PROOF OF INSURANCE (2011) CLOSEDr-1 Cl O6 :07
Al-C-�RZe DATE (MWDD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE F 9/13/2010
[PRODUCER (760) 795 -2002 FAX: (760) 929 -0534 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
atter, Williams & Purdy Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
12230 Faraday Ave ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Carlsbad CA_ 92008 INSURERS AFFORDING COVERAGE NAIC #
INSURED ' INSURERA:Interstate Fire & Casualty Co 22829
Ace Electric, Inc. INSURER B: Golden Eagle Insurance Corp 10836
P.O. BOX 601071 INSURER C: National Union Fire Insurance 19445
INSURER D:
San Diego CA 92160 INSURER E:
r0VFROGFS
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
350 Main Street
El Segundo, CA 90245 -38�
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,t�i�
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INSR ADD'L POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
I TYPE OF INSURANCE
LIMITS
AUTHORIZED REPRESENTATIVE
GENERAL LIABILITY
EACH OCCURRENCE S
1, 000, 000
X COMMERCIAL GENERAL LIABILITY
I DAIdAGE't0 RENTED ..
PREMISES occurrence1 _ $
_.
501.000
A X CLAIMS MADE X , OCCUR SGL1002233 3/25/2010 3/25/2011
MED EXP (Any one person) $
Excluded_
PERSONALBADVINJURY S
_. . —. .- - ..- -
11000,000
-
GENERAL_ AGGREGATE !S
2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP /OP AGG $
2 , 000 , 000
POLICY! X PRO- LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
11000,000
X ANY AUTO �
(Ea accident)
--
B X ALL OWNED AUTOS DA8133142 4/15/2010 4/15/2011
I BODILY INJURY
$
SCHEDULED AUTOS
I (Per pew)
X HIRED AUTOS
BODILY INJURY S
X NON -OWNED AUTOS
(Per accident)
PROPERTY DAMAGE S
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT S
ANY AUTO
EA ACC $
OTHER THAN -
AUTO ONLY: AGG S
EXCESS / UMBRELLA LIABILITY
EACH OCCURRENCE S
2,000,000
X OCCUR CLAIMS MADE
; AGGREGATE S
2, 000, 000
a
i
C X DEDUCTIBLE 85060717701 3/25/2010 3/25/2011
E
RETENTION $
S
WORKERS COMPENSATION
WC STATU- OTH -'
TORY.LIMITS ER
AND EMPLOYERS' LIABILITY Y / N
.. ...
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. EACH ACCIDENT S
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH)
E.L. DISEASE_- EA EMPLOYEE' S _
If yyes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMIT S
OTHER
i
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
City of 91 Segundo, its officers, officials, employees, agents and volunteers are named
Additional Insured
Res Recreation Park Phase III Lighting Project, Project No.: PW10 -07
*Except 10 days notice for nonpayment of premium
rcorrorrATe Unl neo / \ / (1AN(`GI I ATUIN
ACORD 25 ( 2009 /01) W I Vtft$ -ZUUS AUUKU JUKrUKA I IUr4. Aii ngms reserves.
INS025 (200901) The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City of E1 Segundo
DATE THEREOF, THE ISSUING INSURER WILL 0({XJ6 )fMMAIL *30 DAYS WRITTEN
350 Main Street
El Segundo, CA 90245 -38�
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,t�i�
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NrlisXiiswwlbL�
AUTHORIZED REPRESENTATIVE
Nickie Einertson, CIS
ACORD 25 ( 2009 /01) W I Vtft$ -ZUUS AUUKU JUKrUKA I IUr4. Aii ngms reserves.
INS025 (200901) The ACORD name and logo are registered marks of ACORD
Q. 0 .i
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized
representative or producer, and the certificate holder, nor does it affirmatively or negatively amend,
extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 (2009/01)
INS025 (200901)
40 8 6. I
Forming a part of
Policy Number: BAS133142
Coverage Is Provided In Golden Eagle Insurance Corp
Named Insured: Agent:
Ace Electric, Inc. Hatter, Williams & Purdy Ins., Inc.
P.O. Box 601071 2230 Faraday Avenue
San Diego, CA 92160 Carlsbad, CA 92008
LAgent Code: 4292779 Agent Phone: (760)795 -2002
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORM
TRUCKERS COVERAGE FORM
The person or organization shown in the Schedule is an insured to the extent of their liability for the conduct of an insured
under Section II- Liability Coverage of this policy.
SCHEDULE
City of El Segundo, its officers, officials, agents
and volunteers
350 Main Street
El Segundo, CA 90245 -3813
GECA 812 (10/96)
POLICY NUMBER: SGL1002233
11 � 8 6
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Name of Person or Organization:
City of El Segundo, its officers, offici s, mp yees, agents
and volunteers
350 Main Street
El Segundo, CA 90245 -3813
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured person or organization shown in the Schedule,
but only with respect to liability arising out of "your work" for that insured by or for you.
Coverage provided by this policy to the Additional Insured(s) shown in the Schedule shall be
primary insurance and any other insurance maintained by the Additional Insured(s) shall be
excess and non - contributory, but only if required of the Named Insured and by written contract.
CG2010 11 85
Copyright, Insurance Services Office, Inc., 1984
Page 1 of 1
Policy No. SGL1002233
4086 .
Interstate Fire & Casualty Co
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:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
City of El Segundo, its officers, officials, employees, agents
and volunteers
350 Main Street
El Segundo, CA 90245 -3813
(if no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement)
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHER TO US Condition (Section IV — COMMERCIAL
GENERAL LIABILITY CONDITIONS) is amended by the addition of the following:
r - IC .
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 operations 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 10 93 Copyright, Insurance Services Office, Inc. 1992 Page 1 of 1
ISSUE DATE: 09 -13 -2010
CITY OF EL SEGUNDO
350 MAIN ST
EL SEGUNDO CA 90245 -3813
4v 86 .
POLICYHOLDER COPY
P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
GROUP: 000238
POLICY NUMBER: 0005452 -2009
CERTIFICATE ID: 283
CERTIFICATE EXPIRES: 01 -01 -2011
01 -01- 2010/01 -01 -2011
SD JOB:RECREATION PARK PHASE III LIGHTING
PROJECT NO PW 10 -07
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employe.
We will also give you 30 days advance notice should this po icy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy.
� 4��-
thorized Representative Interim President and CEO
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT #1600 - HINDS, JEFFREY PR SEC TR - EXCLUDED.
ENDORSEMENT #1600 - ENSMINGER, DAVID J. VP - EXCLUDED.
ENDORSEMENT #2085 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01 -01 -2009 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2010 -09 -13 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME:
CITY OF EL SEGUNDO
EMPLOYER
ACE ELECTRIC INC
PO BOX 601071
SAN DIEGO CA 92180
SD
[B10,SD[
PRINTED : 09 -13 -2010
(REV.1 -2010)
SD
4086 174
NOT TRANSFERABLE POST IN A CONSPICUOUS PLACE
CITY OF EL SEGUNDO
BUSINESS LICENSE BUSINESS LICENSE CERTIFICATE
EXPIRATION GATE
. 14402 .. This business legistration lea document does not constltule a permit to engage In any business.
In approprtate cases when required by City ordinance a separate permit is issued. 12/31/2010
DATE PAID'
9/14/2010
TAX CODE BUSINESS LOCATION IN EL SEGUNDO _ - BUSINESS TYPE
222 Out of City Business Contractor - Gen /Elect/Plumb 4 -2 -2
DBA's:
t
BUSINESS NAME ACE ELECTRIC INC
ATTENTION
MAILING ADDRESS PO BOX 601 071
CITY AND STATE SAN DIEGO, CA 92160 -1071
OWNER, PARTNER OR
,CORPORATE OFFICER JEFFREY HINDS
10 1672 414 4,161:1 LIMA 1119 1 d • • ► LORI
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