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PROOF OF INSURANCE (2022 - 2022) CLOSEDDATE(MM/DD/YYYY) C"'R " CERTIFICATE OF LIABILITY INSURANCE -~" 1 12/22/2021 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 endorsements . PRODUCER ONT.CT KLC Global ftAME: Ismart One Insurance PHONE 02 Fes" (844) 210 2 Noy U CI ,19q,,,.A� ,. 0 (213) 335-3550 2501 E. Chapman Ave. P E-MAIL ADDRESS: nialn,@Ismartone.net ... ....... _ ..._,-_. INSURERS/ AFFOR GcovERAGE NAIL# ...... ........ Fullllerton CA 92831 .-----___ ---- . _____-.._ INSURERA UNITED NATL INS CO 13064 INSURED nusuReaB: PROGRESSIVE COMMERCIAL PROGRESSL .. .. ..............---- ---- Union ion CompanyINSURERD c FALLS LAKE FIRE & CASUALTY COMPANY ... ....... - I 15884 1232 N. PacfictAve R Kinsale Insurance Company C H INSURERE ... .. ... ..... ------- Glendale CA 91202 INSURERF; COVERAGES CERTIFICATE NUMBER- RFVlglrlfd NIIMRFP- 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. OLI � Y rM0iMO11�ACCVY'M'EYXY"PY T LIMITS ILTR._.._,'. ------- TYPEOFINSURANCE .--- 44CIOG.� 1➢Ali.-..INFID POLICXNUMBER-�..kPOLICY CO MMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE �XOCCUR AMAGS "I0_RSh Sff �_IY OOO,., ..... q Y person)... A X CST0001756 03/21/2021 03/21/2022 . PERSONAL & ADV INJURY $ .1,000.000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- . �. POLICY Ll JEC..T LOC ,PRODUCTS COMP/OPAGG $ 2,000,000 _ OTHER, HER, $ IAUTOMOBILE LIABILITY 4ANY COMBINED L LIMlq F"� acI" oD.,$ 1,000,000 tp - -- — AUTO BODILY INJURY (Per person) $ B AO OS ONLY ✓"� AUTOSULED 082655706 09/30/2021 09/30/2022 µB U ........ ---- ------------ BODILY INJURY (Per accident) $ HIRED NON -OWNED ___-- AUTOS ONLY ..._.-... AUTOS ONLY —z- ----- ------- --- i�ItOPER7'Y^�IAMAi'f' $ Per,cnderri I UMBRELLA LIAB X OCCUR j � �, OCCU RRENCE O 1 OOO OOO . EGGREGATE ` C �X I EXCESS LIAB CLAIMS MADE 111 X TBD 12/22/2021 12/22/2022 AACH $ 000 0 0 - ------ DED RETENTION $ M $ WORKERS COMPENSATION %� I ST TU EORH EMPLOYERS' LIABILITY Y.l ANY Ebelow E ,wI _ 00 C EXCLUDED? YN � N / A FLA011765-02 06/01/2021 06/01/2022 EL AccI (Mandatory in NH) oISEAEACH .EOO describe under.�: DIf ESCRIPTION PTION OF OPERATIONS E.L DISEASE -POLICY LIMIT ITE $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) The certificate holder is named as an additional insured to the policy. The waiver of Subrogation wording and primary and non contributory endorsement is included. Project Location: Civic Center Maintenance and Repair Project 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. 350 Main Street AUTHORIZED REPRESENTATIVE ElSegundo CA 90245 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 20 33 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL AL INSURED - OWNERS, LESSEES O CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN A WRITTEN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured 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. However, the insurance afforded to such additional insured: 1. Only applies to the extent permitted by law; and 2. Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: 1. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or the failure to render any professional architectural, engineering or surveying services. CG 20 33 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to SECTION IV -CONDITIONS, Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us: We waive any right of recovery we may have against a person or organization because of payments we make for injury or damage arising out of your ongoing operations or "your work" and included in the "products completed operations hazard" provided you have agreed to do so in writing in a contract or agreement with that person or organization. All other terms and conditions of the policy apply. EPA-1719 (01/2014) Includes copyrighted material of ISO Commercial Risk Services, Page 1 of 1 Inc. with its permission. Copyright, ISO Commercial Risk Services, Inc. COMMERCIAL GENERAL LIABILITY CG 20 01 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following; COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84 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 2ww5% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Blanket Waiver of Subrogation As respects to all CA jobs performed by the named insured during the policy period where by written contract a waiver of subrogation is required prior to the commencement of work. 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 06-01-2021 Policy No. FLA011765-02 Endorsement No.. Insured Insurance Company Shin, Paul (An Individual) Falls Lake Fire & Casualty Company CountersignedBy_................................................................... ©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved.