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PROOF OF INSURANCE (2010) CLOSED3984 . , CERTIFICATE OF LIABILITY INSURANCE OP ID RR -^ I-O' CJCOC -K 09423,409 PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Crosby Insurance, Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 8181 E. Kaiser Blvd ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Anaheim CA 92808 Phone: 714- 221 -5200 Fax: 714- 221 -5210 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: GOLDB.N ZMMZ INS. CORPORATION INSURER B: Granite State Ins . Co . CJ Concrete Construction, Inc. INSURER C: 10142 Shoemaker Avenue INSURER D: Santa Fe Springs CA 90670 INSURER E: v THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NON' TYPE OF INSURANCE POLICY NUMBER DATE MM /DD/YYYY DATE MMIDDN YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 E7o RENTS 'REMISES(Eaoccurence) $ 100,000 A X COMMERCIAL GENERAL LIABILITY CBP1610655 09/11/09 09/11/10 MED EXP (Any one person) $ 5,000 CLAIMS MADE a OCCUR PERSONAL SADVINJURY $ 1,000,000 X Owner /Copt Prot. GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG s2,000,000 PRO- LOC POLICY JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 A X ANY AUTO BA1550759 09/11/09 09/11/10 (Ea accident) ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS REVISED SUPE CEDES X HIRED AUTOS BODILY INJURY $ PRIOR DATED: 9/17/09 (Per accident) X NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AGG EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ 2 , 000, 000 AGGREGATE $2,000,000 A OCCUR �CLAIMSMADE CU8710936 09/11/09 09/11/10 $ $ RDEDUCTIBLE X RETENTION $ WORKERS COMPENSATION X I TORY LIMITS ER B AND EMPLOYERS' LIABILITY YIN /E ECUTIVE� 9928089 11/16/08 11/16/09 E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $1,000,000 OFFICER /MEMBER EXCLUDE (Mandatory In NH) E.L. DISEASE - POLICY LIMIT $1,000,000 If yes, describe under SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS *Ten Days notice of cancellation will be given for non - payment of premium. The City of El Segundo,its officers, agents and employees are included as additional insured with regard to liability ar defense of suits arising from "your work" performed by or on behalf of the named insured regardless of whether liabili is attriburable to the named insured or a combination of the named and the additional insure ACC)KU 20 (2UUM /Ul) I .-. ro....- a. -- - -- The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CTYSEGU 1 DATE THEREOF, THE ISSUING INSURER WILL E+�1"_D MAIL *30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, # I bv realstered or certified mail City of El Segundo 250 Main Street El Segundo CA 90245 [AUTHORIZED REP ENT E ACC)KU 20 (2UUM /Ul) I .-. ro....- a. -- - -- The ACORD name and logo are registered marks of ACORD 3984. IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. Forming a part of 3984. Policy Number. CBP1610655 overage Is Provided In GOLDEN EAGLE INSURANCE CORPORATION Named Insured: Agent- Crosby Insurance CJ CONCRETE CONSTRUCTION, INC. Agent Code: Agent Phone: 714 221 -5200 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products - completed operations hazard ". SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): City of El Segundo Location And Description Of Completed Operations: ANY LOCATION AT WHICH YOU PERFORM WORK DESCRIBED IN WRITING IN THE CONTRACT, AGREEMENT OR PERMIT FOR A PERSON OR ORGANIZATION THAT HAS BEEN QUALIFIED AS AN ADDITIONAL INSURED UNDER THE TERMS OF THIS ENDORSEMENT Information required to complete this Schedule, if not shown above, will be shown in the Declarations. ® ISO Properties, Inc., 2004 CG 20 37 (07/04) Fonning a part of 3984 { • Policy Number: CBP1610655 overage Is Provided In GOLDEN EAGLE INSURANCE CORPORATION Named Insured: Agent: Crosby Insurance CJ CONCRETE CONSTRUCTION, INC. Agent Code: Agent Phone: 714 221 -5200 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -- OWNERS, LESSEES OR CONTRACTORS — SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) ( Location(s) Of Covered Operations Or Oreanization(s): ANY PERSON OR ORGANIZATION WHEN YOU AND SUCH PERSON OR ORGANIZATION HAVE AGREED IN WRITING IN A CONTRACT, AGREEMENT OR PERMIT THAT SUCH PERSON OR ORGANIZATION BE ADDED AS AN A,=TkONAL INSURED ON YOUR POLICY TO PROVIDE INSURAffCE S H AS IS AFFORDED UNDER THIS COVERAGE PART t'--\ I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. ® ISO Properties, Inc., 2004 CG 20 10 07 04 Page 1 of 1 03114/2009 8008984 NEUMCM 103 PGDM080D J04751 GCAFPPN 00008780 P890 89