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PROOF OF INSURANCE (2008) CLOSED08/21/2008 16:52 FAX 818 772 0984 White Oak Insurance Z0002/0003 ACORD CERTIFICATE OF LIABILITY INSURANCE DAT0811812008WY) ' TM. TYPE OF INSURANCE OE LIABILITY X COMMERCIAL. GENERAL LIABILITY PRODUCER Phone: (818) 772.0807 Fax (018) 772.0964 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION WHITE OAK INSURANCE SERVICES INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 21383 LASSEN ST SUITE 5200 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR CHATSWORTH CA 91311 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. EL SEGUNDO, CA 90245 CLAIMS MADE OCCUR Attention: INSURERS AFFORDING COVERAGE NAIC 5 Apncy LIa:DE2aes2 - INSURER A: Great American Assurance Co PERSONAL i AOV INJURY S 11000,000 26344 INSURED ARMAND GONZALES, INC. OBA: GONZALES CONSTRUCTION, INSURER B: Groat American Assurance CO 26344 INSURER C:� DBA ASG CONSTRUCTION 19531 VENTURA BLVD., SECOND FLOOR - 3 2,000,000 TARZANA CA 91358 INSURER D: S 2,000,000 INSURER E: PRODUCTS- COMPIOP AGG. L wvr.rv+vca THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR 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. = TYPE OF INSURANCE OE LIABILITY X COMMERCIAL. GENERAL LIABILITY PDLICY NUMBER GLP8263337 POLICY EFFECTIVE 08131107 ►INJf YeXPMAT10N 08131108 LIMITS EACH OCCURRENCE i 1,000,000 PgEE�g.na 3 60,000 AUTHORIZED REPRESENTATIVE EL SEGUNDO, CA 90245 CLAIMS MADE OCCUR Attention: O n A. Crites Jr. wwe NED. EXP (My one pemon) $ EXCLUDED PERSONAL i AOV INJURY S 11000,000 A t GENERAL AGGREGATE 3 2,000,000 !_j S 2,000,000 GEN -L AGGREGATE LIMIT APPLIES PER: PRODUCTS- COMPIOP AGG. POLICY M jERC`T� LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea w4dent) 3 BODILY INJURY (Per person) S ALL OWNED AUTOS J SCHEDULED AUTOS 3 - HIRED AUTOS NON -OWNED AUTOS I BODILY INJURY (Per aecideM) — - PROPERTY DAMAGE Per Accident $ GARAGELULBfUTY AUTOONLY- EAACCIDENT 3 OTHER THAN EA ACC_ AUTO ONLY: AGG ANY AUTO S 3 EXCESS I UMBRELLA LIABILITY EXC 9264009 10/79/07 08/31/08 EACH OCCURRENCE S 3,000,000 AGGREGATE S 3,000,000 X OCCUR n CLAIMS MADE DEDUCTIBLE _— 3 RETENTION $ 0 WB COMPENSATION ANO YV6a OTMA TORYladrte E -L- EACH ACCIDENT $ EMPLOYERS' LIABILITY AMT PaOPaETCwpMTNEwEIIECUTIVE WriCLVMFMelR EcLUDEDT E.L. DISEASE -EA EMPLOYEE 3 _ EL ISEASE- POLICY LIMIT $ M Fa dooenlo,wAr pEdAl PRQMIE.4 blow ER: DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES !EXCLUSIONS ADDED 3' ENDORSEMENTI SPECIAL PROVISIONS ADDITIONAL INSURED AS RESPECTS THEIR INTEREST PER COMPANY FORM CG 20 33 07 04 WITH COMPLETED OPERATIONS AS PER FORM CO 20 37 07 04. PUBLIC WORKS DEPARTMENT. EL SEGUNDO CITY HALL. PROJECT: FIRE STATION52.10 DAYS NOC FOR NON -PAY. THIS SUPERCEDES ALL PRIVIOUS CERTIFICATES. ACORD N (2001/08) cenillcale s Tusoc ^��•.� ,,..•.....�^ _ . - -- l v 4'5 e. - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS MNUTTE4 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE PUBLIC WORKS DEPARTMENT TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THIS INSURER, EL SEGUNDO CITY HALL ITS AGENTS OR REPRESENTATIVES. 350 MAIN STREET AUTHORIZED REPRESENTATIVE EL SEGUNDO, CA 90245 Attention: O n A. Crites Jr. wwe ACORD N (2001/08) cenillcale s Tusoc ^��•.� ,,..•.....�^ _ . - -- l v 4'5 e. 08/21/2008 16:53 FAX 818 772 0984 White Oak Insurance IMPORTANT 00003/0003 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 The Certificate of Insurance on the reverse side of this form 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 -5 (2001 /08) Certificate #9482 345 • ..:� �, 08/21/2008 16:52 FAX 818 772 0984 White Oak Insurance Q0001/0003 Facsimile White Oak Insurance Services Inc. 21363 Lassen St Suite #200 Chatsworth CA 91311 Fax ($1$) 772 -0984 Phone (818) 772 -0807 Agency Lic* OE28852 August 21, 2008 Insured: ARMAND GONZALES, INC. DBA GONZ Company: Great American Assurance Co Policy #: EXC 9254009 Policy Period: OCT 19 07 To: AUG 3108 Agency Lie#: OE28852 Total Number of Pages: 2 CITY OF EL SEGUNDO - CITY CLERK DEPARTMENT Phone: Fax: (310) 615 -4529 Attention: MONA S. Re: ARMAND GONZALES, INC. DBA: GONZALES CONSTRUCTION, Dear Mona,: Attached is the revised certificate, as requested. If any questions, please let me know. Sincerely, Annie Karapetyan akk Page 1 38 S V 4 5•. a 64 GENERAL LIABILITY ADDITIONAL INSURED ENDORSEMENT CITY OF EL SEGUNDO In consideration of the premium charged and notwIttistending any Inconsistent statement in the policy to which this endorsement is attached or any endorsement now or hereafter attached thereto, It Is agreed as follows: 1. ADDITIONAL INSURED. The City of El Segundo, Its officers, agents and employees are included as addltlonal 'Insured with regard to liability and defense of suits arlaing from "your work" performed by or on behalf of the named Insured regardless of whetherllablllty Is attributable to the named Insuredore combination of the named and the additional Insured. 2. CONTRIBUTION NOT REQUIRED. Anyother Insurance maintained bythe Clyof El Segundo is excess of this Insurance and will not contribute with It. 3. SEVERABILITY OF INTEREST. This insurance applies separately to each Insured against whom claim to made or suit is brought except with respect to the company's limits of Itablilty. The Inclusion of any person or organization as an Insured does not affect any right which such person or organization would have as a claimant if not so Included. 4. CANCELLATION NOTICE, With respect to the Interests of the City of El Segundo, this Insurance may not be canceled, reduced In coverage or'ilmita or non- renewed, except after thirty (30) days prior written notice by R,EEGI!f,�iE, I30RCERTIFIEDMAiLhasbeengivenlothePublicWorksDirectorofElSegundoaddressedas follows, Public Works Department, El Segundo City Hall, 350 Main Street, El Segundo, CA 90246 i 6. APPLICA04,tTY. The Insurance pertains to the operations and/or tenancy of the named Insured under an written agreements in force with the City of El Segundo unless checked here ( ) In which one only the failowing-epecific agreements with the City of El Segundo are covered: 6. MAILING ADDRESS: Completed endorsements shall be Issued to the City of EI Segundo as follows: PUBLIC WORKS DEPARTMENT El Segundo City Hall 3130 Main Street El Segundo, CA 90245 /far el) aQ 6c Ik , 61 7, CLAIMS: Underwriter's representative for claims pursuant to this Insurance: .7�' S of T / ire r'o OL SI L,._A Cq g0L9/7 Except as stated above, nothing herein shall be hold to wah)e, sitar or extend any of the Urrtte, conditions, agreements, or exclusions of the policy to which this endorsement Is attached. I Zvi/ G r/ 4 c r / u U r r r / (print/type name), warrant than have authority to bind the below4lsted Insurance company and by my "sn�l/gmiture hereon do so birylthle company to this endorsement, IL signatupY % /r /? r AuthorbmO Rep rdat (orlginal signatife required on copy famished to the Attomay) TITLE: Ce /;e tip/ t j e. ORGANIZATION: nee AAA e// !C Anrmrmsa! '125 . T f146ie, -z) Q ,rf TELEPHONE d 13 400 ` .� 1 (area code) (telephone number) Page 1 of 2 MpNs_ MAffrM 9 OF WCe PAM , MJ (04.7607) �3�00 GENERAL UASI trY ADDMOM MUROD ENDORSEMENT CI7YOF ELBEGUNDO {CONTINUED) 10. babelse (check its appib:abis)r () Broad Form LIabUNy Endorcoment () Brood Form Property Damage Uld Opsi+ Ons Inderground Hazard ka"elsd Operadons Lfe6 Py ipeYs Legal Liebft C= aftW LlabW Owned Automobiles 3845 • . . . Hired Aubm"Uss i; Ma L.ger LbbRRy bell a 6, A e.�c�cl 6z'n <��1 d� f,. te a: Co M''" ,� b, e 64 S U, umib *fuabilft . c G( .t< / /n 13.- PoQcyParbd: FronILB� To• a 1101 t#, Oeducels () SeN{nsured aalemim (dmk whiob) *f$ Q Q0 applies to _ f-c-i L••• coverage. ( ) Per Ckdm XPer Oca mm 1b. Otberprvwslone: t' G te. Nameskmaed and Addreea: �"r %M l/ �T (i q��S ! C' /953/ �e� �`u�a �3/ 4/ 17. In.arancacon,per►y: ts. Poley Number 63/L of � A 5)14 l l7C ITIM�IC/JvJ / �� r, y # q L_P 7g57 X337 18. Endomiumm Number. 20. Effsattve Ante of Endonrarrient: KAPORMSNOTM81¢ (8W) WA Page 2 of 2 3545 - Customer Service 800 - 444 -4487 800 -556 -0014 (fax) Mailing address Progressive P,O. Box 94739 Cleveland, OH 44101 -4739 Monday, August 18, 2008 7:40:10 PM Total Number of Pages:03 Requested policy documents To: ANNIE Fax number: 1 -818- 772 -0984 Message: CERTIFICATE OF INSURANCE FOR 06110915 -0 WHITE OAK INSURANCE 21363 IASSEN ST #200 CHATSWORTH,CA 91311 818- 772 -0807 Certificate of Insurance erfti kjft No" buwed Additional Insured ARMAND GONZALES, INC. PUBLIC WORKS DEPT E GONZALES CONSTRUCTION 350 MAIN ST 19531 VENTURA BLVD EL SEGUNDO, CA 90245 TARZANA, CA 91356 3845•,,..: Policy number: 06110915 -0 Underwritten by United Financial Casualty Company August 18, 2008 Page 1 of 2 Agent WHITE OAK INSURANCE 21363 tASSEN ST #200 CHATSWORTH, CA 91311 This document certifies that insurance policies identified below have been issued by the designated insurer to the insured named above for the period(s) indicated. This Certificate is issued for information purposes only It confers no rights upon the Certificate holder and does not change, alter, modify, or extend the coverages afforded by the policies listed below The coverages afforded by the policies listed below are subject to all the terms, exclusions, limitations, endorsements, and conditions of these policies Policy Effective Date: Dec 15, 2007 Policy Expiration Date: Dec 15, 2008 b"ra of a weravels) links Bodily Injury/Property Damage $1,000,000 Combined Single limit Uninsured /Underinsured Motorist $1,000,000 Combined Single Limit Employees Non -Owned Auto BIPD $1,000,000 Combined Single Limit Hired Auto Bodily injury/Property Damage $1,000,000 Combined Single Limit Description of LocationNeWdes/Special Items Scheduled autos only 2001 BMW 74011 WBAGH83491OP25124 Stated Amount $25,000 Medical Payments $1,000 Comprehensive $1,000 Ded Collision $1,000 Ded w/Waiver 2002 NISSAN XTERRA XE/SE 5N1ED28T52C538131 Stated Amount $15,000 Medical Payments $1,000 Comprehensive $1,000 Ded Collision $1,000 Ded w/Waiver 2005 BMW 5451 WBANB335XSCN64668 Stated Amount $48,000 Medical Payments $1,000 Comprehensive $1,000 Ded Collision $1,000 Ded w/Waiver 2004 TOYOTA LANDCRUISER JTEHTO5J542056274 Stated Amount $45,000 Medical Payments $1,000 Comprehensive $1,000 Ded Collision $1,000 Ded w/Waiver 0 Continued 1006 TOYOTA TUNDRA 5TBJU321165471864 Medical Payments Comprehensive Collision ............................. ............................... 2004 TOYOTA TUNDRA 5TB1N321645440071 Medical Payments Comprehensive Collision Certificate number 231OW3915 38 4 5 . ,.." ftlicy number. 0611091" "�igr 2 of 2 Stated Amount $15,000 $1,000 $1,000 Ded J , 41 Ded wfWAiver Stated Amount 1'�,(K)0 $1,000 $1,000 Ded $1,000 Ded w/Waiver Please be advised that additional insureds and loss payees will be notified In the event of a mid-term cancellation. �71 00�1- Fain 5241000 STATE COMPENSATION INSURANCE FUND FEBRUARY 2, 2009 CITY OF EL SEGUNDO CITY CLERK 350 MAIN ST EL SEGUNDO CA 90245 -3813 IN REPLY REFER T0: CERTIFICATE OF WORKERS' ----------------------- COMPENSATION INSURANCE ---------------------- CANCELLATION /CONVERSION NOTICE ------------------------ - - - - -- RE: CERTIFICATE DATED AUGUST 12, 2008 THE WORKERS' COMPENSATION COVERAGE PROVIDED UNDER THE POLICY LISTED BELOW IS BEING CONVERTED TO A NEW POLICY EFFECTIVE JANUARY 1, 2009. THE NEW POLICY WILL PROVIDE UNINTERRUPTED COVERAGE. YOU WILL RECEIVE A NEW CERTIFICATE OF INSURANCE UNDER THE NEW POLICY NUMBER: 719 - 0000550-08. IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT THE CUSTOMER SERVICES UNIT AT THE NUMBER LISTED BELOW. EMPLOYER: GONZALES CONSTRUCTION 19531 VENTURA BLVD FL 2 TARZANA, CA 91356 POLICY 238 - 0004496 -07 CUSTOMER SERVICES UNIT LOS ANGELES DISTRICT OFFICE (323) 266 -5000 1275 Market Street • San Francisco, CA 94103— 1410 Mailing Address: P.O. Box 420807 • San Francisco, CA 94142 -0807 SCIF 19102 3845•...: CERTHOLDER COPY Sc STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807 COMPENSATION I N S U R A N C E FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE GROUP: 000238 ISSUE DATE: 08 -12 -2008 POLICY NUMBER: 0004496 -2007 CERTIFICATE ID: 64 CERTIFICATE EXPIRES: 01 -01 -2009 01- 01- 2008/01- 01 -2009 CITY OF EL SEGUNDO SC JOB:EL SEGUNDO FIRE STATION #2 PW 08 -06 CITY CLERK 350 MAIN ST EL SEGUNDO CA 90245 -3813 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 employer. We will also give you 30 days advance notice should this policy 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. THORIZED REPRESENTATI PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT 1!1600 - GONZALES, SUSANA DIRECTOR - EXCLUDED. ENDORSEMENT 61600 - GONZALES, ARMAND P,S T - EXCLUDED. ENDORSEMENT 65 ENTITLED CERTIFICATE HOLDERS/ NOTICE EFFECTIVE 01 -01 -2008 IS ATTACHED AND ENDORSEMENT 112570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2008 -08 -12 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO EMPLOYER ARMAND GONZALES, INC DBA: GONZALES SC CONSTRUCTION 19531 VENTURA BLVD FL 2 TARZANA CA 91356 [VMG,CNI PRINTED : 08 -12 -2008 (REV.2 -05)