Loading...
PROOF OF INSURANCE (2022 - 2023) CLOSED (2)la DATE (MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 06/29/2022 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 I .,wM T KLC Global Ismart One Insurance 2501 E. Chapman Ave. #250 Fuller. --...................................................�............................. INSURED Paul P W Shin (Dba: Union Construction Company) 1692 Cordova Street., Los Angeles CA 90007 1 INSURER F : I r^1100Af-_CQ ur to ll:nr^ ATr_KIIIIIUI RFVICI[1NI PitimRFR• 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. EFF POLICCY Y _.... ....-i .. INS AOCIL 'hf FC POLICi NUMBER MM01 IJHC TYPE OF INSURANCE LIMITS COMMERCIAL GENERAL LIABILITY CO„ EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE x OCCUR �1}1�JIA6'�`ETO`AEN'rE --- PRg AeJ-- ..,. .......�. $--- ........................m....,,.......... -_....... .................. MED EXP (Any one person) 11­1..........., p $ 5,000 ......... A X X 01CPKP20049951-0 03/21/2022 03/2112023I PERSONAL a.novlN�URY $ 1,000,,000 .. m — — GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE _ $2 000000........ _m .. PRO: 1 PPOLICRY E E LOC PRODUCTS COMPIOPAGG .,... S _ 2,000,000 ..... ..._. _ $ AUTOMOBILE LIABILITY COMBINED SINGLE UMi „1Eatsccudeou _ $ 1,000,000 .......... ....... ._....- ._. ANY AUTO BODILY INJURY (Per person) $ B OWNED SCHEDULED X„ 082655706 09/30/2021 09/30/2022 INJURY (Per accident) $ AUTOBODILY AUTOS ,,...._. NON-OWNEDm'ROPERl""('' H REDS ONLY DAMAt" EI .. AUTOS ONLY �..... ,. AUTOS ONLY ,..(,Peraoddent ____ ...$,,, .-...........-__ -------- $ UMBRELLA AB OCCUR � EACH OCCURRENCE $ _ ..... ................- EXCESS pBIMS-MADE ...{_CLA AGGREGATE .. , ,..,. ..7 $ DED RETENTION $ $ WORKERS COMPENSATION X PER OTH AND EMPLOYERS' LIABILITY YIN ` 0 C ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? Y N/A X FLA011765-03 06/01/2022 06/01/2023 (Mandatory in NH) E L DISEASE EA EMPLOYEE ..........................................�...,..,-....-.-..... $ 1,000,000 U........, If es, describe under y DESCRIPTION OF OPERATIONS below E L .. DISEASE - POLICY LIMIT $ 1,000,000 BPP 10,000 Commercial Property D NN1365973 01/27/2022 01/27/2023 BI/EE 100,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The certificate holder is named as an additional insured to the policy. The waiver of Subrogation and Primary and Non -Contributory endorsement is included. CERTIFICATE HOLDER CANCELLATION 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 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 ATEGRITY SPECIALTY INSURANCE COMPANY ENDORSEMENT NO. ATTACHED TO AND FORMING A ENDORSEMENT EFFECTIVE NAMEDINSURED AGENT NO. PART OF POLICY NUMBER DATE (12:01 AM STANDARD TIME) 01-C-PK-P20049951-0 03/21/2022 Paul P Shin 0000002073 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERICAL GENERAL LIABILITY COVERAGE PART With respect to this endorsement, SECTION II —WHO IS AN INSURED is amended to include as an additional insured any person or organization whom you are required to add as an additional insured on this policy under a written contract, written agreement or written permit which must be: a. Currently in effect or becoming effective during the term of the policy; and b. Executed prior to the "bodily injury," "property damage," or "personal and advertising injury." The insurance provided to these additional insureds is limited as follows: i. That 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: a. Your acts or omissions; or b. The acts or omissions of those acting on your behalf. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. 2. With respect to the insurance afforded to these additional insureds, the following exclusions are added to item 2. Exclusions of SECTION I— COVERAGES: This insurance does not apply to "bodily injury," "property damage" or "personal and advertising injury" occurring after: a. 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 b. That portion of "your work" out of which the in- jury or damage arises has been put to its in- tended 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. 3. The limits of insurance applicable to the additional insured are those specified in the written contract, written agreement or written permit or in the Declarations for this policy, whichever is less. These limits of insurance are inclusive of, and not in addition to, the Limits of Insurance shown in the Declarations for this policy. 4. Coverage is not provided for "bodily injury," "property damage," or "personal and advertising injury" arising out of the sole negligence of the additional insured. 5. The insurance provided to the additional insured does not apply to "bodily injury," "property damage," or "personal and advertising injury" arising out of an architect's, engineer's or surveyor's rendering of or failure to render any professional services including: a. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, re- ports, surveys, field orders, change orders or drawings and specifications; and b. Supervisory, inspection, architectural or engineering activities. ASIC-GL-0028-0818 Page i of 2 6. Any coverage provided hereunder will be excess over any other valid and collectible insurance avail- able to the additional insured whether primary, excess, contingent or on any other basis unless a written contract specifically requires that this insurance be primary. When this insurance is excess, we will have no duty under SECTION I —COVERAGES to defend the additional insured against any "suit" if any other in- surer has a duty to defend the additional insured against that "suit." If no other insurer defends, we will undertake to do so, but we will be entitled to the additional insured's rights against all those other insurers. ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED. Includes some copyrighted material of Insurance Services Office, Inc., with its permission. AUTHORIZED REPRESENTATIVE / DATE ASIC-GL-0028-0818 Page 2 of 2 COMMERCIAL GENERAL LIABILITY CG 20 0104 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. iWol 0[$10 This endorsement modifies insurance provided under the following:. COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the additional insured. 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 CG 20 0104 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER:01-C-PK-P20049951-0 .:, This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Any person or organization with whom the insured has agreed to waive rights of recovery, provided such agreement is made in writing and prior to the loss Information reauired to comDlete this Schedule. if not shown The following is added to Paragraph B. 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. will be shown in the Declarations. CG 24 04 05 09 0 Insurance Services Office, Inc., 2008 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 2..5% 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 06-01-2022 Policy No. FLA011765-03 Endorsement No. Insured Insurance Company Shin, Paul (An Individual) Falls Lake Fire & Casualty Company Countersigned By ©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved.