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PROOF OF INSURANCE (2022 - 2023) CLOSEDID lFr Nliimhar, VARTOTTS Date Entered: 10/13/2022 DATE (MMIDDIYYYY) ✓CERTIFICATE OF LIABILITY INSURANCE 1 10/13/2022 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). eSilva PRODUCER q E (408)Diane D86- 334 .... . _Lido (4� _.. Mary Barnard Insurance PHONE eAX CONTACT ��ni m�08) 286 642 2190 Stokes Street E-MAIL ennie@barnardinsurance.com Suite 201 San Jose, CA 95128 INSURED Range Maintenance Services, L .°.. . Inance L.L.C. Donna Foggiato 303 McCloud Avenue Mt. Shasta, CA 96067 _ SURER#;S) AFFORDING t INSURERA: Evansto n Insurance RERc:STATE COMPENSATION INSURANC..... ND INSU E: _ Mlic # 35378 19232 35076 COVERAGES CERTIFICATE NUMbLK: ��• �,� . .� . �- 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, A EXCLUS IONS AND CONDITIONS OF SUCH POoLuICIES�eLIMITS SHOWN MAY HAVE BEEN R�ODI�OCY OD BY PAIDO C� LAIMS. '___. ._ LIMITS INTR TYPE OF INSURANCE POLICY NUMBER. M: Da"YYY MNTJRR"_ YYL COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE m 1 , 000 , 000 aMAGE^ 100 000 C�C1RRt NC,E $ s.tl'ol/zz/ol/zoz3 r _..°.� CLAIMS -MADE Ix OCCUR 3AA610874 PF�`�acvr.urrs:r,�J�. $�. MED F-XP An one erlran) $ 5 , 000 1 000 000 PERSONAL & AOV [NJUR'Y $ r � GEKL AGGREGATE LIMIT APPLIES PE 2 I 000 000 RCN-.m." PRODUCTS f,OM6lOPI4C�G R: 9.aENILIaA4 AgGRFgG $ U INCLDED OiHER: COMBINEDSfNLELIMIT $ 1, 000,0 .._. — 0 0 AUTOMOBILE LIABILITY B ANYAUTO 648827264 1$./1./2022 11/1/2023 BODILY INJURY (Per person) $,,,,,,, OWNED . SCHEDULED ( ) BODILY INJURY Per accident $ AUTOS ONLY AUTOS m._ PROPL,RTY IJ�fVkACxG $ HIRED NON -OWNED ,r a dcti1 AUTOS ONLY AUTOS ONLY UMBRELLA LIAB ]�OCCUR EACH OCCURRENCE S W....... EXCESS LIAB LMS-MADE $ AGGREGATE �......._.. �.......", OEIN � RE"CLN"'C'IfNN'$ PER Orfa• YIN 1760432 srA�N�E WORKERS COMPENSATION AND EMPLOYERS'LIABILITY EL EACAaC ID PMPLOYFE $.1,000,OOO C ANY PROPRIETOR/PARTNER/EXECUTIVE "'— NIA P.1�/Ol/22 1,.1.,/Dl/2023 •--w•••---• OFFICERIMEMBER ECCLUE $ 1, 0 0 0, 0 0 0 (Mandat" In NH) E L. EACHACCIDENT LIMIT $ __— . -- If yea. describe gander 1, 0 0 0, 0 0 0 DESCRII rDN OF OPERATIONS b0ow' DESCRIPTION OF OPERATIONS.I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) *TEN DAYS NOTICE OF CANCELLATION APPLIES FOR NON-PAYMENT OF PREMIUM 30 DAYS FOR ALL OTHER. RE: ALL CALIFORNIA OPERATIONS. CERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED. CERTIFICATE HOLDER CANCELLATION CITY OF EL SEGUNDO, CITY CLERK ATTENTION: BRIAN EVANSKI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS. EL SEGUNDO, CA 90245 AUTHORIZED REPRESENTATIVE, � �IW © 1988-2015 AGO S CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 3AA61 0874 COMMERCIAL GENERAL LIABILITY CG20100413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY ADDITIONAL f INSURED - OWNERS, LESSEES Of CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Blame Of Additional Insured Person(s) Or Organiat'ion(s) __ Information required to SCHEDULE this Schedule, if not shown A. Section Il — 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 Lability 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. Of Covered Operations will be shown in the Declarations. 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 worm" 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 III — Limits Of Insurance: CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 3AA610874 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 shall not increase the applicable Limits of Insurance shown in the Declarations. Page 2 of 2 0 Insurance Services Office, Inc., 2012 CG 20 10 04 13 HOME OFFICE SAN FRANCISCO ALLEFFECTIVE DATESAR£ AT 12:01 AM PACIFIC STANDARD TIME 09 THE TIME INDICATED AT PACIFIC STANDARD TIME .FAl0ORSFM12NT AGNEGMENT R- ROKER COPS' WAIVER OF SUBROGATION BLAMXET BASIS 1760432 RENEWAL NA 6--17--16-03 EFFECTIVE NOVEMBER 1,2021 AT 12.01 A.M. PAGE I OF 1 AND EXPIRING NOVEMBER 1,2022 AT 12.01 A.M. RANGE MAINTENANCE SERVICES, LLC 301 MARY BELLE WAY ANGELS CAMP, CA 95222 WE HAVE THE RIGHT TO RECOVER. OUR PAYMENTS VROM ANYONE LIABLE FOR AN INJURY COVERED BY THIS POLICY. WE WILL NOT ENFORCE OUR RIGHT AGAINST THE PERSON Olt ORGANIZATION MANED IN THE SCHEDULE. . THIS AGREEMENT APPLIES ONLY TO THE EXTENT THAT YOU PERFORM WORK UNDER A WRITTEN CONTRACT THAT REQUIRES YOU TO OBTAIN THIS .AGztEWWT F'RO21 US, THE ADDITIONAL PREMIUd FOR THIS ENDORSEMENT 8"LL BE 2.00% OF THE TOTAL POLICY PREMIUM, SGNEDULE PERSON OR ORGANIZATION SOB DESCRIPTION ANY PERSON OR ORGANIZATION BLANKET WAIVER OF FOR WHOM THE NAMED INStRED SUBROGATION HAS AGREED BY WRITTEN CONTRACT TO FORNTSFI THIS WAIVER NOTHING IN THIS ENDORSEMENT CONTAINED SHALL B£ HELD TO VARY, ALTER, WAiV6 OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED, NOTHING ELSEWHERE IN THIS POLICY SHALL HE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIQNS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUE) AT SAN FRrAWSCO: NOVEMBER 1 2021 AU'llIOT417R) HEPR F NTA '6 PRF l0EKr AND CFO 2572