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PROOF OF INSURANCE (2021 - 2022) CLOSEDACCORD® CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYY)
8/24/2021
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
Orr & Associates Insurance Services
28780 Single Oak Dr
255
CONTACT
NAME: Certificates
PHONE FAX
A/C No Ext : 800-311-3081 A/c, No): 800-474-3003
E-MSte
ADDRESS: certs@orrandassociates.com
INSURER(S) AFFORDING COVERAGE
NAIC#
Temecula CA 92590
INSURERA: James River Insurance Company
12203
License#: OE63493
INSURED RAMEROO-01
Ramey Roofing Inc
1411 11th Street
INSURERB: State Compensation Ins Fund
35076
INSURERC:
INSURERD:
Santa Monica CA 90401
INSURER E
INSURER F :
COVERAGES CERTIFICATE NUMBER: 1805411464 REVISION NUMBER: 2
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
A
X
COMMERCIAL GENERAL LIABILITY
Y
Y
000925902
6/7/2021
6/7/2022
EACH OCCURRENCE
$ 1,000,000
CLAIMS -MADE OCCUR
DAMAGE TO RENTED
PREMISES Ea occurrence
$ 50,000
MED EXP (Any one person)
$ 5,000
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:
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
Ea accident
$
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
UMBRELLALIAB
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LAB
CLAIMS -MADE
DED RETENTION $
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
Y
9162512-2021
6/28/2021
6/28/2022
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)
Certificate is subject to policy limits, conditions and exclusions.
City of El Segundo, Its Officials & Employees are named as Additional Insured as per policy endorsement form(s).
CG2404-0509 Waiver of Subrogation - Where required by Written Contract
AP5031 US-0410 Primary and Non Contributory
CG2010-0704 Additional Insured - Owners, Lessees or Contractors Where required by written contract or written agreement. All operations of the Named
Insured
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
ACCORDANCE WITH THE POLICY PROVISIONS.
Its Officials & Employees
AUTHORIZED REPRESENT WE
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
ACAORV DATE(MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 02/05/2021
THIS CERTIFICATE IS ISSUED ASA 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
t confer rights to the certificate holder in lieu of such endarsement(s).
PRODUCER es may require an endorsement Astatementonthlscertlficae�doMeco,® - _
conditions of thepdicy.certalnpoltl � CONTACT
Jodi Bush
Jodi Bush PHONE FAX
43545 17th St W Ste 503 (A/C, NO, E)CT1: 661-942-6685 (A/C, No): 661-729-2142
E-MAIL
ADDRESS: jbushl@farmersagent.com
Lancaster CA 93534-5858
INSURER(S)AFFORDINGCOVERAGE NAIC#
INSURED INSURERA Truck Insurance Exchange 21709
INSURERS: Farmers Insurance Exchange 21652
RAMEY ROOFING INC INSURERC: Mid Century Insurance Company 21687
221 1 /2 ARENA ST INSURER O
INSURER E
EL SEGUNDO CA 90245 IN SURERF:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
I F-IIS IS 10 CER I FY THAI T HL POLICIES OF INSURANCE LIS I EU BELOW HAVE BEEN ISSUED TO I HE INSURED NAME ABOVE FOR I HE POLICY PERIOD INDICAI ED, NOI WI T HSTANDING ANY
REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT -TO WHICH THIS CERTIFICA'rF MAY BE NSUED OR MAY PERTAIN. THE IN.SURAN'CF AFFORDED BY THE
POIJICIESDEiSC:RIBED IIEREINISSJf3JEC1 TOALL 'THETERMS, EXCLUSIONS AND CONDITIONS OFSUCl/POLICIES LIMITS SIIOWN MAY IIAVEBEEN REDUCED BYPAID CLAWS ,
INSR ......... - ... INSD WVD (MM LICYEFYY) POUCYEXP LIMITS
ADOTL SUER POLICY NUMBER
LTR TYPEOFINSURANCE __ ... (MM/DD/YYYY) , ,,,,.. ..._.. ... .._.
__ ,....,..,, ._..�,,,a _ ,., ,,, _
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE
DAMAGE TORE:N'TED ,S
'.... CLAIMS -MADE OCCUR PREMISES (Ea Occurrencv)
MFD FXP (Anyone jrsrson)
PERSONAL lkRtDVINJURY
C. CN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE ,S
T,RorvU+"TS•COMP/OPAGG S
POLICY '�i PROJECT" LOC
OTHER....... .... ..... ....... ., ......
CC:}I�M1F31NEC7 ExINCiLE I..IMIi` I
AUTOMOBILE LIABILITY (Ea accident)
ANYAUTa J Per pet 1 1 000 000
BODILVIIV INJURY (r ... . _- q, a.
OWNEDAUTOS SCHEDULED BODILY II'dJURY (Per acelderrl) f
A` 0NLY X AUTOS, 606767923 10/26/2020 10/26/2021
HIRFn AUTOS NON""OWNFr1 WtT('kTxF R1`Y r7AXef.Au;�I'- 1S
X''... ONLY AU'TOSONLY [Prrrlcccdcnlp._.. .__ 100„000,
i M 1
UMBRELLALIAB OCCUR FACH OCCURRENCE 1
EXCESS UAB ChAIMS-MADE At,C-RF CxAY'F
DED RETENTIONS �_ S
WORKERS COMPENSATION
PEE "1
i AND EMPLOYERS' LIABILITY STATUTE' OTHER
_ ....
ANY PROPRIETOR/PARTNER/ YYN F I FACHACCFDFNT
FXECUTIVEOFFICER/MEMBER ..._ ". N/A .... ,,....,,,, A11
E.L., DISEA SE-EFMPLOYE: E
EXCLUDCD-f (Mandatory InNH) 6._. .... -- !...
If yes, describe under DESCRIP110N OF EJ_. DISEASE- P01_ICY I IM11 !$
OPFRATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD I D 1, Additional Remarks Schedule, maybe attached if more space is required)
Additional Insured City of El Segundo its Officials & Employees
CERTIFICATE HOLDER CANCELLATION "
City of El Segundo " SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Its Officials & Employees POLICY PROVISIONS.
WILL BE DELIVERED IN ACCORDANCE WITH THE PO
350 Main Street w mm
... ,,.(.:A ..,.''�.��"� ,..,,,,,� ,,,.. DATE THEREOF, ,�'.L...�"^rF'
.. .. ............,,,,
AUTHORIZED REPRESENTATIVE
ACORD 25 (2016/03) C� '69
B -2.015 ACORD CORPORATION. All Rights Reserved
31-1769 11-15 The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: 00092590-2
COMMERCIAL GENERAL LIABILITY
CG 20 10 07 04
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 Organ izations :
Locations Of Covered Operations
Where required by written contract
All operations of the Named Insured.
or written agreement.
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", "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) desig-
nated above.
B. With respect to the insurance afforded to these
additional insureds, the following additional exclu-
sions apply:
This insurance does not apply to "bodily injury" or
"property damage" occurring after:
1. All work, including materials, parts or equip-
ment 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 in-
tended use by any person or organization oth-
er than another contractor or subcontractor
engaged in performing operations for a princi-
pal as a part of the same project.
CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 0
POLICY NUMBER:
COMMERCIAL GENERAL LIABILITY
CG 20 28 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - LESSOR OF
LEASED EQUIPMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
Where required by written contract or written agreement.
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", "property
damage" or "personal and advertising injury"
caused, in whole or in part, by your maintenance,
operation or use of equipment leased to you by
such person(s) or organization(s).
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, this insurance does not apply
to any 'occurrence" which takes place after the
equipment lease expires.
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 28 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1
POLICY NUMBER: 00092590-2
COMMERCIAL GENERAL LIABILITY
CG 20 37 07 04
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
SCHEDULE
Name Of Additional Insured Person(s)
Or Or anization s :
Location And Description Of Completed Opera -
tions
Where required by written contract
All operations of the Named Insured.
or written agreement.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
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".
CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 0
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY AND NON CONTRIBUTORY
ENDORSEMENT
This endorsement modifies insurance provided under the following:
ALL COVERAGE PARTS
Name Of Additional Insured Person(s)
Or Organization(s):
If no entry appears above, this endorsement applies to all Additional Insureds covered under
this policy.
Any coverage provided to an Additional Insured under this policy shall be excess over any other
valid and collectible insurance available to such Additional Insured whether primary, excess,
contingent or on any other basis unless a written contract or written agreement specifically
requires that this insurance apply on a primary and noncontributory basis.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
AP5031 US O4-10 Page 1 of 1
POLICY NUMBER: 00092590-2
COMMERCIAL GENERAL LIABILITY
CG 24 04 05 09
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
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:
Where required by written contract or written agreement.
Information required to complete this Schedule, if not 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 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 0
ENDORSEMENT AGREEMENT
WAIVER OF SUBROGATION REP 04
9162512-21
RENEWAL
SP
4-47-88-58
PAGE 1
HOME OFFICE
SAN FRANCISCO
ALL EFFECTIVE DATES ARE
AT 12:01 AM PACIFIC
STANDARD TIME OR THE
TIME INDICATED AT
PACIFIC STANDARD TIME
RAMEY ROOFING
EFFECTIVE JULY 15, 2021 AT 12.01 A.M.
AND EXPIRING JUNE 28, 2022 AT 12.01 A.M.
1411 11TH ST
SANTA MONICA, CA 90401
ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING,
IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND
WAIVES ANY RIGHT OF SUBROGATION AGAINST,
CITY OF EL SEGUNDO
WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS
POLICY IN CONNECTION WITH WORK PERFORMED BY,
RAMEY ROOFING
IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN
PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION
OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE
EMPLOYER.
IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH
EMPLOYEES SHALL BE INCREASED BY 03%.
NOTHING IN THIS ENDORSEMENT SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND
ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY
OTHER THAN AS ABOVE STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE
HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR
LIMITATIONS IN THIS ENDORSEMENT.
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: JULY 22, 2021
2570
AUTHORIZED REPRESENT /IVE PRESIDENT AND CEO
SCIF FORM 10217 (REV.4-2018)