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PROOF OF INSURANCE (2025 - 2025)DATE (MMIDDIYYYY) A4C"Rai CERTIFICATE OF LIABILITY INSURANCE ,✓'"' 10/22/2024 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(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 CONTACT NAME, Heidi Farmanl SIP Insurance Services - Orange PHONE rAx --- 750 The City Drive South, 450 t�d..6* .1 ast jg11j365 5tk Np 626-564-65Ei5 E—MAIL Orange CA 92868 awrpDr,sIdm�sk�rcroers corm A: T I")�f2.pf?;.4r#N..D.�!..��gr�. _,INS,URERray .....,....."...,ra, INSURED BACKAPP-01 INSURER B: T..... 20435 S. Susana Road )NSURER a Long Beach CA 90810 INSURERD__ INSURER E : INSURER F COVERAGES CERTIFICATE NHMRFR-Q1ARA'7FAA RFi/'ISInM NIIMIRF'R'- 25674 25682 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. ILTR ......NSR,.... .. ._....... ....... AOO I., q%.. .. .. ."."...... 06cf 'reff" 0b.01CY-E.x-P -...... ....... ----...... .......". ... POLICY.... TYPE OF INSURANCE LIMITS NUMBER MMlON7�P"M"A''YY MMA17�DfYYYY A X J COMMERCIAL GENERAL LIABILITY Y 630BJ664090 10/31/2024 10/31/2025 EACH OCCURRENCE $ 1,000,000 mm ...- ..... .�-1 CLAIMS -MADE X OCCUR PREM,I$E_$_(Fa occurr�ce) $ 300,000 .. ._ ............ MED EXP (Any o one person) " $ 5, 000 PERSONAL 8 ADV INJURY $ 1,000 000 c GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 I..................... POLICY X ] PE� I LOC ....... ................ ..,........... ._ -.. PRODUCTS - COMP/OP AGG $ 2.000.000 _ OTHER, B AUTOMOBILE ...................... LIABILITY BA714173419 10/31/2024 10131/2025 COMBINEOSINUEFT1IMIT .-('fin ac�GldilRp)�. ............. $1,000000 ........ ........... ".. X ANY AUTO BODILY INJURY (Per person) ''..... $ OWNED SCHEDULED '.. AUTOS ONLY AUTOS .BODILY INJURY (Per accident) .... $ X... HIRED WNED __. A'ROPERT'no AOE $ ....... . AUTOS ONLY ....X.. AUUTOS ONLY � F'dr acaudctnt]� A UMBREA.B...X.O CUP9J209005 10/31/2024 10/31/2025 .. OCCURRENCE m..- ....... �,....... EXCESS J LAIMS MADE .... AGGREGATE $5.000,000 l q.LALI. DED 4 RETENTION $ m „•000.000 $ ....�._ A WORKERS COMPENSATION Y UB-3R155740 8I27I2024 8127l2025 X $TATIITE �._ER �RH AND EMPLOYERS' LIABILITY Y / N - -"- ANYPROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $ 1 000 000 0 OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) N/A ""'"'" E.L DISEASE - EA EMPLOYEE $ 1,000,00'0 If yes, describe under __ DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1 ,OOQ000 A Property 630BJ664090 10131/2024 10131/2025 Bus Personal Property Included DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Subject to all policy terms, exclusions and conditions. RE: Annual testing and maintenance of backflow devices; City of El Segundo is an Additional Insured with respects to attached General Liability endorsement if required by written contract. Attached Workers Compensation Waiver of Subrogation endorsement applies to City of El Segundo if required by written contract. ER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. Public Works Dept. 350 Main St. El Segundo CA 90245 AUTOO IEO REPRESENTATIVE United States �,�"e l ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 6308J664090 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. XTIIII IIII:,,:,,:,,:,ND0RSEME1YT MIR MANUF'ACI UIZERS AND 1 WH01111 ESAL1:,,,:,,:,,�,RS Z GENERAL DESCRIPTION OF COVERAGE — This endorsement broadens coverage. However, coverage for a injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded limited by another endorsement to this Coverage Part, and these coverage broadening provisions do not apply the extent that coverage is excluded or limited by such an endorsement. The following listing is a gene coverage description only. Read all the provisions of this endorsed ment anthe rest of your policy careftuilly determine rights, duties, and what is and is not covered. I A. Who Is An Insured —Unnamed Subsidiaries B. Who Is An Insured — Employees And Volunteer Workers — Bodily Injury To Co -Employees And Co -Volunteer Workers C. Who Is An Insured — Newly Acquired Or Formed Limited Liability Companies D. Blanket Additional Insured — Broad Form Vendors E. Blanket Additional Insured —Controlling Interest F. Blanket Additional Insured — Mortgagees, Assignees, Successors Or Receivers G. Blanket Additional Insured — Governmental Entities — Permits Or Authorizations Relating To Premises PROVISIONS A. WHO IS AN INSURED — UNNAMED SUBSIDIARIES The following is added to SECTION 11 — WHO IS ANINSURED: Any of your subsidiaries, other than a partnership or joint venture, that is not shown as a Named Insured in the Declarations is a Named Insured a. You are the sole owner of, or maintain an ownership interest of more than 50% in, such subsidiary on the first day of the policy period; and ' b. Such subsidiary is not an insured under similar other insurance. No such subsidiary is an insured for "bodily injury' or "property damage" that occurred, or "personal and advertising injury" caused by an offense committed: H. Blanket Additional Insured — Governmental Entities — Permits Or Authorizations Relating To Operations 1. Blanket Additional Insured — Grantors Of Franchises J. Incidental Medical Malpractice K. Medical Payments — Increased Limit L. Blanket Waiver Of Subrogation M. Contractual Liability — Railroads a. Before you maintained an ownership interest of more than SO% in such subsidiary; or b. After the date, if any. during the policy period that you no longer maintain an ownership interest of more than 50% in such subsidiary. For purposes of Paragraph 1. of Section 11 — Who Is An Insured, each such subsidiary will be deemed to be designated in the Declarations as: a. A limited liability company; b. An organization other than a partnership, joint venture or limited liability company; or c. A trust; as indicated in its name or the documents that ,v,ovem its structure. CG D4 58 02 19 C) 2017 The Travelers Indemnity Company. All rights reserved. Page 1 o It! Includes copyrighted material of Insurance Services Office, Inc. with its permission I COMMERCIAL GENERAL LIABILITY B. WHO IS AN INSURED — EMPLOYEES AND VOLUNTEER WORKERS — BODILY INJURY TO CO -EMPLOYEES AND CO -VOLUNTEER WORKERS The following is added to Paragraph 2.a.(1) of SECTION II — WHO IS AN INSURED: Paragraphs (1)(a), (b) and (c) above do not apply to "bodily injury" to a co -"employee" while in the course of the co -"employee's" employment by you or performing duties related to the conduct o f your business, or to "bodily injury" to your other "volunteer workers" while performing duties related to the conduct of your business. C. WHO IS AN INSURED — NEWLY ACQUIRED OR FORMED LIMITED LIABILITY COMPANIES The following replaces Paragraph 3. of SECTION II — WHO IS AN INSURED: 3. Any organization you newly acquire or form, other than a partnership or joint venture, and of which you are the sole owner or in which you maintain an ownership interest of more than 50%, will qualify as a Named Insured if there is no other similar insurance available to that organization. However: a. Coverage under this provision is afforded only: (1) Until the 180th day after you acquire or form the organization or the end of the policy period, whichever is earlier, if you do not report such organization in writing to us within 180 days after you acquire or form it; or (2) Until the end of the policy period, when that date is later than 180 days after you acquire or form such organization, if you report such organization in writing to us within 180 days after you acquire or form it; b. Coverage A does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed the organization; and c. Coverage B does not apply to "personal and advertising injury" arising out of an offense committed before you acquired or formed the organization. For the purposes of Paragraph 1. of Section II — Who Is An Insured, each such organization will be deemed to be designated in the Declarations as: a. A limited liability company; b. An organization, other than a partnership, joint venture or limited liability company; or c. A trust; as indicated in its name or the documents that govern its structure. D. BLANKET ADDITIONAL INSURED — BROAD FORM VENDORS The following is added to SECTION II — WHO IS AN INSURED: Any person or organization that is a vendor and that you have agreed in a written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only with respect to liability for "bodily injury" or "property damage" that: a. Occurs subsequent to the signing of that contract or agreement; and b. Arises out of "your products" that are distributed or sold in the regular course of such vendor's business. The insurance provided to such vendor is subject to the following provisions: a. The limits of insurance provided to such vendor will be the minimum limits that you agreed to provide in the written contract or agreement, or the limits shown in the Declarations, whichever are less. b. The insurance provided to such vendor does not apply to: (1) Any express warranty not authorized by you or any distribution or sale for a purpose not authorized by you; (2) Any change in "your products" made by such vendor; (3) Repackaging, unless unpacked solely for the purpose of inspection, demonstration, testing, or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container; (4) Any failure to make such inspections, adjustments, tests or servicing as vendors agree to perform or normally undertake to perform in the regular course of business, in connection with the distribution or sale of "your products' Page 2 of 5 ® 2017 The Travelers Indemnity Company. All rights reserved. CIS D4 58 02 19 Includes copyrighted material of Insurance Services Office, Inc. with its permission (5) Demonstration, installation, servicing or repair operations, except such operations performed at such vendor's premises in connection with the sale of "your products"; or (6) "Your products" that, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or on behalf of such vendor. Coverage under thi s provision does not apply to: a. Any person or organization from whom you have acquired "your products", or any ingredient, part or container entering into, accompanying or containing such products; or b. Any vendor for which coverage as an additional insured specifically is scheduled by endorsement. E. BLANKET ADDITIONAL INSURED — CONTROLLING INTEREST 1. The following is added to SECTION II —WHO IS AN INSURED: Any person or organization that has financial control of you is an insured with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" that arises out of: a. Such financial control; or b. Such person's or organization's ownership, maintenance or use of premises leased to or occupied by you. The insurance provided to such person or organization does not apply to structural alterations, new construction or demolition operations performed by or on behalf of such person or organization. 2. The following is added to Paragraph 4. of SECTION II — WHO IS AN INSURED: This paragraph does not apply to any premises owner, manager or lessor that has financial control of you. F. BLANKET ADDITIONAL INSURED — MORTGAGEES, ASSIGNEES, SUCCESSORS OR RECEIVERS The following is added to SECTION II — WHO IS AN INSURED: Any person or organization that is a mortgagee, assignee, successor or receiver and that you have agreed in a written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only with respect to its COMMERCIAL GENERAL LIABILITY liability as mortgagee, assignee, successor or receiver for "bodily injury", "property damage" or "personal and advertising injury" that: a. Is "bodily injury' or "property damage" that occurs, or is "personal and advertising injury" caused by an offense that is committed, subsequent to the signing of that contract or agreement; and b. Arises out of the ownership, maintenance or use of the premises for which that mortgagee, assignee, successor or receiver is required under that contract or agreement to be included as an additional insured on this Coverage Part. The insurance provided to such mortgagee, assignee, successor or receiver is subject to the following provisions: a. The limits of insurance provided to such mortgagee, assignee, successor or receiver will be the minimum limits that you agreed to provide in the written contract or agreement, or the limits shown in the Declarations, whichever are less. b. The insurance provided to such person or organization does not apply to: (1) Any "bodily injury' or "property -damage" that occurs, or any "personal and advertising injury' caused by an offense that is committed, after such contract or agreement is no longer in effect; or (2) Any "bodily injury", "property damage" or "personal and advertising injury" arising out of any structural alterations, new construction or demolition operations performed by or on behalf of such mortgagee, assignee, successor or receiver. G. BLANKET ADDITIONAL INSURED — GOVERNMENTAL ENTITIES — PERMITS OR AUTHORIZATIONS RELATING TO PREMISES The following is added to SECTION II — WHO IS AN INSURED: Any governmental entity that has issued a permit or authorization with respect to premises owned or occupied by, or rented or loaned to, you and that you are required by any ordinance, law, building code or written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" arising out of the existence, ownership, use, maintenance, repair, construction, erection or removal of any of the following for which that governmental entity has CG D4 58 02 19 ® 2017 The Travelers Indemnity Company. All rights reserved. Page 3 of 5 Includes copyrighted material of Insurance Services Office, Inc. with its permission COMMERCIAL GENERAL LIABILITY issued such permit or authorization: advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, elevators, street banners or decorations. H BLANKET ADDITIONAL INSURED — GOVERNMENTAL ENTITIES — PERMITS OR AUTHORIZATIONS RELATING TO OPER- ATIONS The following is added to SECTION II — WHO IS AN INSURED: Any governmental entity that has issued a permit or authorization with respect to operations performed by you or on your behalf and that you are required by any ordinance, law, building code or written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" arising out of such operations. The insurance provided to such governmental entity does not apply to: a. Any "bodily injury', "property damage" or "personal and advertising injury" arising out of operations performed for the governmental entity: or b. Any "bodily injury' or "property damage" included in the "products -completed operations hazard". I. BLANKET ADDITIONAL INSURED — GRANTORS OF FRANCHISES The following is added to SECTION II — WHO IS AN INSURED: Any person or organization that grants a franchise to you is an insured, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" arising out of your operations in the franchise granted by that person or organization. If a written contract or agreement exists between you and such additional insured, the limits of insurance provided to such insured will be the minimum limits that you agreed to provide in the written contract or agreement, or the limits shown in the Declarations, whichever are less. J. INCIDENTAL MEDICAL MALPRACTICE services", first aid or "Good Samaritan services" to a person, unless you are in the business or occupation of providing professional health care services. 2. The following replaces the last paragraph of Paragraph 2.a.(1) of SECTION 11 — WHO IS AN INSURED: Unless you are in the business or occupation of providing professional health care services, Paragraphs (1)(a), (b), (c) and (d) above do not apply to "bodily injury" arising out of providing or failing to provide: (a) "Incidental medical services" by any of your "employees" who is a nurse, nurse assistant, emergency medical technician, paramedic, athletic trainer, audiologist, dietician, nutritionist, occupational therapist or occupational therapy assistant, physical therapist or speech - language pathologist: or (b) First aid or "Good Samaritan services" by any of your "employees" or "volunteer workers", other than an employed or volunteer doctor. Any such "employees" or "volunteer workers" providing or failing to provide first aid or "Good Samaritan services" during their work hours for you will be deemed to be acting within the scope of their employment by you or performing duties related to the conduct of your business. 3. The following replaces the last sentence of Paragraph 5. of SECTION III — LIMITS OF INSURANCE: For the purposes of determining the applicable Each Occurrence Limit, all related acts or omissions committed in providing or failing to provide "incidental medical services", first aid or "Good Samaritan services" to any one person will be deemed to be one "occurrence". 4. The following exclusion is added to Paragraph 2., Exclusions, of SECTION I — COVERAGES — COVERAGE A — BODILY INJURY AND PROPERTY DAMAGE, LIABILITY: 1. The following replaces Paragraph b. of the Sale Of Pharmaceuticals definition of "occurrence" in the "Bodily injury' or "property damage" arising DEFINITIONS Section: out of the violation of a penal statute or ordinance relating to the sale of b. An act or omission committed in providing pharmaceuticals committed by, or with the or failing to provide "incidental medical knowledge or consent of, the insured. Page 4 of 5 ® 2017 The Travelers Indemnity Company. Al rights reserved. CG D4 58 02 19 Includes copyrighted material of Insurance Services Office, Inc. with its permission 5. The following is added to the DEFINITIONS Section: "Incidental medical services" means: a. Medical, surgical, dental, laboratory, x-ray or nursing service or treatment, advice or instruction, or the related furnishing of food or beverages; or b. The furnishing or dispensing of drugs or medical, dental, or surgical supplies or appliances. 6. The following is added to Paragraph 4.b., Excess Insurance, of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: This insurance is excess over any valid and collectible other insurance, whether primary, excess, contingent or on any other basis, that is available to any of your "employees" for "bodily injury" that arises out of providing or failing to provide "incidental medical services" to any person to the extent not subject to Paragraph 2.a.(1) of Section II — Who Is An Insured. K. MEDICAL PAYMENTS — INCREASED LIMIT The following replaces Paragraph 7. of SECTION III — LIMITS OF INSURANCE: 7. Subject to Paragraph 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, and will be the higher of: COMMERCIAL GENERAL LIABILITY a. $10,000; or b. The amount shown in the Declarations of this Coverage Part for Medical Expense Limit. L. BLANKET WAIVER OF SUBROGATION The following is added to Paragraph 8., Transfer Of Rights Of Recovery Against Others To Us, of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: If the insured has agreed in a contract or agreement to waive that insured's right of recovery against any person or organization, we waive our right of recovery against such person or organization, but only for payments we make because of: a. "Bodily injury" or "property damage" that occurs; or b. "Personal and advertising injury" caused by an offense that is committed; subsequent to the execution of the contract or agreement. M. CONTRACTUAL LIABILITY — RAILROADS 1. The following replaces Paragraph c. of the definition of "insured contract" in the DEFINITIONS Section: c. Any easement or license agreement; 2. Paragraph f.(1) of the definition of "insured contract" in the DEFINITIONS Section is deleted. CG D4 58 02 19 ® 2017 The Travelers Indemnity Company. All rights reserved. Page 5 of 5 Includes copyrighted material of Insurance Services Office. Inc. with its permission AMIk WORKERS COMPENSATION TRAVELERSJ AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 WA Z ply, I q 4 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA (BLANKET WAIVER) 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. The additional premium for this endorsement shall be 2. 00 % of the California workers' compensation pre- -fflium. Terson or Organization Job Descriptior ANY PERSON OR ORGANIZATION FOR ALL OPERATIONS WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER. 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 08/27/2024 Policy No. Endorsement No. Insured Backfiow Apparatus & Valve Co. Premium Insurance Company Countersigned by DATE OFISSUE: 09-18-24 ST ASSIGN: Page 1 of 1