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