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PROOF OF INSURANCE (2022) CLOSED (2)�1 COMM-35 OP ID: CERTIFICATE OF LIABILITY INSURANCE DATb11210712021 I20;21 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 an this certificate does not confer rights to the certificate holder in lieu of such endorsementisl. PRODUCER bZb_1!J5-9921 IC NT'ACT Supple -Merrill & Driscoll Inc. PHONE Insurance A ents and Brokers tArc, Ne, EXS : 626-795-9921 P: 0. Boat 2408 �J . Pasadena, CA 91102 Supple -Merrill & Driscoll Inc. __INSURER/SV AFFORDING COVERAGE .•. rsIReRA, Certain linderwriters at Lloyds INSURED tNSLIRER@;State Compensation Ins. Fund Commercial Transportation Services Inc. .. ......... Dino Perugino INSURER C;Mt. Hawley Insurance Co, 702 S. Treanor Avenue Sons Dimas, CA 91773 INSURER D : _ ...._ INSURER F } utr rz� 'I: rw f* Ll TrL ld^A A� All NSA-,-. �. 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 __. AOOL ... @ 'm POLLCY EFF POLICY E7(P LIMITS ......-._..•._ TYPE OF INSURANCE POLICY NUMBER A X I COMMERCIAL GENERAL LIABILITY EACI•t OCCURRENC S 1,000,000 CLAIMS -MADE XOCCUR TRCP336923 09101/2021 09/01I2022 D'MAG gUrRNrEE •` X X X 100,000 iLllrLS.tIt_ MEDEXP An one ersanim, S,ODO - - _..- �.-. PERSONAL B ADV INJURY 1,000,000 !GFNi AGGREGATE LIMIT APPLIES PER: GENERALAGGRE..5.__ X PEFL}Cl jE GATE 2,000,000 LOC PRODUCTS - COMPIOP A G S 2'000'000 OTHER: PROF 1,000,000 AUTOMOBILE LIABILITY Cp6%B4fdEO SINGLE LIMIT ANY AUTO OWNED SCHEDULED BODILY INJURY••1„Per ersan S •^••••••--�•••--•• AUTOS ONLY AUTOS... BRRODILY INJURY Per acciden! AUTOS ONLY AiOiiOOCd PtsdrC"as.ICpnt.. RAGE. g ...... S UMBRELLA UAB X '.. OCCUR ACH OCCURRENCE S 2,000,000 X GGREGATE, 2,000,000 EXCESS LAB CLAIMS -MADE GXS0006122 09/18/2021 09101120221 .m $ DED RETENTIONS Iprodagg 2,000. 00 B WORKERS COMPENSATION ANDEMPLOYERS"UASILITY X PER OTH- sT.AT T ANY PROPRIETORMARTNEP&XFCUTIVE YIN O�^F6GEgAMM6R'E7'iCLUGI'YED? ❑ N!A X 1650779 09/O1I2021 O9I0112O22 E.L.EACHACCIDENT 5 1,OQ0,000. I_ Mandala ru a 000, If yes, describe under E�LDISF8SE-FAEMPL YE - -� •• S DESCRIPTION PRAT( NSbalaw _ E1...DISEASE-POLICY %MIT 1I000�000 ' ' DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more apace Is required) City of El Segundo is named as Additional Insured as respects the Insureds Worations per CIS20 33 0413. General liability applies Per CG 24 04 05 09, rkers compensation waiver included. CITYELS 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. 400 Lomita Street El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE Hrtlw z' At-UKU Y5 (LU1blU3) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 20 33 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ` OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section li — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured any person or additional insureds, the following additional organization for whom you are performing exclusions apply: operations when you and such person or This insurance does not apply to: organization have agreed in writing in a contract or agreement that such person or organization be 1. "Bodily injury", "property damage" or "personal added as an additional insured on your policy. and advertising injury" arising out of the Such person or organization is an additional rendering of, or the failure to render, any insured only with respect to liability for "bodily professional architectural, engineering or injury", "property damage" or "personal and surveying services, including: advertising injury' caused, in whole or in part, by: a. The preparing, approving, or failing to 1. Your acts or omissions; or prepare or approve, maps, shop drawings, 2. The acts or omissions of those acting on your opinions, reports, surreys, field orders, change orders or drawings and behalf; specifications: or in the performance of your ongoing operations for b. Supervisory, inspection, architectural or the additional insured. engineering activities. However, the insurance afforded to such This exclusion applies even if the claims against additional insured: any insured allege negligence or other wrongdoing 1. Only applies to the extent permitted by law; in the supervislon, hiring, employment, training or and monitoring of others by that insured, if the 2. Will not be broader than that which you are "occurrence" which caused the "bodily injury" or required by the contract or agreement to "property damage", or the offense which caused provide for such additional insured. the "personal and advertising injury", involved the A person's or organization's status as an rendering of or the failure to render any professional architectural, engineering or additional insured under this endorsement ends surveying services. when your operations for that additional insured are completed. CG 20 33 0413 © Insurance Services Office, Inc., 2012 Page 1 of 2 2. 'Bodily injury" or "property damage" occurring after: a. Al 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 b. 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 C. With respect to the insurance afforded to these additional insureds, the following is added to Section ill — Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement you have entered into with the additional insured; 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 © Insurance Services Office, Inc., 2012 CG 20 33 04 13 POLICY NUMBER:ATR/CP/336923 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 PRODUCTSICOMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Locations) of Covered Operations s designated in Written contract with the named Insured CALIFORNIA Information re aired to com fete 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 PERUDII 6!2E IQ, i DATE (MMMONYYY) - C E - RTIFICATE OF LIABILITY INSURANCE 0711/2021 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 BETIMEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED. the policy(les) 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 endorsoment(s), PRODUCER cT Erika Fuentes Supplo-Merrill & Driscoll Inc, PHONE FAX 626-577-665,6 Insurance A, ants and 13'rohers P. O. Box 24% _E Pasadena, CA 91102 Supple-Mirrill & Driscoll Inc. S. Tre5nor Ave Dimas, CA 91773-3420 NJ_Mql Wy_ Ins,air,ance, 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, WAITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I Nsa fttm TYPE OF INSURANCE 1,13OLZOOR POLMY NUMMER YEFF F IMMD_r0= norevvyl LIMITS COMMERCIAL GENERAL LIABILITY CLAINIS-MADE E- _1 OCCUR LAG GREGA'TE LMUT APPLIES PER, POLICY L11 AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS 0, ILY All.. J MRS ONLY _q _J UMBRELLA LIAB 'OCCUR EXCESS LIAB CLAIMS -MADE WOR6PSCOMP01SA ON L XST AND U.V YIN ANY _J N:IA If *C &%Cfte under 04120149615 � 07/151202110111512022 DESCRIPTION OF OPERATIONS J LOCATIONS I VEHICLES fACORD 101, AddItIbnal Remarks Schtdu)e, may be attached if more space Is required) ?001CHEV`R0LESILVERADPKP4 2GCEC19T911396791 2017 TOYOTA 4 RUNNER JTE2U5JR3H5149180 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 Supple -Merrill & Driscoll Inc. ACORD 25 (2010/03) 9 1968-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CCommercial Transportation Services Inc. Waiver of Automobile Liability July 21, 2021 City of Rancho Cucamonga 8794 Lion Street Rancho Cucamonga, CA. 91730 To whom it may concern, Auto: C.T.S. Inc. does not have a commercial auto exposure with the regard to the services we provide to the city. We are waiving the Automobile Liability and will park our vehicle outside of the City's premises. Should you have any questions, please contact our office at (626) 966-1509 Sincerely Dino Perugino President/CEO 142 E. Bonita Ave. #107 San Dimas, CA 91773 (626) 966-1509 email: dino-cts@verizon.net ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS HOME OFFICE SAN FRANCISCO EFFECTIVE SEPTEMBER 1, 2021 AT 12.01 A.M. AND EXPIRING SEPTEMBER 1, 2022 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME COMMERCIAL TRANSPORTATION SERVICES 142 E BONITA AVE # 107 SAN DIMAS, CA 91773 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 2.00% OF THE TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER JOB DESCRIPTION BLANKET WAIVER OF SUBROGATION 1650779-21 RENEWAL SC 0-58-54-42 PAGE 1 OF NOTHING IN THIS ENDORSEMENT SHALL SE 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; SEPTEMBER 2, �+2021 /JI/ 2572 ALIICOIIEI1 REPR'ESEIT IVE PRESIDENT AND CEO SCiF FORM 10217 iREV-4-20181 1 OLD DP 217