Loading...
PROOF OF INSURANCE (2021 - 2022) CLOSEDJEFFTRA-01 ,a►� �zO" CERTIFICATE OF LIABILITY INSURANCE DATE 11/2021 D/YYY1) 7 ....... /1/2 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 holde r 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 endors+ementfsl, PRODUCER License IF urvitu4ti C NTACT Jennifer�( R e Orlon Risk Management Insurance Services, An Alera Group Insurance A ency, LLC ... ._ . .,.... PHONE JNC No„ Es t) (949) 608-4917 e�-�p�A�° 100 quail Street, Suite 110 kIo Iaako ctrionr eR EJ /_._....Q... Newport Beach, CA 92660 .+ INSURED Land Forms Landscape Construction, Inc. 1901 E. Carnegie Ave., #E Santa Ana, CA 92705 INSURER F : 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. IR_ ,'. ADDL -........SUE PdPOLICYEFIF r Fi6iLi.......... ......--------- ,,.... ......... ......... TYPE OF INSURANCE POLICY NUMBER CY EXP .___... nrvvv%q LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X I OCCUR L AGGR'IEGATE LIMIT APPLIES PER: POLICY € X ECT LOC A AUTOMOBILE LIABILITY X ANY AUTO OWNED . SCHEDULED 1 AUTOS ONLY I„ AUTOS HIRED I !NON -OWNED . AUTOS ONLY ...... AUTOS ONLY A = UMBRELLA LIAB ? X OCCUR X EXCESS LIAB CLAIMS -MADE ........... .... ...0 ...-. ... .._ t X A0131960004 I 3 DED I X 1 RETENTION $ 01 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN EXECUTIVE ANY "I"rER/MEMBER NP N I A EXCLUDED a,ndatory in NH) '.. If ves. describe under 6/30/2021 6/30/2022 a one 1,000, 10, 1,000, 2,000,000 MBIN e SINGLE LIMIT $ ------ 1,000, A0131960001 6/30/2021 6/30/2022 BODILY INJURY (Re person) Iwo____ BODILY INJ,URX (Per accident) $ PROPERfifDAMAGE [ ..1. Ora ....... .......... COMP%COLL DED ...�...... ... _ .......... _.............. _..___ ................ EACH OCCURRENCE.._._._ ..._.._.. 000' A0131960005 6/30/2021 6/30/2022 5,000, s.$ ..�. ... f ......... .......-.-. _____-..____.... X PEh"t �OTH� Tr i1 9 R LAWC117475 12/1/2020 12/1/2021 X ,i P.I F'Af.H 18�t'",C".ImY{"` 1,000, DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Acacia Park. City of EL Segundo is included as Additional Insured per the terms of the attached CG2010 0413/CG2037 0413 Endorsements. of Subrogation applies per the terms of the attached WC 9904 10B Endorsement. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of EL Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo, CA 90245 ........................... �_........ AUTHORIZED REPRESENTATIVE _............ .............. . ACORD 25 (2016103) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: A0131960004 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: A COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE 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", "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 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. JZ_ 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 0 Insurance Services Office, Inc., 2012 CG 2010 0413 POLICY NUMBER: A0131960004 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES 0 CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Persons) Location And Description Of Completed Or Organization(s) Operations required b written c..... ._... � .... ... as required b�F� ��----- as re—� .... q y contract. q Y written contract, i i 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) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III - Limits Of Insurance: with respect to liability for "bodily injury" or If coverage provided to the additional insured is property damage" caused, in whole or in part, by required by a contract or agreement, the most we "your work" at the location designated and will pay on behalf of the additional insured is the described in the Schedule of this endorsement amount of insurance: performed for that additional insured and included 1. Required b the contract or agreement; or in the "products -completed operations hazard". q Y 9 However: 2. Available under the applicable Limits of 1. The insurance afforded to such additional Insurance shown in the Declarations; insured only applies to the extent permitted by whichever is less. law„ and This endorsement shall not increase the 2. If coverage provided to the additional insured applicable Limits of Insurance shown in the is 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. �7L CG 20 37 0413 ©insurance Services Office, Inc., 2012 Page 1 of 1 L7L WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 0410 C (Ed. 01-19) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA BLANKET BASIS 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 perscn 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 calculated by applying a factor of 2% to the total manual premium, with a minimum initial charge of $350, then applying all other pricing factors for the policy to this calculated charge to derive the final cost of this endorsement. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule, Blanket Waiver Person/Organization Job Description All CA Operations Schedule Blanket Waiver — Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. Waiver Premium (prior to adjustments) 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 Fffective- 12/01/2020 PoficyNo, LAWC117475 Endorsement No.: Insured; Land Forms Landscape Construction, Inc. Premium S Insurance Company: Cypress insurance Company Countersigned by WC990410C (Ed. 01-19)