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PROOF OF INSURANCE (2022 - 2022) CLOSED
LANFORM-01 IQCa4MP DATE (MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 1117/2021 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. ..... ._....,�m......... 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 License # OM70471 _ C7 CT Newport Beach, CA 92660 p I N , E tI g49 263-8 Arc No) (04 . Orion Risk Management Insurance Services, An Alera Group Insurance PHONE Arc 850 I g) 263 8860 1 00 Ctuail Street Suite 110 4�s< _._ p INSURED Land Forms Landscape Construction, Inc. 1901 E. Carnegie Ave., #E Santa Ana, CA 92705 F 10855 COVERAGE$ _....... CERTIFICATE NUMBER: .�.....�........... . ... REVISION NUMBER��IT 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, OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EXCLUSIONS AND CON.......COMMERCIALLIABILITYEx TYPE OF INSURANCE POLICY NUMBER I A X 1AOOOwOiIO I CLAIMS -MADE X,..1 OCCUR �_ ..1 X A0131960004 6/30/2021 6/30/2022 P�SMA E RENTED � 500 q0 0 .. i ... ..— PoNAL ADv Ahaa `� s 1' p000„000 K EN L, AGGRFpjAT�E LIMIT APPLIES PER: .. ... t9tlEIiAL A,OnisREG>A" 3,000 OOO PR —., POLICY �...X JECOT LOC ... PRODUCTS- FtODU ;T;x_ C-- , . ,'ACTS ..S........ 2,O00,000 OTHER: X TOMOBILE LIABILITY �A0131960001 S I OMI3INECI'tiINGI E I CEO �B COMBINED I. LIMIT 1,000,000 ANY AUTO AU ... 6/30/2021 6/30/2022 OL11LY INJURY PPr a S' OWNED SCHEDULED AUTOS ONLY „AUTOS rsoxw ( P. I •• AUTOS ONLY NON-OWNED ONLY ff...enl� D --- LA LIAB X � OCCUR A J X.... A0131960005 RENOE � � �,,0�'O000 . EXCESS L, B CLAIMS MADE 6/3012021 6/30/2022 f AGGRECr,N�,TE 5, 000 000 ...� DED X I RETENTI NO EMPLOYERS"LIABILt'61" _. .�.,.,__... .. COMPENSATMX.. I. ...._....... _.. H f�T4(.TE.,. ..: I ,ANY PROrnaRIEt¢�p�?. RrEXCLUDED? E kJTI�VL YNsI NIA X AWC219911 (Mandatory ld! "—''-` ..WORKERS .. 12/1/2021 12/1/2022 r ,L EACH A,CCIbCNfi,... is - I I 1,000,000 �'F If as describe I �„E:.L OVSEAS EA MP'LOYEIE ..... 1,0106 yy under DESCRIPTION OF OPERATIONS below .,.... r .. E:,L. (DISEASE • POLICY LIMIT I S m' , .„..... I., 1,000,000'! DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Acacia Park. City of EL Segundo is included as Additional Insured per the terms of the attached CG2010 0413/CG2037 0413 Endorsements Waiver of Subrogation applies per the terms of the attached WC 99 04 1 OC Endorsement. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of EL Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 ........... . ........ _ AUTHORIZED REPRESENTATIVE I ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: A0131960004 COMMERCIAL GENERAL LIABILITY CG20100413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURE - 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) ........................ __..................... __........ Any person or organization from whom you are required to waive your right to recover under a written contract or agreement in effect prior to any loss or damage Location(s) Of Covered Operations All locations per written contract, agreement or permit Description: All jobs performed that have a written contract, agreement or permit 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) designated above. 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. CG20100413 A0131960 Middlesex 1 00001 0000000000 21179 0 N 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 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 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. © Insurance Services Office, Inc., 2012 8057e680-5378-4a00-a372-bd3db60c7e1a Page 1 of 2 06/28/2021 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 applicable Limits of Declarations. shall not increase the Insurance shown in the Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 0413 A0131960 Middlesex 06/28/2021 POLICY NUMBER: A0131960004 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES O 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 Any person or organization you are required to add as All locations and jobs performed that have a written an contract, agreement or permit additional insured under a written contract or agreement in effect prior to any accident, injury, loss or damage 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 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". 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. CG 20 37 0413 A0131960 Middlesex 1 00001 0000000000 21179 0 N 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 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 applicable Limits of Declarations. © Insurance Services Office, Inc., 2012 493701c7-8b4b-47d2-b76e-Oc54d632e808 shall not increase the Insurance shown in the Page 1 of 1 06/28/2021 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 (priorto adjustments) All CA Operations 1016.00 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: 12/01/2021 PolicyNo.: LAWC219911 Endorsement No.: Insured: Land Forms Landscape Construction, Inc. Premium $ Insurance Company: Cypress Insurance Company Countersigned by WC990410C (Ed. 01-19)