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PROOF OF INSURANCE (2022) CLOSEDDATE (MWDD/YYYY) C"� R CERTIFICATE OF LIABILITY INSURANCE 9/16/2021 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). ...... CONTACT PRODUCER .,...�.„ " uNr 4ACC. klo,.F). (888) 780 5381 f f ,n Na m t' (866) 828 2424 WTW MIDWEST INC D E-MAIEss; Certificate@Hanover.com 233 S WACKER DR,SUITE 2000 INSURER(S) COVERAGE NAIC # CHICAGO IL 60606 INSURER A : Citizens Ins Co of America .- ...----- 31534 INSURED INSURER B . Hanover Insurance Co .................. ........ ...,,,,,..... 22292 '..... ,,,... ....-----........... INSURER C Hanover American Ins Co 36064 BUCKNAM INFRASTRUCTURE GROUP INC I . ........- 3548 SEAGATE WAY STE 230 IN . ..... ......... ........... ........... ..... ................ ... OCEANSIDE CA 92056 INSURER F r f1VFRArFS CFRTIFICATF Nl1MRFR: 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. ............ Y POLICY ExP LIMITS LTR . ,,,,,,,,,,,,, ........ AboL gubk ..........- - ----- .................. „' 'MlDDfYYFYk' ,............. ...._ ......... ,.... ..,.,..... ............,,..,' I I , TYPE OF INSURANCE POLICY NUMBER M MIwDD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE OCCUR �� t1 AWA68 fO"RENtEtS ,� „PEM,ISESfF�aocc�rrgn,,,,e,)m $ 1 000,000 ------ ......... ............. MEP, EXP A one erson °Y..... ... $ 10,000 _.,.. A .......... Y N OBC A399956 07 09/16/2021 09/16/2022 PERSONAL & ADV INJURY $ 2,000,000 . GEN'L ,......,,,, __ ......... ...... AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 �E POLICY JECT LOC PRODUCTS -COMP/OP AGG $ 4,000,000 O n HER, $ AUTOMOBILE LIABILITY OMBI �E OSINGLELIMIT ('' .., $...2000000 ANY AUTO BODILY INJURY (Per person) $ A OWNED - .... SCHEDULED Y N OBC A399956 07 09/16/2021 09/16/2022 ,., .-._.... __.._..... BODILY INJURY (Per accident) ..-.� ......, $ AUTOS ONLY AUTOS HIRED NON -OWNED PR(")I"t RTYDAMAGE $$ AUTOS ONLY AUTOS ONLY (Pe a P;l RR011 --------------------- ....... ... $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ 3,090,999 A EXCESS LIAB CLAIMS -MADE Y N OBC A399956 07 09/16/2021 09/16/2022 AGGREGATE $ 3,000,000 DE D RETENTION $ $ WORKERS COMPENSATION PER OTH- STATUTE AND EMPLOYERS' LIABILITY YIN m03 1,000,000 C ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? N / A Y WZC A399946 07 09/16/2021 09/16/2022 E..L EACH ACCIDENT $ - -- .....•....... -- (Mandatory in NH) E,.L DISEASE EA EMPLOYEE $ 1,000 00 If yes, describe under DESCRIPTION'S OF OPERATIONS below ELL DISEASE - POLICY LIMIT $ 1,000,000 B Architects & Engineers Prof Liab N N LHC H023717 02 09/16/2021 09/16/2022 Claims -Made: $2M Ea Claim/$2M Agg DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of El Segundo are Additional Insured on the General Liability and Auto Liability pursuant to the terms and conditions by form 391-1586. Excess/Umbrella to follow form. Additional Insured is Primary and Noncontributory on General Liability to the extent provided by form: 391-1003 (page 79 of 81). Waiver of subrogation on Workers Compensation as provided by form: WC040306. Cancellation Notice will be provided to the Certificate Holder pursuant to endorsement: 401-1235, 331-0342 and 921-1507. Such notice Is solely for the purpose of informing the Certificate Holder of the effective date of cancellation and does not grant, alter, or extend any rights or obligations under this policy. CERTIFICA 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 AUTHORIZED REPRESENTATIVE 350 MAIN STREET EL SEGUNDO CA 90245�' 01988-2015 ACORD CORPORATION. All rights reserves. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 4AHAnover Insurance Group- OBCA399956 1309570 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, GENERAL LIABILITY SUPPLEMENTARY ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM injury and advertising injury". A. Additional Insured by Contract, Agreement or Permit (2) To any person or organization included as an insured by another endorsement The following is added to SECTION II - issued by us and made part of this LIABILITY, C. Who Is An Insured: Coverage Part. Additional Insured by Contract, Agreement or (3) To any lessor of equipment: Permit (a) ter the equipment lease expires; a. Any person or organization with whom you or agreed in a written contract, written agreement or permit that such person or (b) If the "bodily injury", "property organization to add as an additional insured damage", or "personal and on your policy is an additional insured only advertising injury" arises out of sole with respect to (liability for "bodily injury", negligence of the lessor "property damage", or "personal and (4) To any: advertising injury" caused, in whole or in (a) Owners or other interests from part, by your acts or omissions, or the acts whom land has been leased if the or omissions of those acting on your behalf, '"occurrence" or offense takes place but only with respect to: or the offense is committed after (1) "Your work" for the additional insured(s) the lease for the land expires; or designated In the contract, agreement "bodily (b) Managers or lessors of premises if: or permit including injury" or property damage included in the i The takes lace or C) P H products -completed operations hazard'" the offense is committed after only if this Coverage Part provides such you cease to be a tenant in that coverage. premises; or (2) Premises you own, rent, lease or occupy; (ii) The "bodily injury", "property or damage", "personal Injury" or (3) Your maintenance, operation or use of advertising injury arises out of structural alterations, new equipment leased to you. construction or demolition b. The insurance afforded to such additional operations performed by or on insured described above: behalf of the manager or lessor. (1) Only applies to the extent permitted by (5) To "bodily injury", "property damage" or law; and "personal and advertising injury" arising (2) Will not be broader than the insurance out of the rendering of or the failure to which you are required by thecontract, render any professional services. agreement or permit to provide for such This exclusion applies even if the claims additional insured. against any insured allege negligence (3) Applies on a primary basis if that is or other wrongdoing in the supervision, required bythe written contract, written hiring, employment, training or agreement or permit. monitoring of others by that insured, if the "occurrence" which caused the (4) Will not be broader than coverage "bodily injury" or "property damage" or provided to any other insured. the offense which caused the "personal (5) Does not apply if the "bodily injury", and advertising injury" involved the "' property damage" or "personal and rendering of or failure to render any advertising injury" is otherwise professional services by or for you. excluded from coverage under this d. With respect to the insurance afforded to Coverage Part, including any these additional insureds, the following is endorsements thereto. added to SECTION II - LIABILITY, D. Liability c. This provision does not apply: and Medical Expense Limits of Insurance: (1) Unless the written contract or written The most we will pay on behalf of the agreement was executed orpermitvwas additional insured for a covered claim is the issued prior to the "bodily injury", lesser of the amount of insurance: "property damage", or "personal 391-1586 08 16 Includes copyrighted material of Insurance Services Offices, Inc., with its permission. Page 1 Of 2 1. Required by the contract, agreement or permit described in Paragraph a.; or 2. Available under the applicable Limits of Insurance shown in the Declarations. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations B. Aggregate Limits of Insurance per Project or per Location The following changes are made to SECTION II - LIABILITY: 1. The following is added to SECTION II - LIABILITY, D. Liability and Medical Expenses Limits of Insurance, paragraph 4: The Aggregate Limits of Insurance apply separately to each of "your projects" or each "location" listed in the Declarations. 2. For the purpose of coverage provided by this endorsement only, the following is added to SECTION II - LIABILITY, F. Liability And Medical Expenses Definitions: 1. "Your project" means: a. Any premises, site or "location" at, on, or in which "your work" is not yet completed; and b. Does not include any "location" listed in the Declarations. 2. "Location" means premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway, waterway or right-of-way of a railroad. ALL OTHER TERMS, CONDITIONS, AND EXCLUSIONS REM,,�IN UNCHANGED. 391-1586 0816 Includes copyrighted material of Insurance Services Offices, Inc., with its permission. Page 2 of 2 T1w Innover surance Group.. OBCA399956 1309570 1. SECTION I - PROPERTY, if two or more of However, if you agree in a written this coverage part's coverages apply to contract, written agreement, or the same loss or damage, we will not pay written permit that the insurance more than the actual amount of the loss or provided to any person or damage. organization included as an 2. SECTION II - LIABILITY, it is our stated Additional Insured under this Coverage Part is primary and intent that the various Coverage Parts„ forms, endorsements or policies issued to non-contributory, we will not seek the named insured by us, or any company contribution from any other insurance available to that Additional affiliated with us, do not provide any duplication or overlap of coverage for the Insured which covers the Additional same claim, "suit", "occurrence", offense, Insured as a Named Insured except: accident, "wrongful act" or loss. We will (1) For the sole negligence of the not pay more than the actual amount of Additional Insured; or the loss or damage. (2) When the Additional Insured is If this Coverage Part and any other an Additional Insured under Coverage Part, form, endorsement or another liability policy. policy issued to the named insured by us, b. Excess Insurance or any company affiliated with us, apply to the same claim, "suit", occurrence, This insurance is excess over: offense, accident, "wrongful act" or loss, (1) Any of the other insurance, the maximum Limit of Insurance under all whether primary, excess, such Coverage Parts, forms, contingent or on any other basis: endorsements or policies combined shall (a) That is Fire, Extended not exceed the highest applicable Limit of Coverage, Builder's Risk, Insurance under any one Coverage Part, Installation Risk similar form, endorsement or policy. w coverage for your work"; This condition does not apply to any Excess or Umbrella Policy issued by us (b) That is Property Insurance for specifically to apply as excess insurance premises rented to you or temporarily occupied by you over this policy. with permission of the owner; G. Liberalization (c) That is insurance purchased If we adopt an revision that would broaden P Y by you to rover your liability the coverage under this policy without as a tenant for "property additional premium within 45 days prior to or damage" to premises rented during the policy period, the broadened to you or temporarily coverage will immediately apply to this policy. occupied by you with H. Other Insurance permission of the owner; or 1. SECTION I - PROPERTY (d) If the loss arises out of the If there is other insurance covering the maintenance or use ofaircraft, "autos" or watercraft same loss or damage, we will pay only for to the extent not subject to the amount of covered loss or damage in SECTION II - LIABILITY, excess of the amount due from that other Exclusion g. Aircraft, Auto or insurance, whether you can collect on it or Watercraft; and not. But, we will not pay more than the applicable Limit of Insurance of SECTION 1 (2) Any other primary insurance - PROPERTY. available to you covering liability 2. SECTION II -LIABILITY for damages arising out of the premises or operations, or the If other valid and collectible insurance is products and completed available to the insured for a loss we operations, for which you have cover under SECTION II - LIABILITY, our been added as an additional obligations are limited as follows: insured by attachment of an a. Primary Insurance endorsement. This insurance is primary except when When this insurance is excess, we will have no duty under SECTION II - paragraph b. below applies. If this LIABILITY to defend the insured insurance is primary, our obligations against any suit if any other are not affected unless any of the Insurer has a duty to defend the other insurance is also primary. Then, insured against that "suit". If no other we will share with all that other insurer defends, we will undertake to insurance by the method described in do so, but we will be entitled to the paragraph c. below. 391-1003 08 16 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 79 of 81 13w " Hanover Insurance Group_ OBCA399956 1309570 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO DESIGNATED ENTITY(S) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL LIABILITY UMBRELLA COVERAGE PART HANOVER COMMERCIAL FOLLOW FORM EXCESS AND UMBRELLA POLICY COMMERCIAL PROPERTY COVERAGE PART BUSINESS AUTO COVERAGE FORM BUSINESSOWNERS COVERAGE FORM SCHEDULE Name of Designated Ent' Mailing Address or Email Address Number 9 �Y 9 Days Notice CITY OF EL SEGUNDO 30 350 MAIN STREET EL SEGUNDO, CA 90245 ......... ..... ........... ..... ..... ........ .............._........................_................. ...... ... (Information required to complete this Schedule, if not shown above, will be shown in the Declarations.) If we cancel this policy for any reason other than nonpayment of premium, we will give written notice of such cancellation to the Designated Entity(s) shown in the Schedule. Such notice may be delivered or sent by any means of our choosing. The notice to the Designated Entity(s) will state the effective date of cancellation. Unless otherwise noted in the Schedule above, such notice will be provided to the Designated Entity(s) no more than the number of days in advance of the effective date of cancellation that we are required to provide to the Named Insured for such cancellation. Such notice of cancellation is solely for the purpose of informing the Designated Entity(s) of the effective date of cancellation and does not grant, alter, or extend any rights or obligations under this policy. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED.. 401-1235 12 14 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1 ■rfanover li r Imsurince Group - WZCA399946 1309574 NONCE OF CANCELLATION TO DESIGNATED ENTITY(S) This endorsement modifies insurance provided under the following: WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY SCHEDULE _................. ...................... _......_. ..m Name of Designated Entity Mailing Address or Email Address Number Days Notice CITY OF EL SEGUNDO 30 350 MAIN STREET EL SEGUNDO, CA 90245 Information required to complete this Schedule, if not shown above, will be shown in the Declarations If we cancel this policy for any reason other than nonpayment of premium, we will give written notice of such cancellation to the Designated Entity(s) shown in the Schedule. Such notice may be delivered or sent by any means of our choosing. The notice to the Designated Entity(s) will state the effective date of cancel- lation. Unless otherwise noted in the Schedule above, such notice will be provided to the Designated Entity(s) no more than the number of days in advance of the effective date of cancellation that we are required to pro- vide to the Named Insured for such cancellation. Such notice of cancellation is solely for the purpose of informing the Designated Entity(s) of the effective date of cancellation and does not grant, alter, or extend any rights or obligations under this policy. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. 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 Policy No. W Z C -A3 9 9 9 4 6- 07 Endorsement No. Insured Premium Insurance Company THE HANOVER AMERICAN INSURANCE COMPANY Countersigned By ........................ 331-0342 (09 11) Includes copyrighted materials from ISO, Inc. 2003 Page 1 of 1 Anover In suralic'e t kro up , Endorsement MEMM HEMENVMMIRMOMMINNOW Coverage: Architects and Engineers Liability Endorsement Number: 4 Issued To: BUCKNAM INFRASTRUCTURE GROUP INC Policy Number: LHC-H023717-02 Issued By: The Hanover Insurance Company Effective Date: 09/16/2021 NOTICE OF CANCELLATION OR NON -RENEWAL TO DESIGNATED ENTITY In consideration of the premium charged it is agreed that: If We cancel or non -renew this Policy, We will provide 30 days, except 10 days for non-payment of premium, written notice of such termination or cancellation to the following: CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO, CA 90245 Nothing herein contained shall be held to vary, alter, waive or extend any of the terms, conditions, agreements or limitations of the Policy other than as above stated. In the event cancellation or non -renewal is initiated by the Named Insured, We have no duty to provide such notice. All other terms and conditions remain unchanged. The title and any headings in this endorsement are solely for convenience and form no part of the terms and conditions of coverage. 921 1507 01/18 Page 1 of 1 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 BLANKET AS REQUIRED BY CONTRACT 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 Insured Policy No. W Z C -A3 9 9 9 4 6- 07 Endorsement No. Insurance CompanyTHE HANOVER AMERICAN INSURANCE COMPANY Countersigned By WC 04 03 06 (Ed 04-84)