PROOF OF INSURANCE (2021 - 2022) CLOSEDACCORD® CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYY)
7/1 /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
Wood Gutmann & Bogart
15901 Red Hill Ave., Suite 100
CA 92780
CONTACT
NAME: Brittany Andrakowicz
PHONE FAX
A/C No Ext : 714-505-7000 A/c, No): 714-573-1770
E-MTustin
ADDRESS: bandrakowicz@wgbib.com
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURERA: Vantapro Specialty Ins Co
44768
INSURED AJFIS-1
A.J. Fistes Corporation
1244 N. Gaffey Street
INSURERB: Travelers Property Casualty
25674
INsuRERc: Cypress Insurance Company
INSURERD: ACE American Insurance Co.
San Pedro CA 90731
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: 1024162496 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.
INSR
LTR
TYPE OF INSURANCE
ADDL
INSD
SUBR
WVD
POLICY NUMBER
POLICY EFF
MM/DD
POLICY EXP
MM/DD
LIMITS
D
X
COMMERCIAL GENERAL LIABILITY
Y
Y
G71110515 004
4/19/2021
4/19/2022
EACH OCCURRENCE
$ 1,000,000
CLAIMS -MADE OCCUR
DAMAGE TO RENTED
PREMISES Ea occurrence
$ 100,000
MED EXP (Any one person)
$
PERSONAL &ADV INJURY
$ 1,000,000
GEN'L
AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,000
POLICY � PE� LOC
PRODUCTS - COMP/OP AGG
$ 2,000,000
$
OTHER:
A
AUTOMOBILE
LIABILITY
5087026902
12/8/2020
12/8/2021
COMBINED SINGLE LIMIT
Ea accident
$1,000,000
X
BODILY INJURY (Per person)
$
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per accident)
$
X
PROPERTY DAMAGE
Per accident
$
HIRED X NON -OWNED
AUTOS ONLY AUTOS ONLY
B
UMBRELLALIAB
X
OCCUR
CUP1S48584821NF
7/11/2021
7/11/2022
EACH OCCURRENCE
$1,000,000
X
AGGREGATE
$ 1,000,000
EXCESS LAB
CLAIMS -MADE
DED RETENTION $
$
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
Y
AJWC242129
6/30/2021
6/30/2022
X PER OTH-
STATUTE ER
ANYPROPRIETOR/PARTNER/EXECUTIVE
E.L. EACH ACCIDENT
$ 1,000,000
OFFICE R/M EMBER EXCLUDED? ❑
N/A
E.L. DISEASE - EA EMPLOYEE
$ 1,000,000
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
RE: CITY HALL WINDOW REPLACEMENT PROJECT; PROJECT NO. PW 21-04
City of El Segundo, its officials, and employees are named as additional insured on the General Liability per attached CG 20 37 04 13 and CG 20 10 04 13 as
required by written contract subject to the terms and conditions of the policy.
Primary and Non -Contributory applies on the General Liability per attached CG 20 01 04 13
Waiver of Subrogation applies to the General Liability per attached CG 24 04 05 09
Waiver of Subrogation applies to the Workers' Compensation per attached WC 99 04 10C
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of El Segundo, a general law city and municipal
ACCORDANCE WITH THE POLICY PROVISIONS.
corporation
AUTHORIZED REPRESENTATIVE
350 Main Street
El Segundo CA 90245
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
Policy Number: G71110515 004
COMMERCIAL GENERAL LIABILITY
CG 20 37 0.4 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
O
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)
Location And Description Of Completed Operations
Blanket:when required by written contract and signed
by both parties prior to loss.
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 0 Insurance Services Office, Inc., '012 Page 1 of 1
Policy Number: G71110515 004
COMMERCIAL GENERAL LIABILITY
CG 2010 04 13
THIS ENDORSEMENT CHANGES. THE POLICY. PLEASE READ IT CAREFULLY.
lij
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s)
Locations Of Covered Operations
Blanket when required by written contract and signed
by both.parties prior to loss,
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" "prope.rty
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.
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.
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.
GG 20 10 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1
Policy Number: G71110515 004
COMMERCIAL GENERAL LIABILITY
CG 20 0104 13
THIS ENDORSEMENT CHANGES. THE POLICY. PLEASE READ IT CAREFULLY.
j, a a
M6,111 It:
r A
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 tither Insurance (2) You have agreed in writing in a contract or
Condition and supersedes any provision to the agreement that this insurance would be.
contrary: primary and would not seek contribution
Primary And Noncontributory Insurance from any other insurance available: to the
additional insured.
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
CG 20 01 04 13 Q Insurance Services Office, Inc., 2012 Page 1 of 1
Policy Number: G71110515 004
COMMERCIAL GENERAL LIABILITY
CG 24 04 O.. 09
VITIA VA Me] a Wil 0161 a 4 ZKOJAN M 161 k &K91 M V *0101TJ a a
i
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:
Blanket when required by written contract and signed by both parties prior to loss.
Information required to complete this Schedule, if hot 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 0406 09 Q insurance Services Office, Inc., 2008 Page 1 of 1 13
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 D410 C
(Ed. 01-19)
...........................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................
WAIVER. OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA
BLANKET BASIS
llta'e 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 nairned in the Schedule. (This agreement applies onliy to the extent that you
perform work tinder a written contract that requires you to obtain this agreement from us.)
The additional prernlum for this endorsernent shail be calculated by applying a factor of 2% to the total manual
premium, with a minimum initW charge of , then applying all other pricing f.baors for the policy to. this calculated
charge to derive the final cost of this endorsement.
This agreement shall not operoto directly or i:rndirectly to benefit anyone not named its the Schedule.
Schedule
Stanket Wa lver
Per:soniOrganization Blanket Waiver W Any person or organlzation for whom the Named Insured has
agreed by written contract to furnish this waiver.
Job Description
All CA Operations
This entiorseament 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 Ef aectlue7 6/30/2021 PnliC:yNo.: AJWC242129 Endorsement No.�
tnsUrecd: A.J. Fistes Corporation
lns;ararice Cumpariy: Cypress tr surance Company
Premium $
Countemigned by A&WIRItaile
(Ed, 01-19)