CONTRACT 4048 Other CLOSEDContract Number: 4048
RESIDENTIAL SOUND INSULATION PROGRAM CONTRACT
BETWEEN
THE CITY OF EL SEGUNDO AND
BIG WEST CONSTRUCTION CORPORATION
This contract is entered into this I&r- day of February a 10, by and between the City of El
Segundo, a general law city and municipal corporation ("the City") and Big West Construction
Corporation ("the Contractor").
1. WORK.
A. The Contractor will provide all work required by the Contract Documents (the
"Work"). The Contractor agrees to do additional work arising from changes
ordered by the City in accordance with the Contract Documents.
B. The Contractor and the City agree to abide by the terms and conditions contained
in the Contract Documents;
C. The Contractor will furnish all of the labor; supplies and materials; equipment;
printing; vehicles; transportation; office space and facilities; all tests, testing and
analyses; and all matters whatsoever (except as otherwise expressly specified to
be furnished by the City) needed to perform and complete the Work and provide
the services required of the Contractor by the Contract Documents.
D. "Contract Documents" means the Notice Inviting Bids; Instructions to Bidders;
Supplementary Instructions to Bidders; Proposal; this Contract; Standard
Specifications; Supplementary Conditions; Exhibits; Technical Specifications;
List of Drawings; Drawings; Addenda; Notice to Proceed; Change Orders; Notice
of Completion; and all other documents identified in the Contract Documents
which together form the contract between the City and the Contractor for the
Work. The Contract Documents constitute the complete agreement between the
City and the Contractor and supersede any previous agreements or
understandings.
2. CONTRACT SUM. The City agrees to pay the Contractor a sum not to exceed Seven
hundred seventeen thousand, eight hundred dollars and zero cents ($717,800.00) for the Work in
the manner set forth in the Contract Documents. The City may adjust this amount as set forth in
the Contract Documents.
3. TIME FOR PERFORMANCE.
SEE A. The Contractor will fully complete the Work within the time specified in the
0&4#4 Contract Documents (the "Contract Time.")
Residential Sound Insulation Program Group 39 Construction Contract (02/18/2010)
Contract Number: 4048
B. The Contract Time will commence when the City issues a notice to proceed. The
Contract Documents will supersede any conflicting provisions included on the
notice to proceed issued pursuant to this Contract.
C. The Contractor shall not perform any Work until:
The Contractor furnishes proof of insurance as required by the Contract
Documents; and
ii. The City gives the Contractor a written, signed, and numbered purchase
order and notice to proceed.
D. By signing this Contract, the Contractor represents to the City that the Contract
Time is reasonable for completion of the Work and that the Contractor will
complete the Work within the Contract Time.
E. Should the Contractor begin the Work before receiving written authorization to
proceed, any such Work is at the Contractor's own cost and risk.
4. DISPUTES. Disputes arising from this contract will be determined in accordance with the
Contract Documents and Public Contracts Code §§ 10240-10240.13.
5. TAXPAYER IDENTIFICATION NUMBER. The Contractor will provide the City with a
Taxpayer Identification Number.
6. PERMITS AND LICENSES. Unless otherwise provided, the Contractor, at its sole
expense, will obtain and maintain during the Contract Time, all necessary permits, licenses, and
certificates that may be required in connection with the Work.
7. OWNERSHIP OF DOCUMENTS. All documents, data, studies, drawings, maps, models,
photographs and reports prepared by the Contractor under the Contract Documents are the City's
property. The Contractor may retain copies of said documents and materials as desired, but will
deliver all original materials to the City upon the City's written notice.
8. INDEMNIFICATION. The Contractor agrees to indemnify and hold the City harmless as
set forth in the Contract Documents. The requirements as to the types and limits of insurance
coverage to be maintained by the Contractor as required by the Contract Documents, and any
approval of such insurance by the City, are not intended to and will not in any manner limit or
qualify the liabilities and obligations otherwise assumed by the Contractor pursuant to the
Contract Documents, including, without limitation, to the provisions concerning indemnification.
9. INDEPENDENT CONTRACTOR. The City and the Contractor agree that the Contractor
will act as an independent contractor and will have control of all work and the manner in which
is it performed. The Contractor will be free to contract for similar service to be performed for
other employers while under contract with the City. The Contractor is not an agent or employee
Residential Sound Insulation Program 2 Group 39 Construction Contract (02/18/2010)
Contract Number: 4048
of the City and is not entitled to participate in any pension plan, insurance, bonus or similar
benefits the City provides for its employees. Any provision in this Contract that may appear to
give the City the right to direct the Contractor as to the details of doing the work or to exercise a
measure of control over the work means that the Contractor will follow the direction of the City
as to end results of the work only.
10. AUDIT OF RECORDS. The Contractor will maintain full and accurate records with
respect to all services and matters covered under this Contract. The City will have free access at
all reasonable times to such records, and the right to examine and audit the same and to make
transcript therefrom, and to inspect all program data, documents, proceedings and activities. The
Contractor will retain such financial and program service records for at least three (3) years after
termination or final payment under the Contract Documents.
11. NOTICES. All communications to either party by the other party will be deemed made
when received by such party at its respective name and address as follows:
The Cily
Frank Haywood
City of El Segundo
RSI Program
333 Main Street, Unit A
El Segundo, CA 90245
The Contractor
Thomas Carr
Big West Construction Corporation.
2691 Richter Avenue, #123
Irvine, California 92606
Any such written communications by mail will be conclusively deemed to have been received by
the addressee three (3) days after deposit thereof in the United States Mail, postage prepaid and
properly addressed as noted above. In all other instances, notices will be deemed given at the
time of actual delivery. Changes may be made in the names or addresses of persons to who
notices are to be given by giving notice in the manner prescribed in this paragraph.
12. NO THIRD PARTY BENEFICIARY. This Contract and every provision herein are for the
exclusive benefit of the Contractor and the City and not for the benefit of any other party. There
will be no incidental or other beneficiaries of any of the Contractor's or the City's obligations
under this Contract.
13. INTERPRETATION. This Contract was drafted in, and will be construed in accordance
with the laws of the State of California, and exclusive venue for any action involving this
Contract will be in Los Angeles County.
14. EFFECT OF CONFLICT. In the event of any conflict, inconsistency, or incongruity
between any provision of the Contract Documents, precedence will be as follows:
A. This Contract;
B. Precedence of documents as determined in the Standard Specifications.
Residential Sound Insulation Program 3 Group 39 Construction Contract (02/18/2010)
Contract Number: 4048
15. SEVERABILITY. If any portion of the Contract Documents are declared by a court of
competent jurisdiction to be invalid or unenforceable, then such portion will be deemed modified
to the extent necessary in the opinion of the court to render such portion enforceable and, as so
modified, such portion and the balance of this Contract will continue in full force and effect.
16. AUTHORITYIMODIFICATION. The Parties represent and warrant that all necessary
action has been taken by the Parties to authorize the undersigned to execute this Contract and to
engage in the actions described herein. This Contract may be modified by written amendment.
The City's city manager, or designee, may execute any such amendment on the City's behalf.
17. ACCEPTANCE OF FACSIMILE SIGNATURES. The Parties agree that this Contract,
agreements ancillary to this Contract, and related documents to be entered into in connection
with this Contract will be considered signed when the signature of a party is delivered by
facsimile transmission. Such facsimile signature will be treated in all respects as having the
same effect as an original signature.
18. COVENANTS AND CONDITIONS. The parties agree that all of the provisions hereof
will be construed as both covenants and conditions, the same as if the words importing such
covenants and conditions had been used in each separate paragraph.
19. CAPTIONS. The captions of the paragraphs of this Contract are for convenience of
reference only and will not affect the interpretation of this Contract.
20. TIME IS OF ESSENCE. Time is of the essence for each and every provision of the
Contract Documents.
21. COMMUNITY DEVELOPMENT BLOCK GRANT REQUIREMENT
This is a federally assisted construction contract and Federal labor standards, including Davis -
Bacon requirements, will be enforced. If Federal and State wage rates are applicable, then the
higher of the two will prevail.
[Signatures on next page]
Residential Sound Insulation Program 4 Group 39 Construction Contract (02/18/2010)
Contract Number: 4048
IN WITNESS WHERE OF the parties hereto have executed this contract the day and
year first hereinabove written.
CITY OF EL SEGUNDO:
A gf
RA
ATTEST:
By: 0�0��;�atktA
Cindy rtesen
City Clerk
APPROVED
MARK D. HI
By: Kf� Y
r
arl ft. Berger.
Assistant Cit1/1
TTORNEY
CONTRACTOR:
Big West Construction Corporation.
Tomas Carr
Vice -President
Taxpayer ID
Number �
Contractor State Q
License Number
Contractor City
Business License ag a�a
Number
Residential Sound Insulation Program 5 Group 39 Construction Contract (02/18/2010)
' City of El Segundo
Residential Sound Insulation Program
BOND PREMIUM IS SUBJECT TO CHANGE BASED ON FINAL
r PRICE
4048
FAITHFUL PERFORMANCE BOND
Bond NO.2081255
Bond Fee: $9,610.00
BIG WEST CONSTRUCTION CORPORATION as principal ("PRINCIPAL") and
NORTH AMERICAN SPECIALTY INSURANCE COMPANY a corporation incorporated under
the laws of the State of NEW HAMPSHIRE and; licensed by the State of
California to execute bonds and undertakings as sole surety, as surety ("SURETY"), are held and
firmly bound unto the City of El Segundo ("CITY") in the sum of
SEVEN HUNDRED SEVENTEEN THOUSAND EIGHT HUNDRED AND 00/100 dollars ($ 71 7,800.00
(words)
lawful money of the United States, which may be increased or decreased by a rider hereto
executed in the same manner as this bond, for the payment of which sum PRINCIPAL and
SURETY bind themselves, their successors, and assigns, jointly and severally, by this
instrument.
PRINCIPAL or SURETY
. AA ,jl fgr the faithful perfo' ance of any and all of the
conditions and stipulations se! forth in this bond, Contract Documents for Group 39 (RSI
10 _ 01 of the City oW14eh q' entiai S »
,:� ..... JECT) and
Contract aoaa & s�t 131�*t insElca ! rmance of
..
the conditions and stipulations of this undertaking, it is agror SURETY
will apply the bond or any portion thereof, to the satisfaction apy daWages,,. reclamation,
assessments, penalties,p~ Rfg,4 • son-a6th dwoqW
(1�+1�'Jfi�'l.;li '1t 4't<ti���isi,'r'eR.rr."i , ° •. ' .jt.'.iltJ'+Fits. Ikil'�01*„�lttu'C°>?t1GiU�:i`.s
Bond Conditions to ilj!!4� iEC��:�1 yt� fit f;Yt "41w � .: ":'i � � . 1.. L tx iliiii r4 ..,N1Wt*k E; iiraa e110,
ray i5 •`, :� ff edCri 1.?w" i CtS2's�t c �r ; Nil 0 'ada to 1tyfMliF i ST! :Ibis aW .irlo :::t; g <f
1. PRINCIPAL 0ftJV ajjs dry 4} Iffliw
AL will, corlsl�ct,thp�','�itts islecttif�ed,1+�9Elt#tY dents for
the PROJECT, copses of which ,fie, =.�le_in the GI s Resicten'Yialf` ouri` Insulation
Program offices. Such performance will be in accordance with the requirements of the
Contract Documents which are made a part of this bond by reference.
2. PRINCIPAL's work on the PROJECT will be done in accordance with the requirements
of the Contract Documents for the PROJECT and with permits issued by the CITY.
Should PRINCIPAL fail to complete all required work within the time allowed, CITY
may, at its sole discretion, cause all required work to be done and the parties executing
the bond will be firmly bound for the payment of all necessary costs therefor.
3. PRINCIPAL will guarantee its work against any defective work, labor, or materials on
the PROJECT for a period of one (1) year following the PROJECT's completion and
acceptance by the CITY.
4. PRINCIPAL will pay for all materials and other supplies, for equipment used in, on, for
or about the performance of the Project, and will pay for all work and labor thereon.
Faithful Performance Bond 1
Last Modified: April 22, 2009
i
Certificate pursuant to 996.64o(s) Code of CMtl pr "dur#
COWdy perk of Me Count
of Lea Angak QQ61x,.,...... State of Csff mb, inanal ibr aw courty
DO HEREBY CERTIFY THAT
� s oer�Aaae authority as ai, r: aty tss ey the catNomia
m81 wmCamnleeia W authorizft ttz< :,..Wier to nnew8W8Yy irieurW"in
the so" of CalilOm, a0 #0 baba ims moofft sham in go Dwartfn "Of
MouranOe tiYebeili that aighonny hp iwt rani >iiirAfl Q, reN0lteQ, �9ngetad�
Ganimea. or auapwma
in Touvnwwam County Oil --A-.-...., e t sin"two am ,attaced the steal of
C 4*'`�" COUNTY CLERK
BY: \ .--/, "IA `r Uepuri County Clerk
a. SHERLOCK
4048
City of El Segundo
Residential Sound Insulation Program
5. This bond is conditioned upon and guarantees due compliance with all applicable law
including, without limitation, the El Segundo Municipal Code ("ESMC").
6. SURETY, for value received, agrees that no changes, extensions of time, alteration or
modification of the Contract Documents, or of the obligation; to be performed will in any
way affect its obligation on this bond, and it waives notice o£ any such change, extension
of time, alteration or modification of the contract documents or of the obligation to be
performed.
7. This bond consists of this instrument; the Contract Documents identified above; and the
following two (2) attached exhibits all of which are incorporated herein by reference:
A. A certified copy of the appointment, power of attorney, bylaws or other
instrument entitling or authorizing the persons executing this bond to do so; and
B. A certificate issued by the county clerk for the county in which SURETY's
representative is located conforming with California Code of Civil Procedure
§995.640 and stating that SURETY's certificate of authority has not been
surrendered, revoked, cancelled, annulled, or suspended, or in the event that it
has, that renewed authority has been granted.
8. Should PRINCIPAL perform its obligations within the ti,ine allowed, PRINCIPAL's
obligation will be void upon the acceptance of the performance by CITY; otherwise this
obligation will remain in full force and effect.
• r �N
SIGNED AND SEALED this 22ND day of FEBRUARY , 2010
BIG WEST CONSTRUCTION CORPORATION NORTH AMERICAN SPECIALTY INSURANCE COMPANY
NCIPAL's President SURETY' rest ent YUNG T.�YN-
ICK
ATTOR FACT
PT CIPAL's Secretary
NOTE
ALL signatures must be acknowledged by a notary
PRINCIPAL's Mailing Address
BIG WEST CONSTRUCTION CORPORATION
2691 RICHTER AVE., STE. 123
IRVINE, CA 92606
s Secretary
's Mailing Address
NORTH AMERICAN SPECIALTY INSURANCE COMPANY
701 S. PARKER ST., STE. 3800
ORANGE, CA 92868
Faithful Performance Bond 2 Last Modified: April 22, 2009
r�
ACKNOWLEDGMENT
State of California
County of Orange )
On February 22, 2010 before me, Christine T. Hoang, Notary Public
(insert name and title of the officer)
personally appeared Yune T. Mullick
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/aw
subscribed to the within instrument and acknowledged to me that he**@Abq executed the same in
hisk)ed&je r authorized capacity(*, and that by his/iaa %t ak signature(s) on the instrument the
person(*), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal. `°Fri CHRISTINE T. HOANG
COMM, # 1827909 X
x o NOTARY PU8UGCAUF4RNlA X
ORANGE COUNTY
Signature (Seal) My Comm, Er5 aEC Z. 2012
404
.a
NAS SURETY GROUP
NORTH AMERICAN SPECIALTY INSURANCE COMPANY
WASHINGTON INTERNATIONAL INSURANCE COMPANY
GENERAL POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, THAT North American Specialty Insurance Company, a corporation duly organized and existing under
laws of the State of New Hampshire, and having its principal office in the City of Manchester, New Hampshire, and Washington International
Insurance Company, a corporation organized and existing under the laws of the State of New Hampshire and having its principal office in the City of
Itasca, Illinois, each does hereby make, constitute and appoint:
JENNIFER C. GIBONEY, JAMES W. MOILANEN, YUNG T. MULLICK,
CHRISTINE T. HOANG and P. AUSTIN NEFF
JOINTLY OR SEVLRALLY
Its true and lawful Attorney(s)-in-Fact, to make, execute, seal and deliver, for and on its behalf and as its act and deed, bonds or other writings
obligatory in the nature of a bond on behalf of each of said Companies, as surety, on contracts of suretyship as are or may be required or permitted by
law, regulation, contract or otherwise, provided that no bond or undertaking or contract or suretyship executed under this authority shall exceed the
amount of TWENTY-FIVE MILLION (S25,000,000.00) DOLLARS
This Power of Attorney is granted and is signed by facsimile under and by the authority of the following Resolutions adopted by the Boards of
Directors of both North American Specialty Insurance Company and Washington International Insurance Company at meetings duly called and held
on the 24 h of March, 2000:
"RESOLVED, that any two of the Presidents, any Managing Director, any Senior Vice President, any Vice President, any Assistant Vice President,
the Secretary or any Assistant Secretary be, and each or any of them hereby is authorized to execute a Power of Attorney qualifying the attorney named
in the given Power of Attoriey to execute on behalf of the Company bonds, undertakings and all contracts of surety, and that each or any of them
hereby is authorized to attest to the execution of any such Power of Attorney and to attach therein the seal of the Company; and it is
FURTHER RESOLVED, that the signature of such officers and the seal of the Company may be affixed to any such Power of Attorney or to any
certificate relating thereto by facsimile, and any such Power of Attorney or certificate bearing such facsimile signatures or facsimile seal shall be
binding upon the Company when so affixed and in the future with regard to any bond, undertaking or contract of surety to which it is attached."
�P 1ALirY �/ pnwnaim
�,p510N,q f��
�tippPol�,G r y B
P s
_•.' G r�
SEAL Steven P. Anderson, President & Chief ExemWe Officer of K'aslibiglnn Inlernatiamal Insurance Company i SEAL
s� tp70 4'. m & Senior Vice Presideal of North American Specialty msuraoce Company
iltlFt 1rn
By
David Al. Layman, Senior Vice Presider or Washington International Insurance Company `t�
& Vice President of North American Specialty Insurance Company
IN WITNESS WHEREOF, North American Specialty Insurance Company and Washington International Insurance Company have caused their
official seals to be hereunto affixed, and these presents to be signed by their authorized officers this 20th day of February 20 09
North American Specialty Insurance Company
Washington International Insurance Company
State of Illinois
County of Du Page SS:
On this 20th day of February 20 09 , before me, a Notary Public personally appeared Steven P. Anderson , President and CEO of
Washington International Insurance Company and Senior Vice President of North American Specialty Insurance Company and David M. Layman ,
Senior Vice President of Washington International Insurance Company and Vice President of North American Specialty Insurance Company,
personally known to me, w143 being by me duly- sworn, acknowledged that they signed the above Power of Attorney as officers of and
acknowledged said instrument to be the voluntary act and deed of their restlective commutes.
"OFFICIAL S='
DONNA D. SKLENS
Notary Public, State of Hlix*
My Commission E pi rs 10/OQ II
Donna D. Sklens, Notary Public
I, James A. Carpenter the duly elected Assistant Secretary of North American Specialty Insurance Company and Washington
International Insurance Company, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney given by said North
American Specialty Insurance Company and Washington International Insurance Company, which is still in full force and effect.
IN WITNESS WHEREOF, I have set my hand and affixed the seals of the Companies this 22N day of FEBRUARY 20 10 .
James A Carpenter, Vice President & Assistant Sevetary of Washington InL—ational Insurance Company &
North American Specialty Insurance Company
4 U 1 8.
CALIFORNIA•ACKNOWLEDGMENT
��.��.,c�a',�s�S.�C > ��c�3 �;�5 >,:,� > � ti�a$ � �,.�J$ _%��..c�S S,�$; �aR.: Vim.' . .�t3: ��.3 �.�.�5„�,•.�.�':��.:..�S,�t;�S.�B,�-•�.a'�.�J: �.�S�i;�-•,'�>,?.�
State of California ,,,,,,p
County of �,1� A e's
On — before me,4� L-
Dat 0Hre nsert Name find Title of the Offi r
personally appeared ►�
Name(s) of Signer(s)
KATHY A. PEW
Commission V' 1832085
Z +� Notary Public - California
Los Angeles County
My Comm. Expires Jan 19, 2013
—ww
Place Notary Seal Above
who proved to me on the basis of satisfactory evidence to
be the person whose name)k&am subscribed to the
withj,'n instrument and acknowleda2d to me that
-h hKey executed the same in i /he thair authorized
capaclty(t&j, and that by er heir signature(sf on the
instrument the person(o, or the entity upon behalf of
which the personW acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph is
true and correct.
WITNESS my hand and official seal.
Signature
ignatu e o Notary Public
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Docume nt:�.�i(� I. tmrk f M roy WILAAck— MIA
Document Date: �C�✓►tU 61� oL Number of Pages:
Signer(s) Other Than Named Above: p
Capacity(ies) Claimed by Signer(s)
Signer's Name:
❑ Individual
❑ Corporate Officer — Title(s):
❑ Partner — ❑ Limited ❑ General
❑ Attorney in Fact 7�7
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
Signer's Name:
❑ Individual
❑ Corporate Officer — Title(s): _
❑ Partner — ❑ Limited ❑ General
❑ Attorney in Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing
RIGHT THUMBPRINT
OF SIGNER
02007 National Notary Association • 9350 De Soto Ave., P.O. Box 2402 • Chatsworth, CA 91313.2402 • www.NationalNotary.org Item #5907 Reorder: Call Toll -Free 1-800-876-6827
40°�8•
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
State of California
County of Ora noz ss.
On 31 1 1 before me,
Doke T
e a Title of Officer (e.g., "Jane Doe, Notary
personally appeared J1%2 Q'/�P� l /�
RO�YN J. CARR-OR
GpIII aslin l 117107Zi
INOtory fteft - COWOWAG
Name(s) of Signer(s)
personally known to me
❑ proved to me on the basis of satisfactory evidence
to be the person(s) whose name(s) is/are subscribed
to the within instrument and acknowledged to me that
he/she/they executed the same in his/her/their
authorized capacity(ies), and that by his/her/their
signature(s) on the instrument the person(s), or the
entity upon behalf of which the person(s) acted,
executed the instrument.
WITN my hand and official seal.
Place Notary Seal Above
av�
gnature of Notary Public
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another document.
Description of Attached curne�t /
Title or Type of Document: ��jT
Document Date: a/aa.� (C� Number of Pages:
Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name:
❑ Individual
❑ Corporate Officer — Title(s):
❑ Partner — ❑ Limited ❑ General
❑ Attorney in Fact Top of thumb here
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
Signer's Name:
❑ Individual
❑ Corporate Officer — Title(s):
❑ Partner — ❑ Limited ❑ General
❑ Attorney in Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing
0
RIGHT THUMBPRINT
OF SIGNER
•• • 1
02004 National Notary Association 9350 D- Soto Ave., P.O. Box 2402 Chatsworth, CA 91313-2402 Item No. 5907:11
4048.
City of El Segundo v
Residential Sound Insulation Program
row:
LABOR AND MATERIALS BOND
Bond No.. 2081255
Bond Fee*,PREMIUM IS INCLUDED IN PERFORMANCE BOND
BIG WEST CONSTRUCTION CORPORATION as principal ("PRINCIPAL") and
NORTH AMERICAN SPECIALTY INSURANCE COMPANY a corporation incorporated under
the laws of the State of NEW HAMPSHIRE and licensed by the State of
California to execute bonds and undertakings as sole surety, as surety ("SURETY"), are held and
firmly bound unto the City of El Segundo ("CITY") in the sum of
SEVEN HUNDRED SEVENTEEN THOUSAND EIGHT HUNDRED AND 00/100 dollars ($ 717,800.00
(Wor&)
lawful money of the Unimd Stater wl�igh may be increased or decreased by a rider hereto
executed in the same manne `as Hi' �b'61S�i,�F&-tile payment. of .wbiG4 ;PRINCIPAL and
SURETY bind themeless their successors, and assigns, jointly and severally, by this
x�U'}kv
instrument. T r_,�7 ,p
This bond is conditioned upon and guarantees payment °y1 14o%` contractors,
subcontractors, and p equipment, .payment by,.PRINCIPAL and all PRINCIPAL'S
r r ,g++ t .... .
subcontractors for all �� „ p ><orisry pt ovender, cir otlkrtsa#p i�sgEa> t � ent used in,
upon, for or about inn j
P i� �4 ,the,;v ; coy t �� ' i`fi"4�'°��'�P�Lt;Documents for
Group 39 (RSI 1aci#r't°htItge bfl Segr�jp{``' .' rsttjfion Program
ram;
("PROJECT") and C04VA9t a as. executed for such Prole*p Hk or labor of
a
any kind performed for the. Protect; n the c1se � AYflta�! tt-�.PeYfdrmance of the
conditions and stipulations of, this undertaking, it is� a�ieed 'that P . IPAL'or"5VRETY will
apply the bond or any portion thereof, to the satisfaction of ')Iny damages, reclamation,
assessments, penalties, or deficiencies arising by reason of such defalt.
Bond Conditions
1. PRINCIPAL will construct the improvements identified in the Contract Documents for
the PROJECT, copies of which are on file in the CITY's Residential Sound Insulation
Program offices. Such performance will be in accordance with the requirements of the
Contract Documents which are made a part of this bond by reference.
2. PRINCIPAL will pay all contractors, subcontractors, and persons renting equipment.
3. PRINCIPAL will pay for all materials and other supplies, for equipment used in, on, for
or about the performance of the Project, and will pay for all work and labor thereon.
4. This bond is conditioned upon and guarantees due compliance with all applicable law
including, without limitation, the El Segundo Municipal Code ("ESMC").
S. SURETY, for value received, agrees that no changes, extensions of time, alteration or
Labor and Materials Bond 1 Last Modified: Apri122, 2009
40
CefUftsb pursuant to 995.640(m) Code of CWN PIWIduM
W a AhI C-LOMN ..... County Cl6tofthe Courtly
of Ebs- AngeM .aunty_-- Steft of CaRtMia, In and for "M County
DO HEREBY CERTIFY THAT
Ingmt" (;Omnvssww SU0010%
tm k*snmWwmmvmott tboimw lo'j.c won SurmxW4 NvIommDd,
GWOW4
winuled, or W$PwxwA and afted the seal Of
In Tesgamy ftwv� have =t MY Wd
said County on L
COUNTY CLERK
BY., - Deputy County CIA
~ City of El Segundo 404
Residential Sound Insulation Program
modification of the Contract Documents, or of the obligationto be performed will in any
way affect its obligation on this bond, and it waives notice of', any such change, extension
of time, alteration or modification of the contract documents or of the obligation to be
performed.
6. This bond consists of this instrument; the Contract Documents identified above; and the
following two (2) attached exhibits all of which are incorporated herein by reference:
A. A certified copy of the appointment, power of ! attorney, bylaws or other
instrument entitling or authorizing the persons executing this bond to do so; and
B. A certificate issued by the county clerk for the county in which SURETY's
representative is located conforming with California Code of Civil Procedure §
995.640 and stating that SURETY's certificate . of authority has not been
surrendered, revoked, cancelled, annulled, or suspended, or in the event that it
has, that renewed authority has been granted.
7. Should PRINCIPAL perform its obligations within the time allowed, PRINCIPAL's
obligation will be void upon the acceptance of the performance by CITY; otherwise this
obligation will remain in full force and effect.
SIGNED AND SEALED this 22ND day of FEBRUARY , 2010
BIG WEST CONSTRUCTION CORPORATION NORTH AMERICAN SPEC SURANCE CO NY
RINCIPAL's President S TY' e ent YUNG T. ULLICK,
ATTOR EY-IN-FACT
PRIM AL's Secretary - ' S TY's Secretary
NOTE: ALL signatures must be acknowledged by a notary public.
PRINCIPAL's Mailing Address S11RETY's Mailing Address
BIG WEST CONSTRUCTION CORPORATION NORTH AMERICAN SPECIALTY INSURANCE COMPANY
2691 RICHTER AVE., STE. 123 701 S . PARKER ST., STE. 3800
IRVINE, CA 92606 ORANGE, CA 92868
Labor and Materials Bond 2 ' Last Modified: April 22, 2009
4048
ACKNOWLEDGMENT
State of California
County of Orange )
On February 22, 2010 before me, Christine T. Hoang, Notary Public
(insert name and title of the officer)
personally appeared Yung T. Mullick
who proved to me on the basis of satisfactory evidence to be the person() whose name(is) is/HXX
subscribed to the within instrument and acknowledged to me that he%tgAb+ executed the same in
hisbt*Kklmk authorized capacity(al*, and that by hisftexbftak signature(&) on the instrument the
person(g), or the entity upon behalf of which the person() acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal. �s�LOp CHRISTINE T. HOANG
cV �' a COMM, # 1927SO9 X
a NOTARY PU®LIGCALIFORNIA ;0
1 CL
ORANGE: COUNTY
Signature V MY gym, Ey. +ms DEC n, 2012
� (Seal)
404 8 .
.i
NAS SURETY GROUP
NORTH AMERICAN SPECIALTY INSURANCE COMPANY
WASHINGTON INTERNATIONAL INSURANCE COMPANY
GENERAL POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, THAT North American Specialty Insurance Company, a corporation duly organized and existing under
laws of the State of New Hampshire, and having its principal office in the City of Manchester, New Hampshire, and Washington International
Insurance Company, a corporation organized and existing under the laws of the State of New Hampshire and having its principal office in the City of
Itasca, Illinois, each does hereby make, constitute and appoint:
JENNIFER C. GIBONEY, JAMES W. MOILANEN, YUNG T. MULLICK,
CHRISTINE T. HOANG and P. AUSTIN NEFF
JOINTLY OR SL•VLRALLY
Its true and lawful Attorney(s)-in-Fact, to make, execute, seal and deliver, for and on its behalf and as its act and deed, bonds or other writings
obligatory in the nature of a bond on behalf of each of said Companies, as surety, on contracts of suretyship as are or may be required or permitted by
law, regulation, contract or otherwise, provided that no bond or undertaking or contract or suretyship executed under this authority shall exceed the
amount of: TWENTY-FIVE MILLION (S25,000,000.00) DOLLARS
This Power of Attorney is granted and is signed by facsimile under and by the authority of the following Resolutions adopted by the Boards of
Directors of both North American Specialty Insurance Company and Washington International Insurance Company at meetings duly called and held
on the 24th of March, 2000:
"RESOLVED, that any two of the Presidents, any Managing Director, any Senior Vice President, arty Vice President, any Assistant Vice President,
the Secretary or any Assistant Secretary be, and each or any of them hereby is authorized to execute a Power of Attorney qualifying the attorney named
in the given Power of Attorney to execute on behalf of the Company bonds, undertakings and all contracts of surety, and that each or any of them
hereby is authorized to attest to the execution of any such Power of Attorney and to attach therein the seal of the Company; and it is
FURTHER RESOLVED, that the signature of such officers and the seal of the Company may be affixed to any such Power of Attorney or to any
certificate relating thereto by facsimile, and any such Power of Attorney or certificate bearing such facsimile signatures or facsimile seal shall be
binding upon the Company when so affixed and in the future with regard to any bond, undertaking or contract of surety to which it is attached."
�a'��,,,N���3�,IIJJ+7LY11p,_Ny1yi�� uun�wiuiui
By
i;<�pCMO•'4{-fW.G y _. �p'C10NA(-
A' s
Sln•enP. Aatiersan,PreMenl&Cldef Exemtive Ofhcerof'Aashingtmi Inlematioiiai Insurance Casnpany SEAL,$
1973 y:.^ & Senior Vice President of North Aimn Spectaky Insurance Cmnpany
rner
By.
MAd M. Layman, Senior Vice President or Washhsgtm International Inmrance Company raw
& Vice President of North American Specialty Inmrance Company
IN WITNESS WHEREOF, North American Specialty Insurance Company and Washington International Insurance Company have caused their
official seals to be hereunto affixed, and these presents to be signed by their authorized officers this 20th day of February , 20 09 .
North American Specialty Insurance Company
Washington International Insurance Company
State of Illinois
County of Du Page ss:
On this 20th day of February 20 09 , before me, a Notary Public personally appeared Steven P. Anderson , President and CEO of
Washington International Insurance Company and Senior Vice President of North American Specialty Insurance Company and David M. Layman ,
Senior Vice President of Washington International Insurance Company and Vice President of North American Specialty Insurance Company,
personally known to me, who being by me duly sworn, acknowledged that they signed the above Power of Attorney as officers of and
acknowledged said instrument to be the voluntary act and deed of their respective companies.
DONNA D. SKIENS
Notary Public, State of Min,
P% CommworrExpiies101061wil
Donna D. Sklens, Notary Public
I, James A. Carpenter the duly elected Assistant Secretary of North American Specialty Insurance Company and Washington
International Insurance Company, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney given by said North
American Specialty Insurance Company and Washington International Insurance Company, which is still in full force and effect.
IN WITNESS WHEREOF, I have set my hand and affixed the seals of the Companies this 22ND day of FEBRUARY 20 1 o .
James A Carpenter, Vice President &Assistant Sect-etary of Washington International Insurance CorTmy &
North American Specialty Insurance Company
40
CALIFORNIA-•ACKNOWLEDGMENT
�s s s,�s , s <,�>�s s s ;. s,�.�s,�s r.��,a• �a�s,�s� :-u�..�s� :� ,?�>,:as,.�.,�>�cs, s��a.•�, ..,ems s ,�. e,�c�.,,: �
State of California
County of�
On
whT,hol.2,0
Date
personally appeared
KATHY A. PEW
Commission # 1832085
Z.e Notary Public - California Z
Los Angeles County
My Comm. Expires Jan 19, 2013
Place Notary Seal Above
who proved to me on the basis of satisfactory evidence to
be the person,X whose nameke)(s afafe subscribed to the
within instrument and acknowled ed to me that
hElehey executed the same in bis' e heir authorized
capacity(ies), and that by h4 er them signature( on the
instrument the person(s), or a entity upon behalf of
which the person acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph is
true and correct.
WITNESS my handarld official seal.
Signature
4--- -�-- -11l't
ignatu of Notary Public
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Document: I ��. U r + f V' ow �& a�
Document Date: Number of Pages: cf
Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name:
❑ Individual
❑ Corporate Officer — Title(s): _
❑ Partner — ❑ Limited ❑ General
❑ Attorney in Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
RIGHTTHUMBPRINT
OF SIGNER
o
p of thumb here
Signer's Name:
❑ Individual
❑ Corporate Officer — Title(s):
❑ Partner — ❑ Limited ❑ General _
❑ Attorney in Fact •
❑ Trustee Top of thumb here
❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
02007 National Notary Association- 9350 De Soto Ave., P.O. Box 2402 • Chatsworth, CA 91313-2402 • www.NationalNotary.org Item #5907 Reorder: Call Toll -Free 1-800-876-6827
40�1.
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
Ss�>•SS>•s�S.TZ �aS S>'!.>,c�CS,.�nSi,_..,�S�2,F�S,..1S,.z�...�4,?�3✓.�a.,.�S,..�S,..aS_s�. ,.2.,:vs�tS,c�Q,_.�>,..�QS>' S,c�.s�>,c�>,
State of California
County of
On C before me, ss.
Date Name and�t f Offerer (e.g.
personally appeared 01 t (-W t1T:� . C _
Name(s) of Signer(s)
COIL — ffi c 017"Mi
1,6 RC" J. 4w
Noloiy tuONe - CdNaff"
ihNINNAeft w�
Place Notary Seal Above
KItary Publ
ic")
personally known to me
❑ proved to me on the basis of satisfactory evidence
to be the person(s) whose name(s) is/are subscribed
to the within instrument and acknowledged to me that
he/she/they executed the same in his/her/their
authorized capacity(ies), and that by his/her/their
signature(s) on the instrument the person(s), or the
entity upon behalf of which the person(s) acted,
executed the instrument.
my hand and official seal.
11,T7
ignature of Notary Public
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Document: anti mmutrl ,d
Document Date: c;2J c Z� ,j 10 Number of Pages:
Signer(s) Other Than Named Above: MA
Capacity(ies) Claimed by Signer(s)
Signer's Name:
❑ Individual
❑ Corporate Officer — Title(s):
❑ Partner — ❑ Limited ❑ General
❑ Attorney in Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
RIGHT THUMBPRINT
OF SIGNER
.. of thumb here
Signer's Name:
❑ Individual
❑ Corporate Officer — Title(s): _
❑ Partner-0 Limited ❑ General
❑ Attorney in Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
RIGHT THUMBPRINT
OF SIGNER
.. of thumb here
LLB✓:�✓:�✓:�✓:�3�✓.�✓t�✓4�3�✓:`i7:`y:"3:"✓"i,`✓',%L".•r:�✓:�✓:�✓S"a/?,`Li�Li`✓3�3�✓5�.�.�S�i�i".•7i,`✓.`✓✓�,�✓.`3:`✓`"✓'y,�J,y,"✓";"ri;�i ✓'ii `
O 2004 Nall nal Notary Association - 9350D- Soto Ave., '• Box 24021 •1 80
CERTIFICATE OF INSURANCE ISSUE DATE
02/23/2010
PRODUCER Cert# 57239 TTHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
GEORGE L. BROWN INSURANCE AGENCY +.CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER- THIS CERTIFICATE
1005 CALLS RECODO ' DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
SAN CLEMENTE, CA 92673 i POLICIES BELOW_
949.361.1400
FAX 949,361.2757
COMPANIES AFFORDING COVERAGE
COMPANY
A NORTH AMERICAN CAPACITY INSURANCE CO
'COMPANY
BIG WEST CONSTRUCTION CORPORATION 1 B AMERICAN STATES INSURANCE COMPANY
2691 RICHTER AVE #123
IRVINE. CA 92606
i COMPANY
i. C
COMPANY
THIS tS TO CER TIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN RUED TOTHE INSURED NA16%=D ABOVE FOR THE POLICY PERIOD INDICATED, NOTLV THSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANYCONTRACT OR OTHER DCCUMENTU49TH RESPECT TO 1M iICH THIS C EERTiFr_AT MAYBE ^�Sa" JED OR MAY PERTAUd, T INSURANCE
AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SIiBJEGTTO ALL THE TERNS,B(CLUSONS AND CONDRONS OF SUCH POLICIES. 'LIMEYS SHOWN MAY HA! E BEEN REDUCED BY
PAID CLAIMS.
CO i TYPE OF INSURANCE - PCLICI EFFECTIVE POLICY EXPRAMON 1 c
j i POLICY NUMBER i LIMIT.
LY—R,� _ _ DATE (MKDDrfY) DATE (MMILD,'YY) i
f GENERAL LIABILI TY i — - -- -- 1GENc'T<AL.A3GRe^tiATE `T 2,000,000
Ir-i( f�CONWERGAL GENERAL LiABILtlY S PNII(i`OOM862 MAY 27 09 MAY 2710 PR000CiS pJMPIOG AGO. S
i AIMS MADE rXTi CCCUR i I
�� I PERSONAL 8 ADV INJUR'f I S 1,0OD,000
Al ; aNNER'S A CONTRACTORS PROT
;EACH OCCURRENCE 5
1,000,000
FIRE DAMAGE(ArrrOne Fire) i S
SO,OCU
I 'MED. E.XPENSE(.Any one Pelson) $
---____---T____.__
5,000
;AUTOMOBILE LIABILITY
_--_•- _
X i ANY Aura
- i COMBINED SINGLE LIMIT S
O1 Ci22'.0351 JUL 11 09 JUL 11.10
1,000,000
— j ALL OWNED AUTOS
` rBOD1LY INaUr [
i SCHEDULED AUTOS
{ (Per Po�nj 5
B. X HIRED AUTOS
j — ---- ---�
—
X NON -OWNED AUTOS
BODILY INJURY
; s
(Per Accident)
t
PROPERTY DAMAGE i S
GARAGE LIABILITY
AI U?OONLY-SSACCDF1IT 3
I 'ANY AUTO
OTHER THAN AUTO �vLY:
EACH ACCIDENT j 3 —
i
f 1 -AGGREGATE � 5
i r�CCESS LIABILITY
EACH OCCURRENCE. s
--- - —
T UM13RELI-A FORM
}�
1 �CTHER THAN UMBRELLA FORM
I
AGGREGATE- —
---
WORKER'S COMPENSATION AND �----
--___ _ — — -- -- STATUTORY LIMITS
EMPLOYERS' LIABILITY f
jt EACH ACCIDENT is
THE P.RCPRSrOR1 i --
PARTNc'RS EXECLITiVE ti I.NCL (
DISEASE POLICY Lt&iTY I S
OFFICERS ARE: I EXCL !
I ! DISEASE -EACH EMPLOYEE i $
! OTHER
--__.. _-__------•-------.._____
—
DESCR FMON OF OPERATIONSILOCATIONSrNEHiCLES/SPEC!AL,iEMS
THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS, AND VOLUNTEERS ARE NAMED
ADDITIONAL INSUREDS WITH RESPECTS TO GENERAL LIABILITY INCLUDING PRIMARY & NON-CONTRIBUTORY
WORDING PER FORM CG2010 (11185) AND AUTO LIABILITY PER FORM CA7140 (03107). RE: PROJECT#tRSI 10-01 1
GROUP 391 CONTRACT M48
CERTIFICATE HOLDER
CITY OF EL SEGUNDO
350 MAIN STREET
EL SEGUNDO, CA 90245
ATTN: CITY CLERK
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE THE
EXPIRAMON DATE THEREOF, THE ISSUING COMPANY WILL MAIL - 30 "- D.AYS
WRITTEN NOTICE TO THE CERTEFlCA.TE HOMER NAMED TO THE LEFT.
ID -DAY NOTICE
WES FOR NON-PAY10I OF PRti_=KuM
46 .
POLICY NUMBER:PNG0003862 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 foRcming:
COMMERCIAL GENERAL LIABILITY COVERAGE PART_
SCHEDULE
Marne of Person or Organization:
Any person or organization to which you are obligated by virtue of a written contract to provide
insurance such as is afforded by this policy, but only vAth respect to (1) occurrences taking
Place after such written contract has beer executed and (2) occurrences resulting from -work
performed by you during the policy period.
(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 11) 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 b1,r 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) shale be
excess and non-contributory, but only if required of the Named Insured and by written contract.
CG 20 10 1188 Copyright, Insurance Services Office, Inc.; 1984 Page 9 of 1
4Q`.
COMMERCIAL AUTO
CA71100307
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
modgled by the endorsement.
EXTENDED CANCELLATION CONDITION
Paragraph 2.1b. of the CANCELLATION common
Policy Condition is replaced by the following:
b. 60 . days before the effective date of caric ellation
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 I -.- COVERED AUTM 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 whila 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 If — LIABILITY COVERAGE — A.I. WHO
IS AN INSURED provision is amended by the addition
of the following:
d. Any business entity newly acquirers or formed by
you during the policy period provided you oivvn
60% or more of the business entity and the
business enthyr is not separately Insured for
Business AJAo Coverage. COVOMW Is extended
up to a maximum of 180 days following acquisi-
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 tl LIABILITY COVERAGE — A.11. WHO
1S AN INSURED provision is amended by the addition
of the following:
e. Any person or organization for whom you are re-
quired by an ftsured coniract° to pride Insur-
ance. is. an "Insured", subject to the following
additional provisions;
(11 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 extsrrt 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
'Accldent" occEmIng while a covered 'auto"
is being driven by you or one czf your em-
pis-
(3) TherQ is no coverage provided to this person
or organization far "bodily injury" to its em-
ployees, nor for Aproperty 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 ofalm or °suit" must be
tendered by this person or organization as
soon as practicable to all other insurers
which potentially provide Insurance for such
claim or ®suits
includes copyrighted material of Insurance Services Office, Inc., with its Perm'Ismon.
Copyright, Insurance Services Office, Inc., 1997
CA 71 10 03 07 Sam an to amm rope sus mwsiate3 ndwr ft 01 N.-W Capp MbM
Page 0t 6 EP
(6) The coverage provided will not exceed the
lesser of.
(a) The coverage andlor limits of this policy;
. or
(b) The coverage and/or limits required by
the °insured contract".
(7) A pereWs or organizatloffs status as an
'Insured" sander this subparagraph d ends
when your operations for that "Insured' are
cornpleted.
EMPLOYEE AS INSURED
Under Paragraph A. of Section Il — LIABILITY COV-
ERAGE item f..Is added as follows:
Your %mpioyee' 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 barrow that "auto'. This coverage
Is excess to any other collectible insurance coverage.
FELLOW EMPLOYEE COVERAGE
Exclusion 5. FELLOW EMPLOYEE of SECTION i1 --
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 pm4ded 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-
menis made for °bodily injury" or "property damage"
on behalf of the persons or otganizatons added as
'insureds' under Section It — LIABILITY COVERAGE
— AJ.D. BROAD FORM NAMW INSURED and
A.7.e. BLANKET ADDITIONAL INSURED.
PHYSICAL DAMAGE — ADDITIONAL TRANS-
PORTATION EXPENSE COVERAGE
The first sentence of paragraph A-4. of SECTION ill
—PHYSICAL DAMAGE COVERAG5 is amended as
follows:
We will pay up to $50 per day to a maximum of
$1,5W for temporary transportation expense incurred
by you because of the total theft of a covered
of the private passenger type.
PERSONAL EFFECTS COVERAGE
A. SECTION III — PHYSICAL DAMAGE COVER-
AGE, AA. COVERAGE EXTENSIONS, is
amended by add;ng the following:
M Personal Effects Coverage
For any Owned 'auto" that is Involved in a
covered ", we will pay up, to $5W for
"personal effects" that are lost or damaged
as a result of the covered ",oss", vWthout
applying a deductible.
EXTRA EXPENSE -. BROADENED COVERAGE
Paragralai; A. — COVERAGE of SECTION III —
PHYSICAL DAMAGE COVERAGE is amended to
add:
5. We will pay for the expense of returning a stolen
covered "auto" to you.
AIRBAG COVERAGE
Under paragraph B. — EXCLUSIONS of SECTION Ili
-- PHYSICAL DA GE v-OvER.AGE, the following is
added:
The exclusion relating to mechanical breakdown does
not apply to the accidental discharge of an a€rbag.
NEW VEHICLE REPLACEMENT COST
Under Paragraph C — LIMIT OF INSURANCE of
Section Ill — PHYSICAL DAM -AGE COVERAGE sec -
Von 2 is amended as follows:
1 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 attyour option:
a. The verifiable "new vehicle" purchase price
you paid for your damaged vehicle, not in-
cluding any Insurance or warranties pur-
chased;
Pop 2 of 6
b. The purchase price, as negotiated by us, of
a now vehicle of the same make, model and
equipment, not including any fumishings,
pads or equipment not installed by the
manufacturer or manufk4urer's dealership.
If the same model is not available pay the
purchase price of the mod similar model
available;
c. The market value of your damaged vehicle:
'trot including any furnishings, parts or equip-
ment not installed by the manufacturer or
manufacturer's dealership.
This coverage applies only to a covered "autos
of the private passenger, light tick or medium
truck type (20,000 Its or less gross vehicle
weight) and does not apply to Initiation or set up
casts 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-
ibie it will be waived; or
b. if the applicable Business Auto deduct-
ible is not the smaller (or -smallest) de-
ducftble 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 vAli
be waived.
For the purpose of this endorsement
"companys 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
a. Actual cash value of the damaged or stoien
property as of the time of the loss", less an
adjustment for depredation and physical
condition; or
b. Balance due under the terms of ft 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 associated 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 Near and tear.
(3) Costs for extended warranties, cre-
dit. Ltfs Insurance, Health, Accident
or Disability Insurance purchased
with the loan or lease.
(4) Transfer or rollover balances from
Previous loans or leases.
(3) Fnal payment due under a "Balloon
Loan".
(6) The dollar amount of any
un-repaired damage that occurred
prior to the "total foss" cf a covered
"ate"
(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
g. American States "referred insurance Under era
Company paragraph D. — DEDUCTIBLE of SECTION III
— PHYSICAL DAMAGE COVERAGE, the following Is
h. Safeco Insurance Company of Illinois added:
LOANILEASE GAP COVERAGE No deductible applies to glass damage if the glass is
Under paragraph C — LIMIT OF INSURANCE of repaired rather tian replaced.
swan Ill .— PHYSICAL DAMAGE COVEP.AGE, AMENDED DUTIES IN THE EVENT OF ACCi-
fhe following Is added: DENT, CLAIM. SUiT OR LOSS
4. The most we will pay for a total "loss" In any one -Elie requirement In LOSS CONDITION 2..a.
"accident" is the greater of the following, subject DUTIES IN THE EVENT OF ACCIDENT, CLAIM,
to a $1,500 maximum lir:tit: SUIT OR LOSS — of SECTION IV — BUSINESS
AUTO CONDITIONS that you must notify us of an
CA 71 10 03 07 pop 3 016 Ep
4 0 r .
.accident'* applies only when the `accident" is !mown
to,
(1) You, if you are an individual;
(2) A partner, it you are a partnership; or
(3) An executive officer or insurance manager-, if you
are a corporal€on.
UNINTENTIONAL FAILURE TO DISCLOSE
HAZARDS
SECTION IV — BUSINESS AUM .CONDITIONS —
BZ is amended by. the addition of the following:
If you unintentionally fail to disclose any hazards ex-
isting at the Inception date of your policy, we w€H not
deny coverage under this Coverage Form because of
such fallure. However, this provision does not affect
our right to collect additional premium or exerdse our
right of cancellation or non -renewal.
HIRED AUTO -- LIMITED WORLD WIDE COVER-
AGE
Under. Section IV — Business Condlt;ons, Paragraph
B-7.b.e(1) is replaced by the following:
(1) .The "accident" or gloss" 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
I
ollowing:
"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 Llabtilty cov-
erage .and If Comprehensive, Specified Causes of
Loss or Collision coverages are provided under this
Coverage Form for any "auto" you own. titan 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,
whichevver Is smailest, minus a deductible. The de-
ductible will be. equal to the largest deductible appli-
cable to any owned �auto" of the private passenger
or tight truck type for that coverage. Hired Auto Phy-
sical Damage coverage is excess over any other col-
€eclible insurance. Subject to the above limit,
deductible and excess provis€ons. we will provide
coverage equal to the broadest coverage applicable
to any covered "auto" you own.
HIRED AUTO PHYSICAL DAMAGE COVERAGE —
LOSSS OF USE
SECTION III — PHYSICAL DAMAGE A.4.b. Form
does not apply.
Subject to a maximum of $1,000 per accident, we will
cover loss of use of a hired "auto" if it results from
an accident, you are legally liable and the lessor in.
curs an actual financial losa.
RENTAL REIMSURSkWENFT COVERAGE
A. We will pay for rental reimbursement axPenses
incurred by you for the rental of an 'auto" be -
Cause Of a covered loss' to a covered "auto*.
Payment applies ih addition to the otherwise ap-
plicable amount of each wVe!ae-you -hwsm a --
covered "auto". No deductibles apply to this
coverage.
D. We will pale 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 aural exposes Incurred.
2. $50 per day.
B. This coverage does :rot apply while there are
spare or reserve 'autos" avallableto you for your
operations.
E. If "toss" results from the total theft of a covered
=auto$ of the private passenger type, we will pay
under this coverage only that amount of your
rental reimbursement expenses which is not a! -
ready provided for under the PHYSICAL DAM-
AGE COVEPAGE 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 4ofs
4 0
Rental Reimbursement Coverage Form
CA 99 23.
AUDIO, VISUAL AND DATA ELEC'MONIC
EQUIPMENT COVERAGE
A. Coverage
I. 9Ve �viti 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 0 the equipment is permanently installed
In the covered "aute" 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 "autb's" electrical Wstami in or upon the
Covered "'auto".
2. We will pay wiih respect -to -a -covered -'auto,
for Moss" to any accessories used with the
electronic equipment descrbed in paragraph
A.1. abcve.
However, this does not include tapes,
records or discs.
3. tf Audio, Visual and Data Electronic Equip.
ment Coverage form CA 99 60 or CA 99 94
is attached to this policy, then the Audio, Vi-
SEW and Data Electronic Equipment Cover-
age described above does not apply.
E. 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 add-
tion, the fallowing exclusions aptly.
We will not pay for either any electronic equip
merit or accessories used with such electronic
equipment that is:
1. necessary for the normal operation of the
covered "atqo" 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-
8URANCE provision of PHYSICAL DAMAGE
COVERAGE Is replaced by -the foliowfng:
7. The most We will pay for -loss- to audio, vl-
sual or data electronic equipment and any
accessories used with this equipment as a
result of any one lamldent" is the lesser of
a- The actual cash value of the damaged
or stolen property as of the time of the
"toss"; or
b. The Cost of repairing or replacing the
damaged or sto€en property v►VM other
Property of like kind and quality.
c. $1,000,
2. An adlust,•nent for depreciat€on and physical
00ndition will be -made iri 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
1. If °toss" to the audio, visual or data elec-
tronic egclpment or accessories used with
this equlpnnsnt is the result of a "joss" to the
covered "auto" under the Business Auto
voverage Forrm's Comprehensive drr Co:",,i-
s€Cn Coverage, then for each covered "auto„
our Obligation to pay tor, repair, return or re-
place damaged or stolen property wiG be. re.
duced by the applicable deductible shotrm in.
the Declarations. Any Comprehensive Cov-
erage deductible showy: in the Declarations
does not apply to `loss" to audio, visual or
data electronic equipment caused by fire or
lightning,
2.
a. an integral pail of the same unit housing
any sound reproducing equipment de-
slgsted 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 rtorrnally used by
If lass" to the audio, visual or data e19C-
'Ironic equipment or accessories used with
this equipment is the result of a loss- to the
Coveted 'auto' Linder the Business Auto
Coverage Forms Speed Causes of Loss
Coverage, then tar each covered "auto' our
obligation to pay for, repair, return or, replace
damaged or stolen property will be reduced
by a $100 deductible.
If `Ross' occurs solely to the audio, visual or
data electronic equipment or ac cessorles
used with this equipment, then for each cov-
ered 'auto" our obligation to pay for, relish,
GP. 71 tQ C3 R
Page s ri 8
EP
U4
return or replace damaged or stolen property SECTION V -- DERNITIDNS is amended by aching
will be reduced by a $100 deductible. the foliawing:
4. In the event that there is more than one ap- 4 °Personal ettects" means your tangible
piicabie deductible, only the highest deduce property that is worn or carried by you, ex-
ible Wit apply. In no e�--nt will more than one cept for tools, !"eiry, money, or securities.
deductible apply. R. 'New vehicle' means any `autos of which
you are the original owner and the "auto^
has not been previously titled and is less
than 305 days past the purchase Bats,
Pays 6 of 6
40.
Reproduction of Insurance Services office, Inc. Form
INSURER: LSO FORM CG 20 10 1185: (MODRgW)
POLICY NUM)I L. COMMERCIAL GENERAL LIABILITY
ENDORSEMENT NUMBER E GIMIT 1-A
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.
ADDMONAL INSURED —OWNERS LESSEES.OR
. CONTRACTORS (FORM'B)
This endorsement modift izisumI provided wader the following:
COMMERCIAL GEOQERAL LIABILITY COVERAGE PART.
SCHEDULE
The City, its officers, officials, employees, agents, and volunteers
(If no curry appears above, the m€orrimon required to complete this endoi9w=
will be shown in the Declarationtas applicable to this endorsement.)
WHO IS AN INSURED (Section 10 is amended io -Wade as an fussed the person or orpnization
shown in the Schedule, but only *with respect to .liability arising out of `sour world' for that ftmed by or
foryou.
to ISO form -CG 20 10 1185:
i. The inst ed scheduled above includes. the Inwred's officers, offc➢m, employes and
l
vobmteers.
2. This insurance shall bepdmary as respects to iasnted shown in the schedule above,
or if excess, shall stand in an unbTol= chain of coverage Graeae of the Named
I 's scbe ftW mded1'mg Pmmy coverage. In either event, any other insaraaoe
Wined by fire Insumd scheduled above shall be m excess of tins insurance and
shall not be called upon to contnbute with it.
3. The insurance afforded by this Policy shall not be • canceled except after thirty days
prior written notice by certified mare return rewvt requested has been given to the
hrty.
4. Coverage shall;aot extend to any indemnity coverage for the active the
additional insured in any case where an agreement to indemnify the additional
would be invalid under Subdivision (b) of section 2782 of the Qvn Code.
CG 20 10 1185 Insurance Service OWN*, Inc. Form (Modified)
4C
POLICYHOLDER COPY
STATE P.O. BOX 410807, SAN FRANCIS
COMPENSATION COCA 94142-0807
INSURANCE
FUND CERTIFICATO OF WORKERS' COMPENSATION INSURAN
CE
ISSUE DATE: 02-23-2010
GROUP:
POLICY NUMBER: 1686826-2009
CERTIFICATE ID: gg
CERTIFICATE EXPIRES: 06-01-2010
06-01-2009/08-01-2010
CITY OF EL SEGUNDO
SG JOB:PROJECT RSI 10-1
333 MAIN ST UNIT A RESIDENTIAL SOUND INSULATION PROGRAM
EL SEGUNDO CA 90245-3814 CONTRACT # 4048
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 is3subject to all the terms, exclusions, and conditions, of such policy.
�HORIZEDREPRESENTATI
PRESIDENT
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT #1600 - THOMAS CARR VP,SEC - EXCLUDED.
ENDORSEMENT #1600 - MARGARET CARR VP, CFO - EXCLUDED.
ENDORSEMENT #1600 - ROB YN JANE CARR-EBEL P - EXCLUDED.
ENDORSEMENT #2065 ENTITLED CERT FICATE HOLDERS' NOTICE EFFECTIVE 06-01-2003 IS
ATTACHED TO AND FORMS A PART OF�THIS POLICY.
ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2009-08-24 IS
ATTACHED TO AND FORMS A PART OFITHIS POLICY. THIRD PARTY NAME:
CITY OF EL SEGUNDO
EMPLOYER
1
BIG WEST CONSTRUCTION CORPORATION,
15331 NORMANDIE AVE
IRVINE CA 92604
I
(REV.2-05)
SG
[MPM,CNj
SG
PRINTED : 02-23-2010
0
WAIVER OF SUBROGATION NOTICE
Enclosed is your copy o a certificate of insurance on which the certificate holder
required a waiver of su ogation:
1. Please be advised that a waiver of subrogation requires that a 3% surcharge
will be applied by Stafe Fund ONLY to the premium assessed on the payroll
of your employees ea�ned 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% surc�arge, you must also agree to maintain accurately
segregated payroll re ��ords 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:
Sample Rate:
Regular Premium equals:
Surcharge:
Additional Waiver 'charge:
Total premium equals
$5,000.00
13.30%
$ 665.00
3.00%
$ 19.95
$ 684.95 (665.00 + 19.95)
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BIG
WEST
CONSTRUCTION
March 1, 2010
James O'Neill
Program Manager
Residential Sound Insulation Program
City of El Segundo
333 Main Street
El Segundo, Ca 90245
Subject: Contract — Group 39
The Contract states on line 1 "entered into this
will be dated in March.
day of February". The Contract
Item 3- Time for Performance- The Preliminary Schedule in the Contract Documents
contains dates for a Pre -Construction Meeting and Site Evaluations that have passed.
Also orders must be placed by March 51". We do not have a revised schedule at this time.
We will make every attempt to accelerate our schedule to start the construction on
schedule if the other events happen in time for us to get our orders placed and all pre -
construction work and mobilization complete.
Item 2 1 - Community Development Block Grant- This paragraph was not included in the
Sample Contract in the specifications. However, it is a requirement of the Program and is
acceptable to Big West Construction.
Sincerely,
Tom Carr
Big West Construction Corporation
2691 Richter Ave. # 123 • Irvine, CA 92606 • 949-253-9032 • fax 949-253-9049 • Ca. License # 812085
California - Oregon - Washington - Idaho
CERTIFICATE QE INSURANCE
ISSUE DATE `
02/23/2010
PRODUCER Cert# 57239 ;THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
GEORGE L. BROWN INSURANCE AGENCY s'CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
1Q05 CALLS RECODO DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
SAN CLEMENTE, CA 92673 ;POLICIES BELOW.
949.361.1400 I _
FAX948.361.2767 rnkmammcz arFnGnln{nrnir_ver_c
COMPANY
A NORTH AMERICAN CAPACITY INSURANCE CO
;NsuReD 1 COMPANY
BIG ;NEST CONSTRUCTION CORPORATION a B AMf=RICAN STATES INSURANCE COMPANY
2691 RIGHTER AVE #123
IRVINE. CA 92808
COMPAI,ff
C -
THIS tS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BE'LOYJ HAVE SEEN ISSUED TOTHE INSURE, NA %r :) ABOVE FOR THE POLICY PERIOD INDICATED, NOTIMTHSTANDING
ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W'iTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERi'AIN, THE INSURANCE
AFFORDED BYTHE POLICIES OESCP.IBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. UNIMS SHOWN MAY HAVE BEEN REDUCED BY
PAID CLAIMS.
CO i '— ------ — POLICY EPFECiiVE POLICY EXPIRATION I
TYPE OF INSURANCE ; POLICY NUMBER LIMTTR
LTR! _ J DATE(MIACOM'1 DATE IMWOUTTI I
GENERAL LIABILITY — — — I _ e
i :GENERAL AGGREGATE 2,000,000
rX I COk GAERCIAI GENERAL LIAP1LIiY { PNG0003862 MAY 27 09 NI��fAY 27 10 ;PRODUCTS COMP/OG AGQ. js 2,000.0m
`— J AIMS MADE r. 1 CCCUR I
--r—
{ PERSONAL & ADV INJUR`r S `1,000,(i0O
AI %OVYNER'S & CONTRACT-OR`S PeZOT.
EACH OCCURRENCE S
'i,000,000
FIRE DAMAGE(Amr One Fire) S
rj0 0G`0
'1AED. EXPETSE(Any One Person) g
000
?AUTOMOBILE LIABILITY 1
is
I AWAUTD 0101224035-1
COMBINED SINGLE LIMP
JUL 11 O9 JUL 11'. E0
i,0400UC
j ALL OWNED AUTOS
' �60DfLY INJU!' i
1
SCHEDULED AUTOS
i IS
(Per Penn)
Bj X HIRED AUTOS
'BODILY
i I I INJURY i
1 X NON -OWNED AUTOSi
I
(PerAccide t)
{
t
j PROPERTY DAMAGE S
j
I GARAGE LIABILITY — -----
--- AUTO ONLY -SAACCOENT $
ANY AUTO '-
j 'OTHER THAN ALTO ONLY
j -
EACH ACClik- T I S
—
I ; I
AGGREGATE 5
-----I
EXCESS LIABILITY -- -- ---
— — -- I — EACH OCCURRENCE-
��--.'t UMBREI L A FORM
-�'CTHER THAN U&IBRELLA FORM—
I I AGGREGATE S
•-
iWORKER'SCOMPENSATIONAND j-------
-----_ —r—STATUTORY LIMITS
—_-
':EMPLOYERS'LIABILITY f
r
IEACHACCIDENT 15
--
1 THE PROPRIETOR! :' INCL j
i D(SEASE-PCUCY LGMIT ; S
PA,RTNERS(EXECUTiVE I
j OFFK:t.RS ARE: i EXCL i
I ; —
I I DISEASE -EACH EMPLOYEE I$
—
! OTHER
I
DESCFUPTiON OF OPERATiOP.SILOC.g10NSlJEHICLESGPC-CIAL,;EMS
THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS, AND VOLUNTEERS ARE NAMED
ADDITIONAL INSUREDS WITH RESPECTS TO GENERAL LIABILITY INCLUDING PRIMARY & NON-CONTRIBUTORY
WORDING PER FORM CG2010 (11)85) AND AUTO LIABILITY PER FORM CA7110 (03107). RE: PROJECT#RSi 10-01 i
GROUP 391 CONTRACT M48
CERTIFICATE HOLDER — — —� ANCCELLATION_—i
-- — ANC
CITY OF EL SEGUNDO ISHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BECANCELLEDBEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY VJf _ MAIL 30 DAYS
350 MAIN STREET ! WRITTEN NOTICE ro THE CERTrFICATE HOLDER NAMED TD THE LEFT.
EL SEGUNDO, CA 90245
i m-DAY NOTCE OF QANeEPATION APP 'ES FOR NON-PANVENT OF PREMIUM
ATTN: CITY CLERK i ;__ T-
I AUTHC. JR� E� iATIVSY' d.
POLICY NUMBER:PNG0003862
5.3
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE REACT IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - (FORM 13)
This endorsement modifies insurance provided under the foltaMng:
COMMERCIAL GENERAL LIABILITY COVERAGE PART_
SCHEDULE
Name of Person or Organization:
Any person or organization to which you are obligated by,6!rtue of a written contract to provide
insurance such as is afforded by this policy, but only vryth respect to (1) occurrences taking
plate after such written contract has beer: executed and (2) oc=rrences resulting from work
performed by you during If to policy period.
(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 11) is amended to include as an insured the person or organization shown in the
Schedule, but only with respect to liabiirty kris ng out of "your work" for that insured t %%/ or for you.
Coverage provided by this policy to the Additional Insured(s) showrT 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 wrhten contract.
CG 20 10 118v Copyright, Insurance Services office, Inc.; 1984 Page' of ❑
f ei o
COMMERCIAL AUTO
CA 7110 03 07
THIS ENDORSEMENT CKANGES THE POLICY. PLEASE READ IT CAREFULLY.
AUTO PLUS ENDORSEMENT
This endorsement modifies insurance provided under the foltowinq-
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 canGellation
it we, cancel for any outer reason. .
TEMPORARY SUBSTITUTE AUTO — PHYSICAL
DAMAGE COVERAGE
Under paragraph G. -- CERTAIN TRAILERS, MO-
BILE EQUiPMUM 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 awn that Is out of service be-
cause of its breakdown, repair, servicing, `Ross" or
destruction.
BROAD FORM MATED INSURED
SECTION If — LIABILITY COVERAGE — A.1. WHO
IS AN INSURED provision is amended by the addition
of the foiiowfng:
d. Any business enft 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 acquisi-
tjon or formation of the business entity. Coverage
under this provision Is afforded only until the end
of the policy period.
BLANKET ADDITIONAL INSURED
SEC11ON 11 LIABILITY COVERAGE — AA. WHO
1S AN INSURED provision is amended by the addition
of the following:
e. Any person or organization for whore you are re-
quired by an Ensured contraet" to provide Insur-
ancs, Is- an Insured", subject to the following
additional provisions:
(11 The `Insured conf*acr must be in effect
during the policy period shown in the iZecla-
rations, and must have been executed prior
to the 'bodily injury" or "property damage".
(2) This person or organization is an Insurae&
only to the extent you are liable clue 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 Fiabie for an
¢accident" occurring whlle 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 'bodiiy inW' 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 accordling 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 all other insurers
which potentially provide insurance for such
claim or "suit'.
Includes copyrighted matenai of Insurance Services Office, ino., with its permission.
Copyright, Insurance Services Office, Inc., 1997
W&-- wn to M—ce loge ass regist w radwra tca of �,mpo,,1ra
CA 7i t0 .Ki rZ7 Page r or s Mp
(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 Ensured contract.
(T) A perscn's or organization's status as an
'Insured" under this subparagraph d ends
when your operations for that 'Insured, are
c olmpleted.
EMPLOYEE AS INSURED
Under Paragraph A. of Section 11 -- LtABIUTY COV-
ERAGE item f. Is added as follows --
Your :Iemployww while using his owned "auto", or an
"a-uta" owned by a member of his or her household,
in your business or your personal affairs, -provided you
do not own, bire or borrow that "auto". This coverage.
Is excess to any other collectible insurance coverage.
FELLOW EMPLOYEE COVERAGE
Exclusion 5. FELLOW EMPLOYEE of SECTION It --
UABILiTY 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
oym or hire.. and pr"ed that any coverage under
this provision only applies in excess aver arey other
collectible insurance.
BLANKET WAIVER OF SUIBROGATION
We waive the right of recovery we may have for pay-
ments made for "bodily injuy. or -property damage"
on behatf of the persons or organizations added as
"Insureds' under Section It — LIABILITY COVERAGE
A.1.15. BROAD FORM NAMW INSURED and
A.i.e. BLANKET ADDITIONAL INSURED,
PHYSICAL DAMAGE — ADDITIONAL TRANS-
PORTATiON EXPENSE COVERAGE
The first sentence of paragraph A.4. of SECTION ill
— PHYSICAL DAMAGE WIVEP.AGE is 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 tNfl 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 Eftcis Coverage
For any owned °auto° that is involved in a
covered loss", we will pay up to $500 for
"personal effects" that are lost or damaged
as a result of the covered "loss", without
applying a d,5ductible.
EXTRA EXPENSE — BROADENED COVERAGE
Paragraph A. — COVERAGE of SECTX)N III —
PHYSICAL DAMAGE COVERAGE is amended to
add:
5. We vAll pay for the expense of returning a stolen
covered 'auto" to you.
AIRBAG COVERAGE
Under paragraph S. — EXCLUSIONS of SECTION III
— PHYSICAL. DAMAGE COVERAGE.. the foll(rMng is
added:
The exclusion relating to mechanical breakdown does
not apply to the accidental discharge of an airbag.
NEW VEHICLE REPLACEMENT COST
Lender Paragraph C — LIMFr OF INSURANCE of
Section lit — PHYSICAL DAMAGE COVERAGE sec-
tion 2 is amended as follows:
1 An adjustment for depreciation and physical con-
dltion will be made In determining actc.ral 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 stxwn In the
deciaratlons, we will pay atyour option:
Pap 2of6
a. The verifiable "new vehicle" purchase price
you paid for your damaged vehicle, not in-
cluding any insurance or warranties pur-
chased;
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 tt:e same model is not available pay the
purchase price of the mod similar model
available;
c. The market value of your damaged vehicle;
hot 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 pate passenger, light truck or medium
truck type (20,000 The or less gross vehicle
welghtj and does not apply to initiation or set up
casts associated with loans or leases.
TWO OR MORE DEDUCTi13LES
Under SECTION III — PHYSICAL DAMAGE COW
ErRAGE, 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. if 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 hsurance Company
a. Actual cash value of the damaged or stolen
property as of the time of the 'loss", less an
adjustment for depreciation and phraical
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 fallowing adjustments:
(11 Overdue payment and financial
penalties associated with those
payments as of t, date of the
alb„
(2) Financial penalties Imposed under a
lease due to high mileage, exces-
sive use or abnormal wear and' ear.
(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.
(3) Final payment due under a "Balloon
Loan'.
(6) The dollar .amount of any
un-repaired damage that occurred
prior to the "total loss" cf a covered
"ate„
(7) 'Security deposits not refunded by a
lessor.
(B) 'All refunds payable or paid to you
as a result of the earty termiration
of S lease agreement or any war-
ranty or extended service agree-
ment on a covered "auto".
e. First National insurance Company of (9) Any amount representing taxes.
America (10) Loan or lease termination fees
f. American States Insurance Company of
Texas GLASS REPAIR — WAIVER OF DEDUCTIBLE
g. American States Preferred insurances ;
Company Under paragraph D. — DEDUCTIBLE of SECTION, lit
— PHYSICAL DAMAGE COVERAGE, the following Is
h. Safeco insurance Company of Illinois added:
LOANILEASE GAP COVERAGE
Under paragraph C — LIMIT OF INSURANCE of
SECTIONill PHYSICAL DAMAGE COVEPAGE,
fhe loliowing Is added:
No deductible applies to glass damage if the glass is
repaired rather thl an. 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 The requirement In LOSS CONDITION 2.a. —
,accident" is the greater of the following, subject DUTIES IN THE EVENT OF ACCIDENT, CLAIM,
to a $1,5W maximum lint SUIT OR LOSS — of SECTION IV — BUSINESS
Auto CONDITIONS that you must notify ue of an
CA 71 10 03 07 Page 3 016 EP
40'.
.accident" applies only when the "accident is krmown
to:
(1) You, if you are an individual;
(2) A partner, if you are a partnership; or
(3) An executive officer or insurance manager, If you
are a corporation.
UNINTENTIONAL FAILURE TO VtSCLOSE
HAZARDS
SECTION IV — BUSINESS AUTO CONDITIONS —
BZ is amended: by. the addition of the following:
If you unintentionally fail to disclose any hazards ex-
isting at the incerion 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
13.7.h.o(1) is replaced by the foliowIng:
(1) The "accident" or "loss" results
from the use of an "auto' aired for
30 days or less.
RESULTANT MENTAL ANGUISH COVERAGE
SECTION V — DEFINITIONS — C. is replaced by tite
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 Collisions coverages are provided under this
Coverage Form for any "auto'° you own. then the
Physical Damage Coverages provided are extended
to "autos' you !?ire or borrow.
The most we will pay for loss to any hired "auto' is
$50.000 or Actual Cash Value or Cast of Ropalr,
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,
deductible and excess provisions, we will provide
coverage equal to the broadest coverage applicable
to any covered "auto' you own.
HIRED AUTO PHYSICAL DAMAGE COVERAGE —
LOSS OF USE
SECTION in — PHYSICAL DAMAGE AA.b. Form
does not apply.
Subject to a maximum of $1,000 per accident, we will
cover loss of use of a hired "auto' if It results from
an accident, you are legally liable and the lessor in-
curs an actual Financial loss -
RENTAL REIMBURSOMENT COVERAGE
A. We will pay for retrial reimbursement expenses
incurred by you tar the rent of an "auto" be-
cause of a covered loss" to a covered "auto'.
Payinent applies 16 addition to the otherwise ap-
plicable amount of each wverage -you -hm-on a --
covered "auto". No deductibles apply to this
coverage.
13. We Mil 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, tills number of
clays Is added to the number of days it takes
to locate the covered sauto" and reium It to
you.
2, al} days.
C. Our payment is limited to the lesser of the fol-
lowing amounts:
4. Necessary and actual expenses incurred:
2. $50 per day.
D. This coverage does not apply while there are
spare or reserve 'autos" avallableto you for your
operations.
E. f "lose" results from the total theft of a covered
"zuW of the private passenger type, we will pay
under #his coverage only that amount of your
rental reimbursement expenses which is not a!-
isady provided for under the PHYSICAL DAM-
AGE COVEPAGE Coverage, Extension,
F. The Rental Reimbursenmrit Coverage described
above does not apply to a covered "auto, that Is
described or designated as a covered 'auto" on
Page 4 Df 6
Dental Reimbursement Coverage Form
CA 99 23.
AUDIO, VISUAL AND DATA ELE'-MONIG
EQUIPMENT COVERAGE
A- Coverage
1. We Vvili pay with respect to a covered -auto-
for doss" to any electronic equipment that
receives or transmits audio, visual or data
signals and that is not designed solely for the
reproduction of sound. 'Ibis 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" siectrical system, in o upon the
covered "auto".
2. We will pay with iespt3ctto-a-covered- auto"
for loss" to any accessories used with the
electronie equipment desorrbed In paragraph
A. 1. above.
However, this does not include tapes,
records or discs,
3. If Audio, Visuat and Data Electronic Equip-
ment Coverage form CA 99 60 or CA og 94
is aifached to this policy, then the Audio. Vi-
sual and Data Electronic Equipment Cover-
age described above does not appsly.
S. 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 addl-
tion, the following exclusions apply.
We will not pay for either any electronic equip-
ment or accessories used with such electronic
equipment that iv-
1. Necessary for the normal operation of the
covered 'aLW far the monitoring of the
covered "auto's" operating systern; or
2. Both:
the manufacturer for the Installation of a
radio-
C. Limit of Insurance
With respect to this coverage, the LIMIT OF IN-
SURAMCE provision of PHYSICAL DAMAGE
COVERAGE Is replaced by'the following:
1. The frost 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 casts 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 wit other
property of like kind and quality.
c. $t,i W.
2. An adjustment for depreciation. and physical
condition Will be -made in deWiTnIri g actual
cash value at the time of the loss".
3. it a repair or replacement results In bettdr
than like kind or quality, via will not pay for
the amount of the betterment.
D. Deductible
I. If °'toss" to the audio, visual or data elec-
tronic equipment or accessories used vAth
this equipment is the result of a "loss" to the
coveted "auto" under the Business Auto
Coverage Form's Comprehensive dr Co;li-
Sion Coverage, then for each covered "auto"
our obligation to pay for repair, return or re-
place damaged or stolen property waif be re-
duced by the applicable deductible, shoran in .
Me Declarations. Any Comprehensive Ciyr-
erage deductible shown, in the Declarations
does not apply to -low' to audio, visual or
data electronic equipment caused by fire or
liightrift?g.
2.
a. an integral pram of the same unit homing
any sound reproducing equipment de-
signed solely for the reproduction of
sound if the sound reproducing
equipment is permanently Installed In 3'
the covered "autos; and
b. permanently installed in the opening of
the dash or console normally used by
If "loss" to the audio, visual or data else
trontc 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, than ;or each covered "auto" our
obligation to pay for, repair return a,. replace
damaged or stolen property will be reduced
by a $109 deductible.
if "loss' occurs solely to the audio, visual or
data electronic equipment of accessoees
used with tills equipment, then for each cov-
ered 'auto" our obligation to pay for. repair,
CA 71 10 L03 R Page 5 of a EP
return or replace damaged or stolen property SECTION V --- DEFINITIONS Is amended by adcling
will be reduced by a $100 deductible, the following:
4. In the event that there is more than one ap- Q, "Personal effects" means your tangible
plicable deductible, only the highest deduct property that is worn or carried by you, ex-
lble will apply. In no event %ill more than one cept for tools, jewelry, money, or securities.
deductible apply. R. 'New vehicle" rnear►s any "autos of which
you are the original owner and the $auto"
has not been previously titled and is less
t1nan 385 days past the purchase date.
Pago 6 or e
4U
Reproduction of Insurance Services office, Inc. Fonn
INSrRUL ISO FORM CG 20 10 1185: (MODFIED)
POLICY NUM13M- COMMERCIAL GENERAL LIABILITY
zmmmn Nummm. omrr i-A
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREnMLy.
ADDITIONAL INSURED —OWNERS LESSEES OR
CONTRACTORS (FORMY)
This endorsement modifies insuraitoe P16videdunder the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
The City, its officers, officials, employees, agents, and volunteers
(if no entry appears above, the information requited to complete this endorsement
will be shown in the Declamdow-as applicable to this endorsement.)
WHO IS AN INSURED (Section 11) is amended to -hichide. as an insmed the person or organization
shown in the Schedule, ;but only Oft respect to liability arising Out Of "Your work" for that kmized by or
for you.
to ISO form -CG 20 10 11
1. The insured scheduled above incluiles.the bstizeds officers, officials, employees andl
volunteers.
2. This insurance shall be-pdmaty as respects the inwredshown in the schedule above
:1
.or if excess, SW stud in an unbialmn chain of coverage excess of the Named
hisared's scbedMW underlying primary covemp in caff event, any other insuraroe
maintained by the Insured scheduled above shall be in MOSS Of this in== and
shall not be called upon to conubw with it
3. IU insurance afforticd by this policy shall not be -canceled except after thirty days
prior written notice by certified mad return receipt requested has been given to the
Entity.
4. Coverage sballiiwt extend to any indemnity coverage for the active neg*= f the
additional insured in MW caw where an agreement to indemnify the additional
would be irrvaliki under Subdivision (b) of section 27C of tba-Civil Code.
_Kz
CG 20 10 1185 Insurance Serikes Office, Inc. Form (Modified)
POLICYHOLDER COPY
STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807
COMPENSATION
INSURANCE
FUND CERTIFICATEi OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 02-23-2010 GROUP:
POLICY NUMBER: 1686826-2009
CERTIFICATE ID: 86
CERTIFICATE EXPIRES: 06-01-2010
05-01-2009/06-01-2010
CITY OF EL SEGUNDO SG JOB:PROJECT RSI 10-1
333 MAIN ST UNIT A RESIDENTIAL SOUND INSULATION PROGRAM
EL SEGUNDO CA 90245-3814 CONTRACT # 4048
This is to certify that we have issued a valid Workers' Compensation insurance
California Insurance Commissioner to the employer named below for the Policy olic policy in period indi form approved by the
icated.
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 ngYice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, end or alter the coverage afforded
ext
by the policy listed herein. Notwithstandinga any requirement, term or condition any contract or other document
with respect to which this certificate of insurancensurance
may be issued or to which it may pertain, the i
afforded by the policy described herein is'isubject 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 #1600 - THOMAS CARR'j'VP,SEC - EXCLUDED.
I
ENDORSEMENT #1600 - MARGARET CARR VP, CFO - EXCLUDED.
ENDORSEMENT #1600 - ROBYN JANE GARR-EBEL P - EXCLUDED.
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06-01-2003 IS
ATTACHED TO AND FORMS A PART OFiTHIS POLICY.
ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2009-08-24 IS
ATTACHED TO AND FORMS A PART OF`ITHIS POLICY. THIRD PARTY NAME:
CITY OF FI ItrMiunn
EMPLOYER
i
BIG WEST CONSTRUCTION CORPORATION
15331 NORMANDIE AVE
IRVINE CA 92804
I
(REV,2-05)
SG
[MPM,CNI
PRINTED : 02-23-2010
SG
WAIVER OF SUBROGATION NOTICE
Enclosed is your copy of a certificate of insurance on which the certificate holder
required a waiver of su „ ogation:
1. Please be advised that a waiver of subrogation requires that a 3% surcharge
will be applied by Stae Fund ONLY to the premium assessed on the payroll
of your employees earned while engaged in work for that certificate holder
who requested the 11p,
(Note: if you have no employee payroll on that job,
then there is no charge.)
2. To apply the 3%. surc;o arge, you must also agree to maintain accurately
segregated payroll re fiords for employees engaged in work on job/s for the
certificate holder who`�,Ihas the waiver. The payroll records are subject to
verification by an auditor.
Example:
Payroll for job:
Sample Rate:
Regular Premium equals:
Surcharge:
Additional Waiver charge
Total premium equals
$5,000.00
13.3001
$ 665.00
3.00%
$ 19.95
$ 684.95 (665.00 + 19.95)