101, Additional RLmarks Schedtile, may be attached if moro space is regUiled)
PRIVATf"r f RAINING C:;I.A ,iSES I''C)R C._MEi.RGL NC;YMANAGE:M N'I FOR GI I IES, (A)UN'I IES AND CORPORA
IIONS. "i HE OWNI'ER OF" I HE COMPANY
IS I IIE ONLY C OVI.T2t: D IN,.,I RUC',I OR NO COVERAGE FOR FIIR[J'') PRIVATE CONTRACTORS. 3LANKE`1
ADDITIONAL INSJNW J, El.,FNCEf
WAIVER OFSUBROGATION AND PRIMARYAND NON CONTRIBLITORY C OVEFZA(3E'_' f4PPLIES'1"o Tiflis I'rou(;;Y.
ADDITIONAL TION,AL. INwilJldE.[): City of 1,-:1 Segundo
_._._..__. ........ .... .w...W.._._.._.
CERTIFICATE TiULDE".R CANCELLATION
wreI'ICAULD ANY OF THE:, ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE E:XPIRA'rld:1N DATE THEREOF, NOTICE WILL. HE DELIVERED IN
ACCORDANCE WWI"rH "THE POLICY PROVISIONS.City of E:I :�el:cllal"irlc)
350 Main vS1. AtIrI-I0 Rr71 17 R E r'RE:SENI"A'rlVe.
El Segundo, CA 90245
;) 1988--2015 ACCORD CORPORATION, All rights reserved.
ACOR.D 25 (2016/03) The; ACORD narrm and logo are reagi.ste;rexd marks of ACORD
AGENCY CLJs,roMER ID:
We
ADDITIONAL. REMARKS SCHEDULE
AG'FNCY NAMED INSURED
Yte,wnrl Insurance, Seivicc,, Inc. Elik-,, CcmUnand "Fraining LLC
P OLI CY NUMBER
CARkIFR I NAIL; CODE
F,FFF.c,rivE DATE:
W191m
ACORD '10.1 (2008/01) 0 2008 ACORD CORPOPA,rtm All rights reserved,
The ACORD narne and logo are registered rri arks of ACORD
POL\CYNUyNBER: NmI262928
COMMERCIAL GENERAL LIABILITY
CG20,1O1219
This endorsement modifies insunanoeprovided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
AINIZINKwo-
Naine Of Additional Insured Person(s)
cat
City of El Segundo A11 Operat--i.oi-is of Named Irisured
Information required to,�L)Tpje shown in the Declarations.
tt�qjs Schedule, if not shown above, will be
A. Section U — Who Is An Insured is amended to
include as an additional insured the person(s) or-
organization(s) shown in the 8ohedu|e, but only
with respect to liability for "bodily injury", "property
damage" or "personal and advertising injury'
cauned, inwhole or- in part, by:
1. Your acts oromisaions� or
2. The acts or, emissions of those acting on your
behalf;
in the performance of your ongoing operations for
the additional insured(s) at the location(s)
designated above.
1. The insurance afforded to such additional
insured only applies \othe, extent permitted by
law: and
2. Kcoverage provided tuthe additional insured is
required by a contract or agreamont, 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.
EL With respect to the insurance afforded to these
additional inounedo, the following additional
exc|umionsapp|y�
This i11SUrance does riot applyUz "bodily injury" or
^ property damage^occurring after:
i. All mmrh, including materia|m, pads or
equipment furnished in connection with such
wmrk, on the project (other than sewire,
maintenance orrepairs) to be performed by or
on behalf of the additional inoured(m) 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 auapart ofthe aamoproject.
CG 20 10 12 19 ( Insurance Services Office, Inc,, 2018 Page I of 2
C. With respect to the insurance afforded to thee %. Available under the applicable |vnby of
additional mouedo, the following is added to insurance;
Section U|—Limoits Of Insurance: ` whichever isless.
If coverage provided to the additional insured is
This endorsement shall not increase the
required by a contract or aUnaement, the most we applicable limits of insurance,
will pay on behalf ofthe additional inounad is the
amount nfinsurance:
1. Required by the contract or agreement, or
CG 20 37 07 M.
I
rp iyj�� ji,
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) Location And Description Of Completed Opera -
Or Oruand -anon ' tions
City of El Segundo
All operations of the Named Insureds.
Information r aired to com late this Schedule, if not shown above, will be shown in the Declarations.
CG 20 37 07 04, 0 ISO Properties,.Inc., 2004 Page 1 oiLEMILN
CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000),
IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES.
I affirm under penalty of perjury under the laws of California one of the following declarations:
(__) I have and will maintain a certificate of consent of self -insure for workers' compensation, issued by the Director
of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement
with the City of El Segundo.
Policy No-
(_) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 forthe performance
of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance
carrier and policy number are:
Carrier
Name of Agent
Policy Number Expiration Date
Phone #
I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not
employ any person in any manner so as to become subject to the workers' compensation laws of California, and
agree that, if k should become subject to the workers' compensation provisions of Labor Code § 3700 i must
immediately comply with those previsions or the agreement will gutomatically become void.
Signature of Applicant
A9 reement for: �✓"'
Dated: C'� _ Xa�
Reviewed by:
Date I Z