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PROOF OF INSURANCE (2025)AC40Rt)r CERTIFICATE OF LIABILITY INSURANCE [!ATE'MMIDDIYYYY) 3/5/2024 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(es) must have ADDITIONAL INSURED provisions or be endorsed.. If SUBROGATIONIS 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 endorsoment(s). PRODUCER Lita'ert Mutual Insurance Co. Nat'l Ins Northeast 500 rNd St, Suite 300 Wausau, WI 54403 'CONTACT PPHONE FAx AI.C_Nt_EX0 ac Na: E-MAIL diDDRE s: CMeCertProduction Llbert Mutual.com (S) AFFORDING COVERAGE NAIL It wwwINSURER bertyMutual,aom INSURER A : Liberty(Mutual Fire Insurance Company 23035 INSURED NSURE SULLY -MILLER CONTRACTING COMPANY INSURER.B: LM Insurance Corporation 33600 INSURERC: 135 S, State College Blvd, Suite 400 Brea CA 92821 INSURER.D INSURERE: INSURER F ». 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. INSR LTR TYPE OF INSURANCEINSD ADDLSUBR WVDPOLICY NUMBER M DDfYYYY POLICY LIMITS A „/ COMMERCIAL GENERAL LIABILITY y+` ' TB2-631-510805-024 4/1/2024... 4/1/2025 EACH OCCURRENCE S2 000000 CLAIMS -MADE OCCUR DAMAGE TO RENTED �� PREMISES Ea occurrence S500,000 Per J'ob Aggregate MED EXP (Any one person) 510 000 Includes XCU ''. PERSONAL & ADV INJURY $2,000 000 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 GEN'L POLICY �I 1:1 ECOT LOC PRODUCTS - COMP/OP AGG $2 000 000 $ OTHER- A AUTOMOBILE LIABILITY ✓ AS2-631-510805-014 4/1/2024 4/1/2025 COMBINED SINGLE LIMIT Ea accident S 2,000„000 ANY AUTO BODILY INJURY (Per Person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY (INJURY Per accident I I S HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident _S 5 UMBRELLA LIAR OCCUR. EACH OCCURRENCE 5 AGGREGATE S EXCESS LIAR CLAIMS -MADE.. DED RETENTION S S B WORKERS COMPENSATION AND EMPLOYERS' WC5-631-510805-034 4/1/2024 4/1/2025 ✓ STATUTE ERH LIABI.LIITY YIN COVOrS All Slate's E.L. EACH ACCIDENT 51,000,000 ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMaEREXCLUDED't E N1A E.L. DISEASE - EA EMPLOYEE S 1 �QQO (Mal dotoryin—, It yyes„ describe under E.L. DISEASE - POLICY LIMIT I S 1,000,000 DESCRIPTION OF OPERATIONS below A Automobile Physical Damage: 10805-014 4/1/2024 4/1/2025 `* All Medium, Heavy, Extra HeavyF. EndraTypes Camp & Coll Deds: $1,500 All Private Passengers, nd Vans Comp & Coll Deds: $500 DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: El Segundo Boulevard Improvement Project / Project No.: PW 29-02 See Addendum" +.+HiwLCLLl-4 I l AJIV Job10290474 Cuty of El Segundo Public Works Department - Engineering Division 359 Main Street El Segundo CA 9'0245 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE Diane Beaudoin U 19W-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 78955929 13-00.1090 14/24-4/25 - Sully Miller I Julie Nelson 13/5/2.024 5.:211:53 PM (Es,r) I page 1 of 2 I= AGENCY CUSTOMER ED: 3-004090 LOG A: Page of AGENCY NAMED INSURED Liberty Mutual Insurance Co. Nat'l ins Northeast SULLY-MlILLER CONTRACTING COMPANY 135S. State College Blvd. Suite 400 POLICY NUMBER Brea CA 92821 CARRIER NAIL CODE EFFECTIVE DATE: . ... ... ............. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability (03/16) HOLDER: City of El Segundo Public Works Department - Engineering Division ADDRESS: 350 Main Street Ell Segundo CA 90245 RE: El Segundo Boulevard improvement Project / Project No.: PW 23-02 The City of El Segundo and its officers, officials, employees and volunteers is/are additional insured with regards to general liability and automobile liability, as their interest may appear, where required by written contract. Coverage is primary and non-contributory,. Waiver of Subrogation is included in favor of the certificate holder on general liability, workers compensation and automobile liability, and applies only to the specific jobs of the insured performed under written contract, and where applicable by law, 30-day Notice of Cancellation, except for 10-day Notice of Cancellation for nonpayment of premium. A%,VKLJ I U-1 kzuuoru 1) (9) 2008 ACORD CORPORATION, All rights reserved, The ACORD name and logo are registered marks of ACORD ADDENDUM 76955919 1 3-004090 1 4/211-4/25 - Sully Miller I Julie Nelson 1 3/5/2024 5;24:53 PM (EST' I Page 2 of 2 Policy Number T62-631-510805-024 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRODUCTS/COMPLETED OPERATIONS COVERAGE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Name of Additional Insured Persoin(s) or Organ ization(s): City of El Segundo, its officers, officials, employees and volunteers Schedule Location of Covered Operations: El Segundo Boulevard Improvement Project Project No.: PW 23-02 A. Section 11 — Who Is An Insured is amended to include as an additional insured-. 1. Any person or organization where required by a "written contract" you have entered into where the contract requires the entity to be added as an additional insured under your Policy; and 2. The particular person or organization, if any, shown in the Schedule of this endorsement at the location(s) shown in the Schedule above, B. The insurance provided to the additional insured is limited as follows: 1. The 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 the acts or omissions of those acting on your behalf, in the performance of your ongoing operations specified in the "written contract"; or b. "'Your work" that is specified in the "written contract" but only for "bodily injury" or "property damage" included in the "products -completed operations hazard", and only if: (1) The "written contract" requires you to provide the additional insured such coverage; and (2) This Coverage Part provides such coverage, 2. If the "written contract" specifically requires you to provide additional insurance coverage via; a. The 10101 edition of CG201 0 (aka CG 20 10 10 01); b. The 10/01 edition of CG2037 (aka CG 20 37 10 01),- or c. The 11/85 edition of CG2010 (aka CG 20 10 11 85), then in Paragraph 13.1. above, the words "caused, in whole or in part, by" are replaced by the words "arising out of'. 3. We will not provide the additional insured any broader coverage or any higher limit of insurance than: a. The maximum permitted by law„ LID 20 116 01 20 to 2020 Liberty Mutual insurance Page 1 of 3 Includes copyrighted material of Insurance Services Office, Inc., with its permission. b. That is required by the "written contract"; c. That is described in B.I. above; or d. That is afforded to you under this Policy, whichever is less. 4. Notwithstanding anything to the contrary in Condition 4. Other Insurance of Section IV — Commercial General Liability Conditions, this insurance is excess over all other insurance available to the additional insured, whether on a primary, excess, contingent or any other basis. But if required by the "written contract" to be primary and non-contributory, this insurance will be primary and non-contributory relative to insurance on which the additional insured is a Named 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: a. The rendering of, or the failure to render, any professional architectural, engineering, or surveying services, including-. (1) The preparing, approving, or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and (2) Supervisory, inspection, architectural or engineering activities; or b. Any premises or work for which the additional insured is specifically listed as an additional insured on another endorsement attached to this Coverage Part. C. Section IV — Commercial General Liability Conditions is amended as follows: 1. The Duties In The Event Of Occurrence, Offense, Claim Or Suit condition is amended to add the following additional conditions applicable to the additional insured: An additional insured under this endorsement will as soon as practicable: (1) Give us written notice of an "occurrence" or an offense which may result in a claim or "suit" under this insurance, and of any claim or "suit"' that does result; (2) Except as provided in Paragraph B.4. of this endorsement, make available any other insurance the additional insured has for a loss we cover under this Coverage Part; (3) Send', us copies of all legal papers received, and otherwise cooperate with us in the investigation, defense, or settlement of any claim or "suit"; and (4) Tender the defense and indemnity of any claim or "suit" to any other insurer or self insurer whose policy or program applies to a loss we cover under this Coverage Part. But if the "written contract" requires this insurance to be primary and non-contributory, this provision (4) does not apply to insurance on which the additional insured is a Named Insured. We have no duty to defend or indemnify an additional insured under this endorsement until we receive from the additional insured written notice of a claim or "suit". D. Only for the purpose of the insurance provided by this endorsement, Section V — Definitions is amended to add the following definition: "Written contract" means a written contract or written agreement that requires you to make a person or organization an additional insured on this Coverage Part, provided the contract or agreement: 1. Is currently in effect or becomes effective during the term of this Policy; and LD 20 116 01 20 @ 2020 Liberty Mutual Insurance Page 2 of 3 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 2. Was executed prior to: a. The "bodily Injury" or "'property damage"; or lb. The offense that caused the "personal and advertising injury", for which the additionaI insured seeks coverage under this Coverage Part. All other terms and! conditions of the Policy remain unchanged. LD 20 116 01 20 @ 2020 Liberty Mutual Insurance Page 3 of 3 Includes copyrighted material of Insurance Services Office, Inc., with its permission. COMMERCIAL GENERAL LIABILITY CG2OO112f9 This endorsement modifies insurance providedumderthe following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART PROD UCTSfC0KHpLETEDOPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in acontract or Condition and supersedes any provision to the agreement that this insurance would be oontmar)r primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the This insurance is primary to and will not seek additional insured. contribution from any other insurance available to an additional insured under your policy provided (1) The additional insured ismNamed Insured under such other inauramce-,ond CG 20 01121S @|msmramce Services Office, |nc,2Q18 Page 1of1 P0805-024 COMMERCIAL GENERAL LIABILITY CG 20 12 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR GOVERNMENTAL AGENCY OR SUBDIVISION OR POLITICAL SUBDIVISION - PERMITS OR AUTHORIZATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART E-1143:1:01111 State Or Governmental Agency Or Subdivision Or Political Subdivision: City of El Segundo, its officers, officials, employees and volunteers I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. I A. Section 11 — Who Is An Insured is amended to include as an additional insured any state or governmental agency or subdivision or political subdivision shown in the Schedule, subject to the following provisions: 1. This insurance applies only with respect to operations performed by you or on your behalf for which the state or governmental agency or subdivision or political subdivision has issued a permit or authorization. However: a. The insurance afforded to such additional insured only applies to the extent permitted by law; and b. 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, 2. This insurance does, not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the federal government, state or municipality; or b. "Bodily injury" or "property damage" included within the ""products -completed operations hazard". 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. Requiired by the contract or agreement; or 2. Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. CG 20 12 1219 @ Insurance Services Office, Inc,, 2018 Page 1 of 1 POLICY NUMBER: TB,2-601-510805-024 COMMERCIAL GENERAL LIABILITY CG 24 04 12 1' 9 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. V This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION (LIABILITY LIMITED COVERAGE PARTS DESIGNATED SITES P'RODUCTSICOMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHIEDULE e Of Person(s) Or Organ ization(s): El Segundo Boulevard Improvement Project 1 Project No.: PW 23-02 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The fallowing is added to Paragraph 8. Transfer of Rights Of Recovery Against. Others To Us of Section IV — Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss, This endorsement applies only to the persons) or organization(s) shown in the Schedule above. CG 24 0412 19 C Insurance Services Office, Inc., 2018 Page 1 of I This endorsement modifies insurance, provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Project(s)- El Segundo Boulevard Improvement Project / Project No.: PW 23-02 Information required to coMlete this Schedule, if not shown above, will be shown in the Declarations, A. For all sums which the insured becomes legally 3. Any payments made under Coverage A for obligated to pay as damages caused by "occur- damages or under Coverage C for medical ex- rences" under Section I — Coverage A, and for all penses shall reduce the Designated Construe - medical expenses caused by accidents under tion Project General Aggregate Limit for that Section I — Coverage C, which can be attributed designated construction project. Such pay - only to ongoing operations at a single designated ments shall not reduce the General Aggregate construction project shown in the Schedule above: Limit shown in the Declarations nor shall they 1. A separate Designated Construction Project reduce any other Designated Construction General Aggregate Limit applies to each des- Project General Aggregate Limit for any other ignated construction project, and that limit is designated construction project shown in the equal to, the amount of the General Aggregate Schedule above, Limit shown in the Declarations, 4,. The limits shown in the Declarations for Each 2. The Designated Construction Project General Occurrence, Damage To Premises Rented To Aggregate Limit is the most we will pay for the You and Medical Expense continue to apply. sum of all damages under Coverage A, except However, instead of being subject to the Gen - damages because of "bodily injury" or "prop- eral Aggregate Limit shown in the Declara- erty damage" included in the "products-com- tions, such limits will be subject to the applica- peted operations hazard", and for medical ex- ble Designated Construction Project General penses under Coverage C regardless of the Aggregate Limit. number of:. a. Insureds„ b. Claims made or "suits" brought; or c. Persons or organizations making cliaims or bringing "suits", CG 25 03 05 09 @ Insurance Services Office, Inc., 2008 Page 1 of 2 E3 B. For all sums which the insured becomes legally C. obligated to pay as damages caused by "occur- rences" under Section I — Coverage A, and for all medical expenses caused by accidents under Section I — Coverage C, which cannot be at- tributed only to ongongi operations at a single des- ignated construction project shown in the Sched- ule above: 1. Any payments made under Coverage A for damages or under Coverage C for medical ex- D. penses shall reduce the amount available un- der the General Aggregate Limit or the Prod- ucts -completed Operations Aggregate Limit, whichever is applicable; and 2. Such payments shall not reduce any Desig- nated Construction Project General Aggregate Limit. When coverage for liability arising out of the "prod- ucts -completed operations hazard" is provided, any payments, for damages because of "bodily in- jury" or "property damage" included in the "'prod- ucts -completed operations hazard" will reduce the Products -completed Operations Aggregate Limit, and not reduce the General Aggregate Limit nor the Designated Construction Project General Ag- gregate Limit. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contracting par- ties deviate from plans, blueprints, designs, spec- ifications or timetables, the project will still be deemed to be the, same construction project. E. The provisions of Section III — Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. Page 2 of 2 C Insurance Services Office, Inc., 2008 CG 25 03 05 09 Policy Number T62-6311-510805-024 Issued by Liberty Mutual Fire Insurance Co. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF-IIINSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR. LIABILITY COVERAGE PART COMMERCIAL LIABILITY — UMBRELLA COVERAGE FORM Schedule NameoOt� her Person(s) f Orf f Email Address or mailing address: Number lays Notice: City o El Segundo Public Works Dept. 350 Main Street El Se undo, CA 90245 30 Engineering Division A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organiizatioins shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 @ 2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc„ with its permission. Policy Number: AS2-631-510805-014 Issued! by: Liberty Mutual Fire Insurance Co. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIERS COVERGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the, provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "'insureds" under the Who Is An Insured Provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage form. Schedule Name of Person(s) or Organizations(s): The City of El Segundo, its elected officials, officers, employees and volunteers Regarding Designated Contract or Project: All Operations of the named insured performed under written contract or agreement Each person or organization shown in the Schedule of this endorsement is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section 11 of the Coverage Form. The following is added to the Other Insurance Condition: If you have agreed in a written agreement that this policy will be primary and without right of contribution from any insurance in force for an Additional Insured for liability arising out of your operations, and the agreement was executed prior to the "'bodily injury" or "property damage", then this insurance will be primary and we will not seek contribution from such insurance. AC 84 23 08 11 (D 2010. Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc. with its permission, POLICY NUMBER: AS2-631-510805-014 This endorsement modifies insurance provided under the following. AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM COMMERCIAL AUTO CA 20 48 110 13 With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organizati:lon(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. SCHEDULE Name Of Person(s) Or Organization (s): City of El Segundo, its officers, officials, employees and volunteers Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section 11 — Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I — Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 10 13 C Insurance Services Office, Inc., 2011 Page 1 of 1 POLICY NUMBER; AS2-631-510805-014 This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM COMMERCIAL AUTO CA O4 44 10 13 With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement, Name(s) Of Person(s) Or Organ ization(s): ,City of El Segundo, its officers, officials, employees and volunteers Information required to comlete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "'loss" under a contract with that person or organization. CA 04 44 10 13 C Insurance Services Office, Inc., 2011 Page 1 of 1 Policy Number AS2-631-510805-014 Issued by Liberty Mutual Fire Insurance Co. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF -INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL LIABILITY —UMBRELLA COVERAGE FORM Schedule Name of Other Person(s,) 1 Organizati Email Address or mailing address: Number Days Notice: City of El SCgLIM30 Public Works Dept. — Engiaecring Div. 350 Main Street Et Segundo, CA 90245 30 A. If we cancel'! this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above, We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 C 2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. NOTICE OF CANCELLATION TO THIRD PARTIES A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule below. We will send notice to the email or mailing address listed below at least 10 days, or the number of days listed below, if any, before cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy, Name of Other Person(s) Organization(s): City of El Segundo SCHEDULE Email Address or mailing address: 350 Main Street Public Works Dept. — Engineering Division El Segundo, CA 90245 All other terms and conditions of this policy remain unchanged. Issued by For attachment to Policy No, VVC5-631-510805-034 Effective Date 04101/2024 Issued to WC 99 20 7'5 @ 2016 Liberty Mutual Insurance Ed. 12/01/2016 Numibe,r Days Notice: Premium $ M4 Page 1 of 1 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 O% of the California workers' compensation premium otherwise due on such remuneration. Schedule [Additional premium is a percent of the California Manual Workers Compensation premium. Subject to a minimum premium charge of $ 0] Person or Organization City of El Segundo, its officers, officials, employees and volunteers Issued by Co 2 - Liberty Mutual Fire Insurance Company Job Description El Segundo Boulevard Improvement Project Project No,: PW 23-02 For attachment to Policy No, WC5-631-510805-034 Effective Date 04/01/2024 Issued to WC 04 03 06 R1 Ed, 08/2013 Premium $ Page I of 1