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PROOF OF INSURANCE (2022) CLOSEDAC��� 07l20/202YYY) CERTIFICATE OF LIABILITY INSURANCE DATE(M/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 NODE: Kathy Macias -Ramirez Millennium Risk Management & Insurance Services PHONE (618) 844-4100 AaC Ner , (818) 638-7920 IC Ao xt An ISU Network Member #OM93299 E-MAIL kathym@mcsins.com -ADDRESS.* 301 E Colorado Blvd #205 INSURER(S)AFFORDING COVERAGE NAIC# Pasadena CA 91101 INSURERA: Mt Hawley Insurance Cc 37974 INSURED INSURER B : Ohio Security Ins Company 24082 INSURER C : Everest Premier Insurance Co. 16045 Trueline Construction & Surfacing, Inc. INSURER D : 12397 Doherty Street INSURER E,. Riverside CA 92503 INSURER F nnv�e A n_ee !`1=0711=1!'ATC ui n A0=0- 2021 - 2022 RFVICIAN NI IMRFR• 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 POLICY NUMBER MMDDY MW POLDDIYYYCY Y LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 rA CLAIMS -MADE OCCUR PREMISES Faoccunrence, 50,000 $ X' MED EXP (Anv one person) $ 5,000 $5,000 Ded - Per OCc Y MGLO193444 07/25/2021 07/25/2022 PERSONAL & ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMPIOPAGG $ 2,000,000 POLICYJECT [::] LOC OTHER: Employee Benefits $ 1,000,000 AUTOMOBILE LIABILITY COMSINEDSI01EL_MR If=a a udLi )_--...®ee-e_ $ 1,000,000 X ANYAUTO BODILY INJURY (Per person) $ B OWNED SCHEDULED AUTOS ONLY AUTOS HIRED N-OWNED �'' AUTOS ONLY ONLY BAS (22) 56945605 07/25/2021 07/25/2022 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ X COMP-$1KLL-$1KUMBRELLA NAUTOS LIAOCCUR EACH OCCURRENCE $ 4,000,000 A X EXCESS LIABCLAIMS-MADE MXL0431710 07/25/2021 07/25/2022 AGGREGATE $ 4,000,000 DIED 1 X1 RETENTION S -0- $ C WORKERS COMPENSATION ANY PROPRIETOR/PARTNER/EXECUTIVE OF FCCE OFFICER/MEMBER EXCLUDED? YIN �Y andatory in N / a 7600016618211 07/25/2021 07/25/2022 X STATUTE ORTH- E L EACH ACCIDENT $ 1,000,000 E L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: 350 Main Street. The City of El Segundo, its officers, officials, employees, agents, and volunteers are included as additional insureds with for General Liability as respects to the insureds operations and only if required by written contract per the attached endorsement, Waiver of subrogation applies to the Workers Compensation. Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. CERTIFICATE HOLDER City of El Segundo 350 Main Street ElSegundo I ACORD 25 (2016/03) 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 CA 90245 @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Policy Number: MGLO193444 Mt. Hawley Insurance Company 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: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location(s) Of Covered Operations: All persons or organizations where required All Locations by written contract executed prior to the commencement of your work. 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 in- clude as an additional insured the person(s) or organi- zation(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: 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 re- pairs) to be performed by or on behalf of the addi- tional insured(s) at the location of the covered operations has been completed; or 1. The insurance afforded to such additional insured 2. That portion of "your work" out of which the injury only applies to the extent permitted by law; and or damage arises has been put to its intended use by any person or organization other than another 2. If coverage provided to the additional insured is contractor or subcontractor engaged in performing required by a contract or agreement, the in- operations for a principal as a part of the same surance afforded to such additional insured will project. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 Insured 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. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 2 of 2 Insured Policy Number: MGLO193444 Mt. Hawley Insurance Company 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 Name of Additional Insured Person(s) or Organization(s) Location and Description of Completed Operations All persons or organizations where required by written All Locations and All Projects contract executed prior to the commencement of your work. 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 dam- age" 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 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 re- quired 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. 2. If coverage provided to the additional insured is required by a contract or agreement, the insur- This endorsement shall not increase the applicable ance afforded to such additional insured will not Limits of Insurance shown in the Declarations. 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 Insured 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA 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.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2% of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOM THE BLANKET WAIVER OF SUBROGATION NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS 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: 07/25/2021 Policy No. 7600016618211 Endorsement No. 001 Insured: Trueline Construction & Surfacing, Inc. Premium $ INCL. Insurance Company: Everest Premier Insurance Company Countersigned By: - 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual - 1999.