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PROOF OF INSURANCE (2024) CLOSEDClient#: 164812 GMBUSIN
DATE (MMIDD/YYYY)
ACORD. CERTIFICATE OF LIABILITY INSURANCE 1 02/22/2023
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,,, .,,,,,,m__..........______ _ P Y( ) —
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the olic 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 any rights to the certificate holder in lieu of such endorsement(s).
PRODUCER N T Sue Nisoff
EPIC Insurance Midwest P€loi�._........................................IT^'FAX _....
(A/C, No Extj _ ----. ........
560 5th Street, Suite 202 E'isMA" .sue„It'➢stiff epicbrf kers.com
Grand Rapids, MI 49504......
INSURER(S) AFFORDING COVERAGE
INSURER A: National Union Fire Ins Co of Pittsburg 19445
INSURED INSURER B : New Hampshire Insurance Company 23841
Goforth 8r Marti Inc. dba GM Business........................................................................_.._._._._.
INSURER C
GM Business Interiors —_
7099 W. La Cadena Dr. INSURER D - ........... ----- - ..�.
INSURER E :
Riverside, CA 92601 _. ................
.....
...........................
_
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
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
CONTRACTOR
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.
LTR
_. TYPE OF INSURANCE
p
—
SUBR
w
POLICY NUMBER
ff
(I p 1lYiF^Fi)
.LICYEXP
(MM/DDIYYYY LIMITS
A
')( COMMERCIAL GENERAL LIABILITY
5180 177
3/01/2023
03/01/20241 EACH OCCURRENCE
$1 000 000
DAMAGE TO RENTED
$300 000
CLAIMS -MADE. OCCUR
PREMISES„(,Eaoccunence,,,,)„
MED EXP (Any one person)
s26,000
$1 09R 0Ot, 0 '..
.....
....-..
PERSONAL & ARV INJURY
._.,................
GEN L AGGREGATE LIMIT APPLIES PER
GENERAL AGGREGATE
$ 2L000OOO
PRt3- ❑
POLICY J�Et��T LOC
PRODUCTS COMP/OPAGG
-- ------.........�...
$2 000 000
1 .._-..L�w,_.
OTHER:
$
p
AUTOMOBILE LIABILITY
�
2961606........................ ..
__
3101/2023
COMBIINEDCSINGLE��LIMIG
03/01/202JBODILY
$1,000,000
X. ANY AUTO
ODILY INJURY (Per person)
$
OWNED SCHEDULED
AUTOS ONLY AS
INJURY (Per accident
._......
j $
$
.....
HIRED NON -OWNED
X
ROPERTY DAMAGE :
AUTOS ONLY AUTOS ONLY
P+sr q:kdpciC._ .___.....................................................................
UMBRELLA LIAB OCCUR
EACH OCCURRENCE
$
EXCESS LIAB E
CLAIMS -MAD
AGGREGATE
$
DED RETENTION $
$
A
WORKERS COMPENSATION
80756387
3I01/2023
PER OTH
03/01/202 X TI�Tmm.
.....---�...mm.._......
ANDEMPLOYERS'LIABILITY Y / N
�,,...�
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. EACH ACCIDENT
$1,OOQ Q00
EXCLUDED'
(Mandatory In NH)
NIA
E.L. DISEASE - EA EMPLOYEE
$1,000 0-00
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$1 000 000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Additional Insured with regard to the General and Automobile Liability on a primary and non-contributory
basis, as required by written contract - City of El Segundo. A Waiver of Subrogation applies
to the General Liability and Workers' Compensation policies where required by written contract in favor of
the additional insured.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City Of El Segundo — City Clerk ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street, Room 5
El Segundo, CA 90245-3813 AUTHORIZED REPRESENTATIVE
©1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD
#S5283549/M5283485 KWI01
POLICY NUMBER: GL 518-01-77
COMMERCIAL GENERAL LIABILITY
CG20100413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - 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) Location(s) Of Covered Operations
ANY PERSON OR ORGANIZATION WHOM YOU PER THE CONTRACT OR AGREEMENT.
BECOME OBLIGATED TO INCLUDE AS
AN ADDITIONAL INSURED AS A RESULT OF
ANY CONTRACT OR AGREEMENT YOU
HAVE ENTERED INTO.
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.
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.
CG 20 10 04 13 * Insurance Services Office, Inc., 2012 Page 1 of 2 0
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 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 ❑
POLICY NUMBER: GL 518-01-77
COMMERCIAL GENERAL LIABILITY
CG 20 37 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
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
WHOM YOU BECOME OBLIGATED
TO INCLUDE AS AN ADDITIONAL INSURED
AS A RESULT OF ANY CONTRACT OR
AGREEMENT YOU HAVE ENTERED INTO.
PER THE CONTRACT OR AGREEMENT,
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 agree-
ment, the insurance afforded to such addi-
tional insured will not be broader than that
CG 20 37 04 13
which you are required by the contract or
agreement to provide for such additional
insured.
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 Insu-
rance shown in the Declarations;
whichever is less.
This endorsement shall not increase the appli-
cable Limits of Insurance shown in the Decla-
rations.
0 Insurance Services Office, Inc., 2012
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Page 1 of 1 ❑
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POLICY NUMBER: GL 518-01 -77
COMMERCIAL GENERAL LIABILITY
CG 02 24 10 93
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
EARLIER NOTICE OF CANCELLATION
PROVIDED BY US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
LIQUOR LIABILITY COVERAGE PART
POLLUTION LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Number of Days' Notice 90
(If no entry appears above, information required to complete this Schedule will be shown in the
Declarations as applicable to this endorsement.)
For any statutorily permitted reason other than nonpayment of premium, the number of days required
for notice of cancellation, as provided in paragraph 2. of either the CANCELLATION Common Policy
Condition or as amended by an applicable state cancellation endorsement, is increased to the number
of days shown in the Schedule above.
CG 02 24 10 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 ❑
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POLICY NUMBER: GL 518-01-77 COMMERCIAL GENERAL LIABILITY
CG 20 01 04 13
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
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 contribu-
tion from any other insurance available to
the additional insured.
CG 20 01 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1
POLICY NUMBER: GL 518-01-77
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
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Person Or Organization:
PURSUANT TO APPLICABLE WRITTEN CONTRACT OR AGREEMENT YOU ENTER INTO,
1I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. 1
The following is added to Paragraph 8. Transfer Of
Rights Of Recovery Against Others To Us of Sec-
tion 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 opera-
tions 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 O Insurance Services Office, Inc., 2008 Page 1 of 1 ❑
ENDORSEMENT
This endorsement, effective 12:01 A.M. 03/01 /2023 forms a part of
policy No.GL 518-01-77 issued to GOFORTH & MART - DBA: GM BUSINESS INTERIORS
by NATIONAL UNION FIRE INSURANCE COMPANY OF P I TTSBURGH , PA
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
AMENDMENT OF LIMITS OF INSURANCE
(Per Project or Per Location Aggregate Limit)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
I. Your policy is amended to include either a Per Project General Aggregate Limit, a Per Location
General Aggregate Limit or a Per Project and Per Location General Aggregate Limit. Please select
only one of the following:
[XI Per Project General Aggregate Limit $ 2,000,000
[ 1 Per Location General Aggregate Limit $
[ 1 Per Project and Per Location General Aggregate Limit $
IF NEITHER OF THESE BOXES ARE CHECKED, THIS ENDORSEMENT IS VOID. IF MORE THAN ONE
OF THE THESE BOXES ARE CHECKED, THIS ENDORSEMENT IS VOID.
II. SECTION III - LIMITS OF INSURANCE , is amended to include the following-,
1. The Limits of Insurance and the rules below fix the most we will pay regardless of the
number of:
a. Insureds;
b. Claims made or "suits" brought; or
c. Persons or organizations making claims or bringing "suits".
2. The General Aggregate Limit is the most we will pay for the sum of:
a. Medical expenses under CoverageC;
b. Damages under Coverage A, except damages because of "bodily injury" or "property
damage" included in the products -completed operations hazard"; and
c. Damages under Coverage B.
3. The Products -Completed Operations Aggregate Limit is the most we will pay under
Coverage A for damages because of "bodily injury" and "property damage" included in the
"products -completed operations hazard".
4. Subject to 2. above, the Personal and Advertising Injury Limit is the most we will pay under
Coverage B for the sum of all damages because of all "personal and advertising injury"
sustained by any one person or organization.
5. Subject to 2. or 3. above, whichever applies, the Each Occurrence Limit is the most we will
pay for the sum of:
a. Damages under Coverage A; and
b. Medical expenses under CoverageC
86681 (9/04) Page 1 of 2
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because of all "bodily injury" and "property damage" arising out of any one "occurrence".
6. Subject to 5. above, the Damage to Premises Rented To You Limit is the most we will pay
under Coverage A because of "property damage" to any one premises, while rented to you,
or in the case of damage by fire, while rented to you or temporarily occupied by you with
permission of the owner.
7. Subject to 5. above, the Medical Expense Limit is the most we will pay under Coverage C
for all medical expenses because of "bodily injury" sustained by any one person.
8. Subject to 2., 4., 5., 6., and/or 7. above, the Per Project Aggregate Limit is the most we
will pay under Coverages A, B, and C combined for the sum of:
a. Damages under Coverage A;
b. Damages under Coverage B; and
c. Medical Expenses under Coverage C
arising out of any single Project described above.
9. Subject to 2., 4., 5., 6., and/or 7. above, the Per Location Aggregate Limit is the most we
will pay under Coverages A, B, and C combined for the sum of:
a. Damages under Coverage A;
b. Damages under Coverage B; and
c. Medical expenses under CoverageC
arising out of the any single Location described above.
The Limits of Insurance of this Coverage Part apply separately to each consecutive annual
period and to any remaining period of less than 12 months, starting with the beginning of the
policy period shown in the Declarations, unless the policy period is extended after issuance for
an additional period of less than 12 months. In that case, the additional period will be deemed
part of the last preceding period for purposes of determining the Limits of Insurance.
III. The Limits of Insurance shown in the Declarations are deleted in their entirety and replaced by
the Limits of Insurance set forth below.
Limits of Insurance
General Aggregate Limit
$
10,000,000
Each Occurrence Limit
$
1,000,000
Products -Completed Operations Aggregate Limit
$
2,000,000
Personal & Advertising Injury Limit
$
1,000,000
Damage to Premises Rented to You
$
300,000
Medical Expense Limit
$
25,000
Per Project General Aggregate Limit, Per Location
$
2,000,000
General Aggregate Limit or Per
Project and Per Location General Aggregate Limit
IV. SECTION V - DEFINITIONS, is amended to include the following:
23. "Location" means premises involving the same or connecting lots, or premises whose
connection is interrupted only by a street, roadway, waterway, or right-of-way railroad.
All other terms and conditions of this policy remain the same.
A+uth ri;zed Representative or
Countersie nature (in States Where
Appii'caC
86681 (9/04) Page 2 of 2
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ENDORSEMENT
This endorsement, effective 12:01 A.M. 03/01 /2023 forms a part of
policy No.CA 2961606 issued to GOFORTH & MART - DBA: GM BUSINESS INTERIORS
by NATIONAL UNION FIRE INSURANCE COMPANY OF P I TTSBURGH , PA
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - WHERE REQUIRED UNDER CONTRACT OR AGREEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
SCHEDULE
ADDITIONAL INSURED:
ANY PERSON OR ORGANIZATION FOR WHOM YOU ARE CONTRACTUALLY BOUND
TO PROVIDE ADDITIONAL INSURED STATUS BUT ONLY TO THE EXTENT OF SUCH
PERSON OR ORGANIZATIONS LIABILITY ARISING OUT OF THE USE OF A COVERED
AUTO.
I. SECTION II - LIABILITY COVERAGE, A. Coverage, 1. - Who Is Insured, is amended to add:
d. Any person or organization, shown in the schedule above, to whom you become obligated
to include as an additional insured under this policy, as a result of any contract or agreement
you enter into which requires you to furnish insurance to that person or organization of the
type provided by this policy, but only with respect to liability arising out of use of a covered
"auto". However, the insurance provided will not exceed the lesser of:
(1) The coverage and/or limits of this policy, or
(2) The coverage and/or limits required by said contract or agreement.
87950 (10/05)
Authorized Representative or
Countersi mature (in States Where
Applicabfe
Page 1 of 1
ENDORSEMENT
This endorsement, effective 12:01A.M. 03/01/2023 forms part of
policy No. CA 296-16-06 issuedto GOFORTH & MARTI - DBA: GM BUSINESS INTERIORS
by NATIONAL UNION FIRE INSURANCE COMPANY OF P I TTSBURGH , PA
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
INSURANCE PRIMARY AS TO CERTAIN ADDITIONAL INSUREDS
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
Section IV - Business Auto Conditions, B., General Conditions, 5., Other Insurance, c., is
amended by the addition of the following sentence:
The insurance afforded under this policy to an additional insured will apply as primary insurance
for such additional insured where so required under an agreement executed prior to the date of
accident We will not ask any insurer thathas issued other insurance to such additionalinsured to
contribute to the settlement of loss arising out of such accident.
All other terms and conditions remain unchanged.
l�
Authorized Representative or
Counters a nature (in States Where
Applicable
74445 (10/99)
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ENDORSEMENT
This endorsement, effective 12:01 A.M. 03/01 /2023 forms a part of
policy No. CA 296-16-06 issued to GOFORTH & MART I - DBA: GM BUS I NESS I NTER I ORS
by NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
Section IV - Business Auto Conditions, A. - Loss Conditions, 5. - Transfer of Rights of Recovery
Against Others to Us, is amended to add:
However, we will waive any right of recover we have against any person or organization with whom you have
entered into a contract or agreement because of payments we make under this Coverage Form arising out of
an "accident' or "loss" if:
(1) The "accident' or "loss" is due to operations undertaken in accordance with the contract existing
between you and such person or organization; and
(2) The contract or agreement was entered into prior to any "accident' or "loss".
No waiver of the right of recovery will directly or indirectly apply to your employees or employees of the
person or organization, and we reserve our rights or lien to be reimbursed from any recovery funds obtained
by any injured employee.
AUT''' ORIZED REPRESENTATIVE
62897 (6/95)
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BLANKET WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different
date is indicated below.
(The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy).
This endorsement, effective 12:01 AM 03/01/2023 forms a part of Policy No. WC 080-75-6387
Issued to GOFORTH & MARTI - DBA: GM BUSINESS INTERIORS
By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA.
We have a right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce
our right against any person or organization with whom you have a written contract that requires you to obtain this
agreement from us, as regards any work you perform for such person or organization.
The additional premium for this endorsement shall be 2.00 % of the total estimated workers compensation premium
for this policy.
WC 04 03 61 Countersigned by - - - - _ _, _ -, - - - _,. _ --
(Ed. 11/90)
Authorized Representative