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PROOF OF INSURANCE (2022) CLOSEDACCORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 1 'll 8/4/2021 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 CONTACT NAME: Marsh & McLennan Agency LLC PHONE FAX 9850 N.W. 41 st Street A/C No Ext : 305-591-0090 A/C, No): E-MSuite ADDRESS: certsmiami@mma-fl.com 100 INSURER(S) AFFORDING COVERAGE NAIC# Miami FL 33178 INSURERA: Berkshire Hathaway Homestate Ins Co 20044 INSURED WESTE1 INSURER B: Great Northern Insurance Company 20303 Western State Design, Inc dba Western State Design Construction Company INsuRERc: Federal Insurance Company 20281 INSURERD: 2331 Tripaldi Way Hayward CA 94545 INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER:411803109 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 B X COMMERCIAL GENERAL LIABILITY Y 36069341 7/1/2021 7/1/2022 EACH OCCURRENCE $1,000,000 CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 1,000,000 X MED EXP (Any one person) $ 5,000 Ded: $0 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY � PRO- � LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: B AUTOMOBILE LIABILITY 73622592 7/1/2021 7/1/2022 COMBINED SINGLE LIMIT Ea accident $1,000,000 X BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY Ded: $0 $ C X UMBRELLALIAB X OCCUR 78188587 7/1/2021 7/1/2022 EACH OCCURRENCE $5,000,000 AGGREGATE $ 5,000,000 EXCESS LAB CLAIMS -MADE DED X RETENTION $ n $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N Y WEWC215677 7/1/2021 7/1/2022 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: Fire Station #1 - 314 Main Street, El Segundo CA 90245; Fire Station #2 - 2261 E. Mariposa Ave., El Segundo, CA 90245 City of El Segundo, its officials, and employees, as Owner/Lessee/Contractor, are Additional Insured as respects General Liability (including Ongoing and Completed Operations) when required by written contract subject to the term, conditions and exclusions of the policy. General Liability is primary and non-contributory when required by written contract subject to the terms, conditions and exclusions of the policy. 30 Day notice of Cancellation in favor of Additional Insured as respects General Liability as required by written contract subject to the terms, conditions and exclusions of the policy. Waiver of subrogation as respects Workers Compensation in favor of Additional Insured when required by written contract subject to the terms, conditions and exclusions of the policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of El Segundo 2261 E. Mariposa Avenue El Segundo CA 90245 AUTHORIZED REPRESENTATIVE @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD C H U B B° Liability Insurance Endorsement Policy Period JULY 1, 2021 TO JULY 1, 2022 Effective Date JULY 1, 2021 Policy Number 3606-9341 TPA Insured WESTERN STATE DESIGN INC Name of Company GREAT NORTHERN INSURANCE COMPANY Date Issued JULY 12, 2021 This Endorsement applies to the following forms: GENERAL LIABILITY Under Who Is An Insured, the following provision is added. Who Is An Insured Owners, Lessees Or A. Persons or organizations shown in the Schedule below are insureds; but they are insureds Contractors - Ongoing only with respect to their liability for bodily injury, property damage, advertising injury Operations or personal 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 person or organization shown in the Schedule at the applicable location described in the Schedule. However, • the insurance afforded to such person or organization only applies to the extent permitted by law; and • if coverage provided to the person or organization is required by a contract or agreement, the insurance afforded to the person or organization will not be broader than that which you are required by such contract or agreement to provide for the person or organization. Liability Insurance Additional Insured - Owners, Lessees Or Contractors - Ongoing Operations, Scheduled continued Form 80-02-2305 (Rev. 3-17) Endorsement Page 1 Liability Endorsement (continued) B. However, no person or organization is an insured for bodily injury or property damage occurring after: 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 person or organization shown in the Schedule at the applicable location described in the Schedule 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 part of the same project. Schedule Designated Owner, Lessee Or Contractor PERSONS OR ORGANIZATIONS WHOM YOU ARE REQUIRED BY A CONTRACT OR AGREEMENT TO AFFORD STATUS AS AN "INSURED" FOR SUCH INSURANCE AS IS AFFORDED BY THIS POLICY. WORDS OR PHRASES IN QUOTATIONS APPEAR IN BOLD PRINT IN THE CONTRACT AND HAVE THE SPECIAL MEANINGS DESCRIBED IN THE DEFINITIONS SECTION OF THE CONTRACT. All other terms and conditions remain unchanged. Authorized Representative last page Liability Insurance Form 80-02-2305 (Rev. 3-17) Additional Insured - Owners, Lessees Or Contractors - Ongoing Operations, Scheduled Endorsement Page 2 C H U B B° Liability Insurance Endorsement Policy Period Effective Date Policy Number Insured Name of Company Date Issued This Endorsement applies to the following forms: GENERAL LIABILITY Who Is An Insured JULY 1, 2021 TO JULY 1, 2022 JULY 1, 2021 3606-9341 TPA WESTERN STATE DESIGN INC GREAT NORTHERN INSURANCE COMPANY JULY 12, 2021 Under Who Is An Insured, the following provision is added. Owners, Lessees Or Persons or organizations shown in the Schedule are insureds; but they are insureds only with respect Contractors - Completed to their liability for bodily injury or property damage caused, in whole or in part, by your work Operations at the applicable location described in the Schedule performed for such person or organization and included in the products -completed operations hazard. However, • the insurance afforded to such person or organization only applies to the extent permitted by law; and • if coverage provided to the person or organization is required by a contract or agreement, the insurance afforded to the person or organization will not be broader than that which you are required by such contract or agreement to provide for the person or organization. Schedule PERSONS OR ORGANIZATIONS WHOM YOU ARE REQUIRED BY A CONTRACT OR AGREEMENT TO AFFORD STATUS AS AN "INSURED" FOR SUCH INSURANCE AS IS AFFORDED BY THIS POLICY. WORDS OR PHRASES IN QUOTATIONS APPEAR IN BOLD PRINT IN THE CONTRACT Liability Insurance Additional Insured - Owners, Lessees Or Contractors - Completed Operations, Scheduled continued Form 80-02-8446 (Rev. 3-17) Endorsement Page 1 Liability Endorsement (continued) Liability Insurance Form 80-02-8446 (Rev. 3-17) AND HAVE THE SPECIAL MEANINGS DESCRIBED IN THE DEFINITIONS SECTION OF THE CONTRACT. All other terms and conditions remain unchanged. Authorized Representative Additional Insured - Owners, Lessees Or Contractors - Completed Operations, Scheduled last page Endorsement Page 2 C H U B B° Liability Insurance Endorsement Policy Period Effective Date Policy Number Insured Name of Company Date Issued This Endorsement applies to the following forms: GENERAL LIABILITY EMPLOYEE BENEFITS ERRORS OR OMISSIONS Conditions JULY 1, 2021 TO JULY 1, 2022 JULY 1, 2021 3606-9341 TPA WESTERN STATE DESIGN INC GREAT NORTHERN INSURANCE COMPANY JULY 12, 2021 Under Conditions, the following provision is added to the condition titled Other Insurance. Other Insurance - If you are obligated, pursuant to a written contract or agreement, to provide the person or Primary, Noncontributory organization described in the Schedule (that is also included in the Who Is An Insured section of this Insurance - Scheduled contract) with primary insurance such as is afforded by this policy, then this insurance is primary and Person Or Organization we will not seek contribution from insurance available to such person or organization. Schedule Persons or organizations described in the Who Is An Insured section of this contract and that you are obligated, pursuant to a written contract or agreement, to provide with primary insurance as is afforded by this policy, but only to the minimum extent required by such contract or agreement. All other terms and conditions remain unchanged. Authorized Representative Liability Insurance Conditions - Other Insurance - Primary, Noncontributory Insurance - Scheduled Person Or Organization last page Form 80-02-2653 (Rev. 7-09) Endorsement Page 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC990410C (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 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 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. Schedule Blanket Waiver Person/Organization Blanket Waiver — Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. Job Description Waiver Premium (prior to adjustments) All CA Operations 5952.00 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: 07/01/2021 PolicyNo.: WEWC215677 Endorsement No.: Insured: Premium $ Insurance Company: Berkshire Hathaway Homestate Ins Co Countersigned by WC990410C (Ed. 01-19)