Loading...
PROOF OF INSURANCE (2024) CLOSEDRCSIN-1 OP ID- MN ACOR CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY)04/03/2'024 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 760-471-7116 CRNTACT Michelle Nowell Alliance Mgt, & Insurance Sery PHONE 760-471 7116 FAX 760-471-9378 '355 Via Vera Cruz #7 IAfC N, Ext)s LAmw ra�l .. CA Agent/Broker Lic# 0737966 oDN'sS, mnowell amiscorp.com 'San Marcos, CA 92078 Michelle A. Nowell INSURERI$) AFFORDING COVERAGE NAIL P INSURER A: Peleus Insurance Company 34118 4189 nvestilaations at+ u E a- s1� INSURER C INSURER D INSURER E INSURER F ^^%J0nA^E!0 hCCi'T"I,.,C'In A'rC K111AA000- pic blight lid tillI IRFR'.. 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, ........LIMITS _... INSR' TYPE OF INSURANCE. ADDL S4dBR POLICY NUMBER........ LIS 006CY EFF POLL Y SX.P ..... A X COMMERCIAL GENERAL LIABILITY EAuH OCCURRENCE E 5 1,000,000 cLAIMs-MADE X OCCUR X PKV0000663 L Ait AGL rO RLN I"90 06/1912023 06/1912024 �yRt�laE Ian ��Ir r��l 100,000 X Errors & Omission MI;Ee rwx.lA,:lv.mhe .,;, 5,000 11000,000 PERSONAL S AOV NNJURY S 4„000„000 GEN L AGGREGAIE LIMIT APPLIES PER: GENERAL A.I�"GRE9'.rATE, ,S..... _X POLICY -..... PRO— .. LOC JECT PRODUCTS - COMP/OP AGG S 1,000,.000 OT IHER A COMBINED SINGLE. LIMIT 1,,000,000 AUTOMOBILE LIABILITY (Ea actidenq , S r�aIN'Y �u.I R) PKV0000663 06/19/2023 06/19/2024 F��"l:(IV INJI, Y (P+na pvsgpJ z s, _ _. OWNED SCHEDULED AUTOS 014'If' AUTOS BODILY INJURY I,'Pw accident}. $ _ I\i1RIFS AIITNOT"aC1 LCYPERAtl�tlAOE $.__.. (::aIMVi a .X _. A UMBRELLA LIAB X OCCUR , EACH OCCURRENCE _.. S ... 1,000„000 X EXCESS LIAB — CLAIMS -MADE UMV0000182 ..... 06/19/2023 06/19/2024 AGGREGATES 1,000„000 DED RETENTION $ WORKERS COMPENSATION PER OTH- STATUTE AND EMPLOYERS' LIABILITY Y' N NT , — ...-ER , ANY PROPRIETOR/PARTNER/EXECUTIVE NIA '..... E.L. EACH ACCIDENT $. OFFICER/MEMBER EXCLUDED? (Mandatory in NH) ------ I '.. E.L.. DISEASE - EA EMPLOYES $ If yes. describe under DESCRIPTION OF OPERATIONS below I L=..N DISEASE - POLICY LIMIT A Professional Liab PKV0000663 06/19/2023 06/19/2024 Occurence 1,000,000 Aggregate 4,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of El Segundo,, its directors, officers, employees, and, agents, are named as an additional insured with respects to the work performed by the named insured. Investigation, CA -- City of El Segundo Human Resources 350 S Main Street El Segundo, CA 90245 ACORD 25 (2016103) CITYELI 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 nwam ato;t � © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PKV0000663 COMMERCIAL GENERAL LIABILITY CIGL 79 03 18 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OFF 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 Blanket as required by valid written contract. Blanket as required by valid written contract. Additional Information: 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 or organization shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" arising out of: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your operations for the additional insured at the location shown in the Schedule. However: a. The insurance afforded to such additional insured only applies to the extent permitted by law; b. If coverage provided to the additional insured is required by a contract or agreement, the insurance CIGL 79 03 18 Includes copyrighted material of Insurance Services Office, Inc. Page 1 of 2 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; and c. Regardless of the date of occurrence or when the injury or damage first occurs or is first discovered, a person's or organization's status as an additional insured under this endorsement ends upon the earliest of: (1) The completion or termination of the contract or agreement between you and the additional insured for the location shown in the Schedule; (2) The date you cease actively performing operations for the additional insured at the location shown in the Schedule; or (3) The expiration or termination date of the policy or this endorsement. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to liability or damages for "bodily injury", "property damage", or "personal and advertising injury": 1. Caused by, arising from, or included in the "products -completed operations hazard"; 2. Arising out of the additional insured's sole negligence; 3. Arising out of work or operations performed by you that were completed prior to the effective date of this endorsement; or 4. Which continues or progressively deteriorates after you cease actively performing operations for the additional insured at the location shown in the Schedule, even if the injury or damage first occurred, or is alleged to have first occurred, during the course of your operations for the additional injured. C. Solely for purposes of this endorsement, the following definition is deleted in its entirety and replaced by the following: 1. ""Products -completed operations hazard": a. Includes all "bodily injury" and "property damage" occurring away from premises you own or rent and arising out of "your product" or "your work" except: (1) Products that are still in your physical possession; or (2) Work that has not yet been completed or abandoned. However, "your work" will be deemed completed at the earliest of the following times: (a) When all of the work called for in your contract has been completed; (b) When all of the work to be done at the location shown in the Schedule has been completed if your contract calls for work at more than one location; or (c) When that part of the work done at the location shown in the Schedule has been put to its intended use by any person or organization other than another contractor or subcontractor working on the same project. Work that may need service, maintenance, correction, repair or replacement, but which is otherwise complete, will be treated as completed. D. 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. CIGL 79 03 18 Includes copyrighted material of Insurance Services Office, Inc. Page 2 of 2 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: U I have and will maintain a certificate of consent of self -insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement with the City of El Segundo. Policy No. (_) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Name of Agent Policy Number Expiration Date Phone # (ZI certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with tho ovisio s or the a ment�wi11 automatically become void. Signature of Applicant Print Name Agreement for: �,' j ye Dated: Reviewed by: 4 Date