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PROOF OF INSURANCE (2010) CLOSEDCERTIFICATE OF INSURANCE ISSUE �DUCER DATE GEORGE L. BROWN INSURANCE AGENCY Cert# 54675 08/21/2009 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY CONFERS 1005 CALLE RECODO SAN CLEMENTE, CA 92673 AND NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE 949.361.1400 COVERAGE AFFORDED BY THE POLICIES BELOW. FAX 949.361.2767 COMPANIES AFFORDING COVERAGE COMPANY INSURED A NORTH AMERICAN CAPACITY INSURANCE CO BIG WEST CONSTRUCTION CORPORATION COMPANY B GENERAL INSURANCE COMPANY OF AMERICA 2691 RICHTER AVE #123 COMPANY IRVINE, CA 92606 C COMPANY COVERAGES D 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 PERTAIN, THE INSURANCE AFFORDED WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY HAVE BEEN REDUCED BY PAID CLAIMS. 8Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS CO OF SUCH POLICIES. LIMITS SHOWN MAY LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION GENERAL LIABILITY DATE (MM/DD/YY) DATE (MWDD/YY) LIMITS X COMMERCIAL GENERAL LIABILITY PNG0003862 GENERAL AGGREGATE $ 2,000,000 MAY 23 09 LAMS MADE a OCCUR. A MAY 23 10 PRODUCTS- COMP /OP AGG. $ 2,000,000 OWNER'S 8 CONTRACTOR'S PROT. PERSONAL 8 ADV INJURY $ 1,000,000 EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE(Any One Fire) $ 50,000 AUTOMOBILE LIABILITY MED. EXPENSE(Any One Person $ 5,000 ANY AUTO 24CC236606 -2 ALL OWNED AUTOS JUL 1109 COMBINED SINGLE LIMIT $ JUL 11 10 1,OOQ0 SCHEDULED AUTOS B BODILY INJURY X HIRED AUTOS (Per Person) $ X NON -OWNED AUTOS BODILY INJURY (Per Accident) $ GARAGE LIABILITY PROPERTY DAMAGE $ ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ EXCESS LIABILITY AGGREGATE $ UMBRELLA FORM EACH OCCURRENCE $ OTHER THAN UMBRELLA FORM AGGREGATE $ WORKER'S COMPENSATION AND EMPLOYERS' LIABILITY STATUTORY LIMITS THE PROPRIETOR/ PARTNERS/EXECUTIVE INCL EACH ACCIDENT $ OFFICERS ARE: EXCL DISEASE- POLICY LIMIT $ OTHER DISEASE EACH EMPLQYEE $ • - •- �.... "—,--, ivn0/vtMIULES /SPECX ITEMS THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS, AND VOLUNTEERS ARE NAMED ADDITIONAL INSUREDS WITH RESPECTS TO GENERAL LIABILITY INCLUDING PRIMARY WORDING PER FORM CG2010 (11/85) AND AUTO LIABILITY PER FORM CA7110 (03/07). RE: ONGOING OPERATIONS PERFORMED BY THE NAMED INSURED FOR THE CERTIFICATE HOLDER AS REQUIRED BY WRITTEN CONTRACT CERTIFICATE HOLDER CITY OF EL SEGUNDO 350 MAIN STREET EL SEGUNDO, CA 90245 r ATTN: CITY CLERK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 10-DAY NOTICE 9FGAOISVLATI05APS FOR NON - PAYMENT OF PREMIUM Reproduction of Insurance Services Office, Inc. Form INSURER: ISO FORM CG 20 101185: (MODHW) POLICY NUMBER; COIvIlVIERCIAL GENERAL LIABILITY ENDORSEMENT NUMBER, EXHIBIT 1 -A 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 The City, its officers, officials, emPloyees, agents, and volunteers (If no entry appears above, the 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 the person or o shown in the Schedule, but only with respect to liability organization for you. tyu►S out of "your work" for that insured by or to ISO form CG 20 10 11 1. The insured scheduled above includes the Insureds officers, officials, employees and volunteers. 2. This insurance shall be- primary as respects the insured shown in the schedule above, or if excess, shall stand in an unbroken chain of coverage excess of the Named Insured's scheduled underlying pnman, coverage. In either evert, any other insurance maintained by the Insured scheduled above sball be in excess of this insurance and shall not be called upon to contribute with it 3. The insurance afforded by this policy shall not be•c�nceled except after thirty days Entity. prior written notice by certified mail return receipt requested has been given to the 4. Coverage shall not extend to any indemnity coverage for the active negligence additional insured in any case when an a tonal insured the would be invalid under Sub to �' the additional insured diV]SIOII (b) Of section 2'7R7 of rhs Address CG 20101185 Insurance Serilcea Office, Inc. Form (Modified) POLICY NUMBER: PN00003862' _. 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. Name of Person or Organization: SCHEDULE insurance such as is afforded person or organization to which you are obligated by virtue of ct to {1} occurrences taking a written contract to provide by this policy, but only with respe Place after such written contract has been executed and (2) occu Performed by you during the policy period. rrences resulting from work (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 the 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, l� CG 20 10 1185 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 p insurance COMMERCIAL AUTO CA 7110 03 07 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AUTO PLUS ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. EXTENDED CANCELLATION CONDITION Paragraph 2.b, of the CANCELLATION Common Policy Condition is replaced by the following: b. 60 days before the effective date of cancellation if we cancel for any other reason. TEMPORARY SUBSTITUTE AUTO — PHYSICAL DAMAGE COVERAGE Under paragraph C. — CERTAIN TRAILERS, MO- BILE EQUIPMENT AND TEMPORARY SUBSTITUTE AUTOS of SECTION 1 — COVERED AUTOS, the following Is added: if Physical Damage coverage is provided by this Cov- erage Form, then you have coverage for: Any *auto" you do not own while used with the per- mission of its owner as a temporary substitute for a covered 'auto" you own that is out of service be- cause of its breakdown, repair, servicing, 'loss" or destruction. BROAD FORM NAMED INSURED SECTION iI — LIABILITY COVERAGE — A.I. WHO IS AN INSURED provision Is amended by the addition of the following: d. Any business entity newly acquired or formed by you during the policy period provided you own 50% or more of the business entity and the business entity is not separately Insured for Business Auto Coverage. Coverage is extended up to a maximum of 180 days following acquisl- tion or formation of the business entity. Coverage under this provision is afforded only until the end of the policy period. BLANKET ADDITIONAL INSURED SECTION II — LIABILITY COVERAGE - A.I. WHO IS AN INSURED provision is amended by the addition of the following: e. Any person or organization for whom you are re- quired by an °Insured contract° to provide insur- ance. is an Insured", subject to the following additional I nal provisions: (1) The 'insured contract" must be in effect during the policy period shown in the Decla- rations, and must have been executed prior to the "bodily injury" or "property damage ". (2) This person or organization is an Insured" only to the extent you are liable due to your ongoing operations for that Insured, whether the work Is performed by you or for you, and only to the extent you are held liable for an 'accident" occurring while a covered °auto" is being driven by you or one of your em- ployees. (3) There is no coverage provided to this person or organization for "bodily injury" to its em- ployees, nor for 'property damage" to its property. (4) Coverage for this person or organization shall.be limited to the extent of your negli- gence or fault according to the applicable principles of comparative negligence or fault. (5) The defense of any claim or 'suit" must be tendered by this person or organization as soon as practicable to ail other insurers which potentially provide insurance for such claim or "suit ". Includes copyrighted material of Insurance Services Office, Inc., with Its permission. Copyright, Insurance Services Office, Inc., 1997 CA 71 10 03 07 Page tot 8 6840 AM the sakoo logo are megft -ed Mmaft m sakes Cmpordm EP (6) The coverage provided will not exceed the lesser of: (a) The coverage and/or limits of this policy; or (b) The coverage and/or limits required by the 'insured contract". (7) A person's or organization's status as an Insured" under this subparagraph d ends when your operations for that "Insured" are completed. EMPLOYEE AS INSURED Under Paragraph A. of Section II — LIABILITY COV- ERAGE item f. is added as follows: Your "employee" while using his owned "auto ", or an "auto" owned by a member of his or her household, in your business or your personal affairs,•provided you do not own, hire or borrow that "auto ". This coverage Is excess to any other collectible Insurance coverage. FELLOW EMPLOYEE COVERAGE Exclusion S. FELLOW EMPLOYEE of SECTION 11 — LIABILITY COVERAGE — B. EXCLUSIONS is amended by the addition of the following: However, this exclusion does not apply if the 'bodily Injury" results from the use of a covered •auto" you own or hire, and provided that any coverage under this provision only applies in excess over any other collectible insurance. BLANKET WAIVER OF SUBROGATION We waive the right of recovery We may have for pay- ments made for "bodily Injury" or "property damage" on behalf of the persons or organizations added as 'Insureds' under Section II — LIABILITY COVERAGE — A.I.D. BROAD FORM NAMED INSURED and A.1.e. BLANKET- ADDITIONAL INSURED. PHYSICAL DAMAGE — ADDITIONAL TRANS- PORTATiON EXPENSE COVERAGE The first sentence of paragraph A.4. of SECTION IiI — PHYSICAL DAMAGE COVERAGE 1s amended as follows: We will pay up to $50 per day to a maximum of $1,500 for temporary transportation expense incurred by you because of the total theft of a covered "auto" of the private passenger type. PERSONAL EFFECTS COVERAGE A. SECTION III — PHYSICAL DAMAGE COVER- AGE, A.4. COVERAGE EXTENSIONS, is amended by adding the following: c. Personal Effects Coverage For any Owned "auto" that is involved in a covered 'loss ", we will pay upv to $.500 for 'personal effects" that are lost or damaged as a result of the covered "loss ", without applying a deductible. EXTRA EXPENSE — BROADENED COVERAGE Paragraph A. — COVERAGE of SECTION III — PHYSiCAL DAMAGE COVERAGE Is amended to add: S. We will pay for the expense of returning a stolen covered "auto" to you. AIRBAG COVERAGE Under paragraph B. — EXCLUSIONS of SECTION III — PHYSICAL DAMAGE COVERAGE, the following is added: The exclusion relating to mechanical breakdown does not apply to the accidental discharge of an airbag. NEW VEHICLE REPLACEMENT COST Under Paragraph C — LIMIT OF INSURANCE of Section III — PHYSICAL DAMAGE COVERAGE sec- tion 2 is amended as follows: 2. An adjustment for depreciation and physical con- dition will be made in determining actual cash value in the event of a total loss. However, in the event of a total loss to your °new vehicle" to which this coverage applies, as shown in the declarations, we will pay at your option: a. The verifiable "new vehicle" purchase price you paid for your damaged vehicle, not in- cluding any Insurance or warranties pur- chased; Page 2 of 6 b. The purchase price, as negotiated by us, of a new vehicle of the same make, model and equipment, not including any furnishings, parts or equipment not installed by the manufacturer or manufacturer's dealership. If the same model is not available pay the purchase price of the most similar model available; c. The market value of your damaged vehicle, not including any furnishings, parts or equip- ment not Installed by the manufacturer or manufacturer's dealership. This coverage applies only to a covered "auto" of the private passenger, light truck or medium truck type (20,000 Ibs or less gross vehicle weight) and does not apply to initiation or set up costs associated with loans or leases. TWO OR MORE DEDUCTIBLES Under SECTION III — PHYSICAL DAMAGE COV- ERAGE, if two or more "company" policies or cover- age forms apply to the same accident, the following applies to paragraph D. Deductible: a. If the applicable Business Auto deduct - Ible Is the smaller (or smallest) deduct- ible it will be waived; or b. If the applicable Business Auto deduct- ible is not the smaller (or.smallest) de- ductible it will be reduced by the amount of the smaller (or smallest) deductible; or c. It the loss involves two or more Busi- ness Auto coverage forms or policies the smaller (or smallest) deductible will be waived. For the purpose of this endorsement "company" means: a. Safeco Insurance Company of America b. American States Insurance Company c. General Insurance Company of America d. American Economy Insurance Company e. First National Insurance Company of America f. American States Insurance Company of Texas g. American States Preferred Insurance Company h. Safeco Insurance Company of Illinois LOAN /LEASE GAP COVERAGE Under paragraph C — LIMIT OF INSURANCE ' SECTION III — PHYSICAL DAMAGE COVERAGE, the following is added: a. Actual cash value of the damaged or stolen property as of the time of the '90ss", less an adjustment for depreciation and physical condition; or b. Balance due under the terms of the loan or lease that the damaged covered "auto" is subject to at the time of the "loss ", less any one or all of the following adjustments: (1) Overdue payment and financial penalties assoclated with those payments as of the date of the 'loss ". (2) Financial penalties imposed under a lease due to high mileage, exces- sive use or abnormal wear and tear. (3) Costs for extended warranties, Cre- dit Life Insurance, Health, Accident or Disability Insurance purchased with the loan or lease. (4) Transfer or rollover balances from previous loans or leases. (5) Fnal payment due under a 'Balloon Loan". (6) The dollar amount of any un- repaired damage that occurred prior to the "total loss" of a covered "auto ". (7) Security deposits not refunded by a lessor. (8) All refunds payable or paid to you as a result of the early termination of a lease agreement or any war- ranty or extended service agree- ment on a covered "auto ". (9) Any amount representing taxes. (10) Loan or lease termination fees GLASS REPAIR — WAIVER OF DEDUCTIBLE Under paragraph D. — DEDUCTIBLE of SECTION 111 — PHYSICAL DAMAGE COVERAGE, the following is added: No deductible applies to glass damage if the glass is repaired rather than replaced. AMENDED DUTIES IN THE EVENT OF ACCI- DENT, CLAIM, SUIT OR LOSS 4. The most we will pay for a total "loss" In any one a The requirement in LOSS CONDITION 2.a. to a $1,500 maximum limit " $1 t: nt" is the greater of the following, subject DUTIES IN THE EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS — of SECTION IV — BUSINESS AUTO CONDITIONS that you must notify us of an CA 71 10 03 07 Page 3 of 6 EP "accident" applies only when the "accident" Is known to: (1) You, if you are an individual; deductible and excess provisions, we will provide coverage equal to the broadest coverage applicable to any covered "auto" you own. (2) A partner, if you are a partnership; or HIRED AUTO PHYSICAL DAMAGE COVERAGE — (3) An executive officer or insurance manager., if you LOSS OF USE are a corporation. SECTION 111 — PHYSICAL DAMAGE AA.b. Form UNINTENTIONAL FAILURE TO DISCLOSE does not apply. HAZARDS Subject to a maximum of $1,000 per accident, we will cover loss of use of a hired 'auto" If It results from SECTION IV — BUSINESS AUTO .CONDITIONS — an accident, you are legally liable and the lessor in- B.2. Is amended by the addition of the following: curs an actual financial loss. If you unintentionally fail to disclose any hazards ex- isting at the inception date of your policy, we will not deny coverage under this Coverage Form because of such failure. However, this provision does not affect our right to collect additional premium or exercise our right of cancellation or non - renewal. HIRED AUTO — LIMITED WORLD WIDE COVER- AGE Under. Section IV — Business Conditions, Paragraph B.7.b.e(1) is replaced by the following: (1) The ~accident" or -loss,, results from the use of an "auto" hired for 30 days or less. RESULTANT MENTAL ANGUISH COVERAGE SECTION V — DEFINITIONS — C. Is replaced by the following: "Bodily Injury" means bodily injury, sickness or dis- ease sustained by a person including mental anguish or death resulting from any of these. HIRED AUTO PHYSICAL DAMAGE COVERAGE If hired "autos" are covered "autos" for Liability cov- erage and if Comprehensive, Specified Causes of Loss or Collision coverages are provided under this Coverage Form for any "auto" you own, then the Physical Damage Coverages provided are extended to 'autos" you hire or borrow. The most we will pay for loss to any hired "auto" is $50,000 or Actual Cash Value or Cost of Repair, whichever is smallest, minus a deductible. The de- ductible will be equal to the largest deductible appli- cable to any owned "auto" of the private passenger or light truck type for that coverage. Hired Auto Phy- sical Damage coverage is excess over any other col- lectible Insurance. Subject to the above limit, RENTAL REIMBURSEMENT COVERAGE A. We will pay for rental reimbursement expenses Incurred by you for the rental of an "auto" be- cause of a covered 'loss" to a covered *auto". Payment applies In addition to the otherwise ap- plicable amount of each coverage you have on a covered 'auto ". No deductibles apply to this coverage. B. We will pay only for those expenses incurred during the policy period beginning 24 hours after the `loss" and ending, regardless of the policy's expiration, with the lesser of the following number of days: 1. The number of days reasonably required to repair or replace the covered •auto ". If loss" Is caused by theft, this number of days Is added to the number of days it takes to locate the covered "auto" and return it to you. 2. 30 days. C. Our payment is limited to the lesser of the fol- lowing amounts: 1. Necessary and actual expenses incurred. 2. $50 per day. D. This coverage does not apply while there are spare or reserve 'autos" availableto you for your operations. E. If "loss" results from the total theft of a covered 'auto" of the private passenger type, we will pay under this coverage only that amount of your rental reimbursement expenses which is not al- ready provided for under the PHYSICAL DAM- AGE COVERAGE Coverage Extension. F. The Rental Reimbursement Coverage described above does not apply to a covered "auto" that is described or designated as a covered "auto" on Page 4 or s Rental Reimbursement Coverage Form CA 99 23. AUDIO, ViSUAL AND DATA ELECTRONIC EQUIPMENT COVERAGE A. Coverage I. We will pay with respect to a covered "auto" for "loss" to any electronic equipment that receives or transmits audio, visual or data signals and that is not designed solely for the reproduction of sound. This coverage applies only if the equipment is permanently installed in the covered "auto" at the time of the "loss" or the equipment is removable from a housing unit which is permanently installed In the covered "auto" at the time of the "loss ", and such equipment is designed to be solely operated by use of the power from the "auto's" electrical system; in or upon the covered "auto ". 2. We will pay with respect to a covered "auto" for 'loss" to any accessories used with the electronic equipment described in paragraph A.I. above. However, this does not include tapes, records or discs. 3. if Audio, Visual and Data Electronic Equip- ment Coverage form CA 99 BO or CA 99 94 is attached to this policy, then the Audio, Vi- sual and Data Electronic Equipment Cover- age described above does not apply. B. Exclusions The exclusions that apply to PHYSICAL DAM- AGE COVERAGE, except for the exclusion relat- ing to Audio, Visual and. Data Electronic Equipment, also apply to this coverage. In addi- tion, the following exclusions apply: We will not pay for either any electronic equip- ment or accessories used with such electronic equipment that is: 1. Necessary for the normal operation of the covered "auto" for the monitoring of the covered "auto's" operating system; or 2. Both: the manufacturer for the Installation of a radio. C. Limit of insurance With respect to this coverage, the LIMIT OF IN- SURANCE provision of PHYSICAL DAMAGE COVERAGE is replaced by the following: 1. The most we will pay for "loss" to audio, vi- sual or data electronic equipment and any accessories used with this equipment as a result of any one 'accident" is the lesser of: a. The actual cash value of the damaged or stolen property as of the time of the "loss"; or b. The cost of repairing or replacing the damaged or stolen property with other property of like kind and quality. c. $1,000. 2. An adjustment for depreciation and physical condition will be made In determining actual cash value at the time of the "loss ". 3. If a repair or replacement results In better than like kind or quality, we will not pay for the amount of the betterment. D. Deductible I. If "loss" to the audio, visual or data elec- tronic equipment or accessories used with this equipment Is the result of a "loss" to the covered "auto" under the Business Auto Coverage Form's Comprehensive or Colli- sion Coverage, then for each covered "auto" our obligation to pay for, repair, return or re- place damaged or stolen property will be re- duced by the applicable deductible shown in . the Declarations. Any Comprehensive Cov- erage deductible shown in the Declarations does not apply to "loss" to audio, visual or data electronic equipment caused by fire or lightning. 2. a. an integral part of the same unit housing any sound reproducing equipment de- signed solely for the reproduction of sound if the sound reproducing equipment is permanently Installed in 3. the covered "auto "; and b. permanently installed in the opening of the dash or console normally used by If "loss" to the audio, visual or data elec- tronic equipment or accessories used with this equipment Is the result of a 'loss" to the covered "auto" under the Business Auto Coverage Form's Specified Causes of Loss Coverage, then for each covered "auto" our . obligation to pay for, repair, return or replace damaged or stolen property will be reduced by a $100 deductible. If "loss" occurs solely to the audio, visual or data electronic equipment or accessories used with this equipment, then for each cov- ered mauto" our obligation to pay for, repair, CA 71 10 03 07 Page 5 of 6 EP return or replace damaged or stolen property will be reduced by a $100 deductible. 4. in the event that there is more than one ap- plicable deductible, only the highest deduct- ible will apply. In no event will more than one deductible apply. Page 6 do SECTION V — DEFINITIONS Is amended by adding the following: Q. "Personal effects" means your tangible property that Is worn or carried by you, ex- cept for tools, jewelry, money, or securities. R. "New vehicle" means any "auto" of which you are the original owner and the "auto" has not been previously titled and is less than 365 days past the purchase date. STATE COMPENSATION INSURANCE FUND POLICYHOLDER COPY P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 08 -24 -2009 CITY OF EL SEGUNDO SG 350 MAIN ST EL SEGUNDO CA 90245 -3813 GROUP: POLICY NUMBER: 1688826 -2009 CERTIFICATE ID: 84 CERTIFICATE EXPIRES: 06 -01 -2010 08 -01- 2009/06 -01 -2010 THIS CERTIFICATE SUPERSEDES AND CORRECTS CERTIFICATE X 83 DATED 08 -21 -2009 JOB:PROJECT NUMBER 09 -14 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. tTHORIZED REPRESENTATI PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE ENDORSEMENT X1600 - THOMAS, CARR PRES - EXCLUDED. ENDORSEMENT #1600 - MAGGIE CARR TRES, SEC - EXCLUDED. ENDORSEMENT X2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06 -01 -2003 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT X2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2009 -08 -24 I ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO i ) EMPLOYER BIG WEST CONSTRUCTION CORPORATION 2691 RICHTER AVE STE 123 IRVINE CA 92606 (REV.2 -05) SG [GJT,CN] PRINTED : 08 -24 -2009 SG WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation: 1. Please be advised that a waiver of subrogation requires that a 3% surcharge will be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certificate holder who requested the waiver. (Note: if you have no employee payroll on that job, then there is no charge.) 2. To apply the 3% surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work on job /s for the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. Example: Payroll for job: $5,000.00 Sample Rate: 13.30% Regular Premium equals: $ 665.00 Surcharge: 3.00°% Additional Waiver charge: $ 19.95 Total premium equals $ 684.95 (665.00 + 19.95)