PROOF OF INSURANCE (2009) CLOSEDCERTIFICATE OF LIABILITY INSURANCE
1wDUCM (714)S69 -2700 FAX (714)SS9 -3099 THIS CERTIFICATE IS MURD AS A
Pridelllark- Everest Insurance Services, Inc. ONLY AND CONFERS NO RIGHTS U
A Leavitt Group Co SOF13093 HOTS ET. THIS CERTIFICATE L%FFOR Ea
1820 E. First Street, Ste 500
to Ana, CA 92705 INSURERS AFFORDING COVERAGE
3965 • ,:.A
I DATE pM1pDUffm
ED Compressed Air gVwlaltios, Inc. WERIRERA! Hartford Casualty Ins Co
1340 Simpson Circle INSURERS: Hartford Fire Insurance Co
Anaheim, CA 92606 -5531 Iwaam0:
INSURER D:
INSURFA E:
OF
THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INOICAI
ANY REWIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE I
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HERRIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND
POLICIES. A04REGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
A
B
OEMAL LIABINTY
X
COMMERCIAL G&MRAL UAEILRr
MAW aOCCUR
GEWL AGGREGATE LMT APPLIES PER:
7 POLICY[I M n LOC
AUTONORU LAAWAM
X AW AUTO
ALL OWNED AUTOS
WHEDULEO AUTOS
X HIRED AUTOS
X NON.OWICD AUTOB
OMAOE LMEILITY
I ANY AUTO
EXCEUIUMBRRLNI UABLnv
7 OCCUR I� CLAIMS MADE
I I RETENTION $
wale RE COW111"ATRON AND
210LOVOW LIAMJTV
ANY PR ROAR LRIVE
OFFICE EXCL
EACH OOOUNINCE S
TO 1
MED DIP (Any oM Peewnl 1
PERSONAL A ACV INJURY 1
GENERALAGOREGATS 5
PRODUCTS, CM P*PAOG 1
COMBINED S11im LBMT I 1
(Ea �eoelnll
BODLY INJURY :
(POr Psi -
ODDLY INJURY s
(PU d W eRg
PROPERTY DAMAGE _
(ter wuanq
AUTO ONLY - EA ACCIDENT 1
OTHBRTHAN RAACC I
AUTO ONLY- AGO I
EACH OCCURRENCE 1
AGOMATE S
i
1
NM 9
!D OR
OF SUCH
1
I E.L. EACH ACCIDENT 111 1
MM- PAYMENT OF PREMIUM.
:E: REPAIR AND MAINTENANCE OF FIR DEPARTMENT -S BREATHING AIR COMPRESSOR.
:FJrT HOLDER IS ADDL INS AS RESPECTS GNRL LIAR PER SS 00 0S 04 OS (PGS. I9-20) ATTACHED.
* *AS REQUIRED BY WRITTEN CONTRACT***
WOULD AMY OF TNS ABOVE 01ECRI930 POLICES N CANCELLED SWORE roK
BX04 RAIWM DATE T1IERSOP. TN@ MOUND INSURIM WILL MPAVOR TO MAIL
'�
3Q OAYS W WTTEN NOTICE TO 711E CERTIPIWIT11 MOLDER NAMED TO TIME 6EFT.
CITY OF EL SEGUNDO BUT FAILUM TO MAIL SUCH NOTICE OHAL1. MOOSE No OSUGATION OR LABILITY
3 SO MAIN ST. ew Amw km up" 7MR MA1,AM, ITS "awTa OR RerlRftaaNTATNEa
EL SRGUNDO, CA 90245 "MORMEDN111"0OITATIVE
Gar lls TER
%CORD 26 (2001108) C]C enrE "CORD CORPORATION 1888
BUSIMASS LIABILITY COVERAGE FORM
F. OPTIONAL ADDITIONAL INSURED
AddManal Insured - Grantor Of Frenerhlaa
COVERAGES
WHO IS AN INSURED under Saeklon C. Is
N listed or shown as applicable In the Declaratons,
amended to include as an sddMlansl Insured
the parson(a) or orgenU Mons) shown in to
one or mors of the following Optional Additional
Dsdersdons as an Additional Insured
Insured Coverages also apply. When any of titeq
Oronlor Of franchise, but only with respect to
Optional Additional Insured Coverages apply,
%* liability as grazs*f of fmnch" b you.
Paragraph il. ( Additional Insureds When Required
by WMen ControcL Written Agreement or PteMA)
il• Additlonal insured - Lessor Of Leesed
of Sedan C., Who is An irtsured, doss not apply
Equipment
to the parsart or organbaMon shown in the
s. WHO 18 AN INSURED txidar Sedlon C. Is
Declarations. These effimm gss see eupjsct to the
amended to Include ae on addMonal
terms end conditions • applicable to lMusitteas
insured to peraon(s) or orgaftizstion(s)
Liability Coverage In this poky. except as
shown In the Declarations as an Additional
provided bsbw.
Insured — Lessor of Lossed Equipment,
1. Additienal Insured - Dsslgnalad Parson Or
but only with m peat to liability for Obodilly
Organittdion
MtjuW. 'property damage or "personal
WHO IS AN INSURED under Section C. is
anti advertising *rye canoed. In elicit or
amended to include an an additional Insured
in part, by your maintenance, operation or
to persons) or mWnization(s) shown in the
use of equipment leased to You by such
person(a) or organlradm(e).
Declarations, but only with respaot to Wilily
I& "bodily In)ury", "property dernegs" or
b. With reaped to the Insurance allbrdad 10
' peraonal and advertising *ft caused. In
these additional Insursde, this insurance
whole or In part, by your actor or omiulons or
k which
doe ate
the als or omissions of those acting on your
aply
obi, is�
y
behalf,
equipment
a. In the performance of your ongoing
S. Additional Insured - Owners Or Other
operations; of
Uterests From Whom Land Has Oven
b. in conneetilon with your promises onned
Leased
by or rented to yes,,
a. WHO IS AN INSURED under Section C. Is
2 Additional Insured - Managers Or Lessors
amended to include as an additional
of Prerniaae
insured it1C person(a) or orgaittedon(s)
shown In the Declarations as an Additional
s. WHO IS AN INSURED under Section C. is
Insured — Owners or Other Injorads From
entertded to Include as an additional bi red
W horn Land Has Been Leased, Out only
the parson(s) or orgardmelion(s) shown In the
with respect to liability erWng out of to
Dedsrdons a an Additional Insured -
ownership, maintenance or use of flat part
Dso%vv led Parson Or Organization; tut only
of tit land leased to you and shown In the
with respect to liability arising out of the
Declarations.
owrwr d*l meinlenance or use of to part of
the promise leased b you and shown In the
b, with respect to eta insurance afforded to
Declarations.
these additional insureds, the lb"
additlorhal ercdusions apply:
b. MIN respect to the Insurance afforded b
This insurance dose not apply to:
these additional insureds, the following
additional exclusions apply.
(1) Any "coam'enoe" that takes place
This Insurance does not apply to:
after you ceps* to Riess, that lend; or
(1) Any 'occurrence" which Iskes place
(2) Structural afterelons, new
aRer you cease to be a tenant In that
oonslfudian or domoMort opereflont
prernlses; or
ramie l by or on bahatf of such
p) 81ructurel alterathms, new
person or oMeribmtion.
eortetruollon or derrtolldan operations
S. Additional Insured - Sure Or Political
perbrmed by or on Walt of such
Subdivision — PerNfa
person or organization.
s. W140 IS AN INSURED under $action C. Is
amended to Include as an additional
insured the stets or political subdivision
shown in lea Declarations as an Additional
Paps 40 of 24 Form fall 00 a 04 of
Form U 00 N 04 as Page Is of 24
SUfl NM UAWLITY COVERAGE FORM
Innumd — State Or Pol ftal Subdivision •
(e) Any bilurs to make such
Permits. but only with reaped, to
Inapsaws, adjualmnle, tear or
operetions parlbrmed by you or on your
servicing sa the vendor has agreed
behalf for which the stets or pd1iboal
to make or norm lly and rlokee to
subdivision has issued a permit.
n ft In the usual aches$ Of
b. With respect to the Insurance afforded to
buaMte4l6 in connection with the
two additional, insureds, the following
dbirb gm or sale d to pnoducls;
additional exclusions apply.
M Dernormusilon, Installation,
This Insureno does not apply to:
servicing or repair opera t m.
(7) "godly lNury, , 60roperly damage' or
except such oparadons performed
at the vendor's. promises in
61 and adverdeln In
'Pena+ 9 j
Connection with the sale of the
for
arising out of operatone perfonr>.d tar
��
the state or municipality; a
(I) Products which, after distribution
(2) "godly iryury' or 'property dameoe'
or sale by you, haw been labeled
Included M the 'product- corrpMted
or relabeled or used as s
op41ratfons` hazard.
Container, part or ingredient of any
7. Additional Insured — Vendors
other riling or substance by or for
a. WHO IS AN INSURED under Section C. Is
the vendor, or
amended to Include as an additional
(h) 'Bodily Irdury' or 'properly
insured this person(s) or organixdien(s)
damage' arising out of the sole
(ralmd b below as vendor) shown in the
negligence of the vendor for tit
Declarations as an AddkkvW Insured -
own acts or omissions or 110441 of
Vendor, but only with respect to "badly
its employees or 41nyon41 eau
Injury' or'lproperty damage" arising out of
acting on Its behalf. However, too
your products' which ere distributed or
exclusion does not apply to;
sold In to regular courss of the vendor's
(1) The eXceptions CoMslnad In
buahesa and only If thta Coverage Part
Subparagraphs (d) or (Q; or
provides coverage for 'bodlly Irrury' or
"property
(ih Such inapediorss,
damage" included within the
Nproduala- completed operations ho=ard'.
adjustrisints, tests or servicing
b. The insurance dforded to taw vordar is
as the vendor has agreed b
mks or normally undertakes
subject to the followtno additional exclusions:
to make In the usual course of
(1) This Insurance does, not apply lo:
business, In connsdion with
(a) •godly Insure or -prey
the distribution or sale of the
dances' for which the vendor to
Pr +or
obligated to pay damages by
(2) This Murence does not apply to any
reason of the assumption of
Insured person or organization from
liability in a contract or agreement,
whom you have acquired rich
This exclusion does not apply to
products. or any Inwedtent, part or
liability for damages that the
oonialner, entering Info,
vendor would have in ttt41 absence
accompanying or containing such
of the oom*W or somement;
products.
(b) Any express warranty
IL Additional Insured - Controlling btere41t
untouthorit41d by you:
WHO 13 AN INSURED under Section C. is
(c) Any physical or chemical cherV
amended to Include as an oddlbonsi Insured
In the product mode Intentionally
the prrson(a) or orga hollon(s) shown in the
by the vendor,
Declarations as an Additional hooted —
(d) Repackoo ng, ti iess unpacked
Cm*olMng Interest, but only with respect to
solely for the purpose of inspection,
*heir Iabitily &rising out of
demonalration, trio&= or the
a. Their financial contrd of you; or
substitution of parts undo►
b. Premlaee they own, mdntain or &antral
Inabucil a tYt m the manuladurer,
while you lease or aoaapy two promises.
and then repackaged In to original
wrMeiner;
Form U 00 N 04 as Page Is of 24
SUMESS UABLI TY COVERAGE PORK
This irwAme does not apply to structural
The limits of Insurance that Apply to additional
sitersdons, new construction and demolition
insureds are, desaibed in Section D. — Ukdte Of
operations perfort wd by or for that person or
Insurance.
o *n•
How this Insurance applies when other Insurance
4. Additional Insured — Owners, Disease or
is awYaMe to an additional Insured Is described Ih
Conloraelors _ Schadnled Persoa Or
the Other Insurance Condition In Section E. —
OrQanlzalion
Usblllty And Medloel Expenses General
a• WHO IS AN INSURED under Section C. is
Condklons.
amended to Include as an addtilwal
8. LIABILITY AND MEDICAL. EXPENSES
Insured the person(s) or organizollon(s)
DEFINITIONS
shown to the Declarations as an Additional
Insured — Owner, Lessees Or Conbedors,
1. 'Advertisement" moans the wideepnead public
but only with respect to ItaMilty for'bodly
dissemination of Ird rmellon or Images that
Nurly', *WrIy d"Go or "personal
has the purpose of inducing the isle of gawk.
and advertising injury" caused. in whole or
products or services ugh:
In part, by your ads or omissions or the
a. (1) Radio:
ids or ornleaions of those acting on your
(2) Television;
behalf:
Taro:
(1) In the park manse of your ongoing
()
(4
4) ice'
operations for me additional
(5) Nswspat�:
insured(&), or
M In coruwotlon with 'your work•
Is. The Internet but only that pert of a web
performed for that additional Insured
site that is about goods, produad or
and included within the 'product-
eenices for the purposes of inducing the
completed operations hazard'. but
sale of geode, products at serAces: or
only if this Coverage Part provides
a Any other pubticeft that is given
coverage for "bodily injury" or
widespread public distr"am.
'property damage' included wifn the
However.'advolsemant! dose not Ina ids:'
'producte- completed operations
Mme'.
a. The design, prlMed malarial, Information
or images f, " nod in, on or upon the
b. With rasped to the inauranca afforded to
padraghg or labeling of any goods or
these additional insureds, this Insurance
products; or
does not apply to "bodily Injury"', "property
"personal
b. An Weradlve corweraation bow"n or
damage or an adveAf.
of the o
hljury' arising out o1 the rendering of, a
arntmg persons through • computer network.
the fidlure to render, any prafesakrnal
2• 'Adverfleing Idea" masna any Idea for an
arrhiteaMrsl, engineering or eurveying
"advertisernent'.
sendoes.Induding.
2. 'Aabsetoe hazard* mara an exposure, or
(1) The preparing, ttppfovinp, or feAur+I ID
threat of exposure to the soxg or alleged
prapam or approve, maps, shop
properties of asbestos and Includes the mere
drawings, opinions, reportk sunmiya,
pn3aance of almlos in any form.
Mid orders, change orders. designs or
4. •quo" means a land motor vehicle, Irailer or
drawings and speotiosdone: or
semitrailer dealMed for bevel on public
(2) Supervisory, Inspection, araldtactiral
roads, including any attached machinery or
or engineering adhft a.
equipmaM. W "auto" does not includa
10. Adidl Mal Insured — CaOwoer Of Insured
NrMls equipmenr.
Promises,
G. 'RodUy, Injury' means physical:
WHO 18 AN INSURED under Section C. is
a. Injury;
enrertded 10 Include as an additional Iraurad
b. Sidtneas; or
she paraon(s) or Organizatkxu(s) shown in the
Decieraflons as an Additional Insured — Co-
Q- Dimes
Owner Of Insured Promieeg, but only vdlh
sustained by a pamn hind, if arising out of Ute
respect to Om* liability as co -owner of the
above, mantel anguish or death at any time.
premises shown In the Deckmans.
a. " Coverage temltayr means:
Pie 20 of 24 Form 88 00 as 04 as
IMPORTANT
If the eertifkate holder is an ADDITIONAL INSURED, the pollcy(ies) must be endorsed. A statement
on this certnicate 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 poky, certain policies may
require an endorsement A statement on this carlifloate does not confer rights to the certificate
holder In lieu of such andorsement(s).
DISCLAIMER
The Card6cate of Insurance on the reverse side of this form does not consdlute a contract between
the Issuing insurer(s), authorized representative or producer, and the catdf>eate holder, nor does it
affffmtatively or negatively amend, extend or after the coverage afforded by the policies fisted thereon.
CORD 26 (2001)06)
POLICYHOLDER COPY SP
S'T'ATE P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807
1104SUMANCR
FUND cownFICATE OF WORKERS COWENSATION INSURANCE
ISSUE DATE: 12-31 -2004 GROUP. 000749
POLICY NUMBER: 0000200 -2001
CERTIFICATE la 14
CERTIfICA 31-4009/12 -31 -200!
CITY OF EL SEOLWO SP JOB :FIRE DEPARTMEW
350 MAIN ST
EL SEGUNDO CA 00245 -9413
This is to certify that we have issued a valid Workers' Compansation 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 slso give you 30 days advance notice should this policy be cancelled prior to its normal expiration.
This certificsts of insurance is not sn insurance policy and does not amend, extend or alter the coverage afforded
by thti policy listed herein. Notwithstanding any requirement, . term or condition of any contract or other document
with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the policy described herein Is subject to all the terns, exchMiens, and conditions, of such policy.
aTH:00O&Z90 REPRESENTATI PRESIDENT
EMPLOYER'S LIAAILITY LIMIT INCLUDING DEFENSE COSTS: $1.000,000 PER OCCURRENCE.
ENDORSEMENT /1900 - TOYNSDO. CHARLES, PRESIDIMfT - EXCLLMED.
ENDORSEMENT x/1000 - TOWNSEND, SNAMN, VICEPRES - EXCLUDED.
•— ENDORSEMENT 1200E ENTITLED CERTIFICATE tiDLDER.S1 NOTICE EFFECTIVE 12 -21 -2009 IS
ATTACHED To AND FORMS A PMT OF THIS POLICY.
EMPLOYER
COMPRESSED AIR SPECIALTIES, INC OSA: SP
CON9+I URD AIR SPECIALTIES
Is" S SIMIPSON Gilt
ANAHEIM CA 42400
10104110
PRINTED : 12 -10 -2008
REV.2.00