PROOF OF INSURANCE (2005) CLOSED,ATT(' -2`3 -2nnR 11 :2R AI INSURANCE GROUP
7065491172 P.01
DATE (MMIOMMY)
�iACQR CERTIFICATE OF LIABILITY INSURANCE 6/2312005
TMDUCER (678) 726 -1000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Al Insurance Group ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O. Box 80568 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Athens, GA 30608
INSURERS AFFORDING COVERAGE NAIC #
INBUREO Hoary International, Inc. INSURER A. Continental Casualty Company
999 Peachtree St., N.E. INSURER B: Zurich American Insurance Company
Atlanta, GA 30309 INSURER C:
INSURER D:
COVERAGES
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.
OFINSURANCE
POLICY NUMBER
POLICY EFFECTIVE
POLICY EXPIRATION
MMCDyY1
LIMITS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE T OCCUR
X Contractor Subs Llab Inc.
C 2058095688
11/1/2004
11/112005
EACH OCCURRENCE
i 11000,00
PREMISES Ea oocurence
$ 100,00
MED EXP (Any one person)
$ 5,00
PERSONAL A ADV INJURY
$ 1,000,00
X
Contractual Liability
OENERALAGGREGATE
$ 2,000,00
GEWL AGGREGATE LIMIT APPLIES PER:
POLICY Fk PRO. LOC
PRODUCTS - COMP /OPAGG
$ 2,000,00
S
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
BAP8196268 -03
311/2005
31112006
COMBINED SINGLE LIMIT
(Ea oxidant)
S 1,000,00
X
BODILY INJURY
(Per person)
$
BODILY INJURY
(Per accident)
S
PROPERTYDAMAGE
(Par accident)
S
GARAGE LIABILITY
ANY AUTO
P
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
AUTO ONLY: AGG
I
S
S
EXCESSIUMBRELLA LIABILITY
OCCUR CLAIMS MADE
DEDUCTIBLE
RETENTION S
EACH OCCURRENCE
$
AGGREGATE
S
i
S
S
B
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICERIMEMBER EXCLUDED?
Ky
SPes,
EC WdeL seribe under PROVISIONS below
WC618626703
3!112005
311/2006
�( TORY TIMIT OTH-
E.L. EACH ACCIDENT
1,000,00
E.L. DISEASE - EA EMPLOYEE
S 1,000,00
E.L. DISEASE - POLICY LIMIT
I S 1,000,00
A
A
OTHER
Professional Liability
Professional Liability
AEA114091454
AEA114091454
411/2005
4/1/2005
4/112006
1 41112006
Professional Llabllity $2,000,00
IDeductible $500,00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
See attached page.
City of El Segundo
Department of Public Works
350 Main Street
El Segundo, CA 90245 -3613
ACORD 25
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISBUINO INSURER WILL ENDEAVOR TO MAIL 3O DAYS W RITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO $O SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
AUTHORIZED REPRESENTATIVE �
C ACORD CORPORATION 1988
AUG -23 -2005 11:28 AI INSURANCE GROUP 7065491172 P.02
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(a).
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
The Certificate of Insurance on the reverse side of this form 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 policles listed thereon.
25 (2001/08)
AUG -23 -2005 11:28 AI INSURANCE GROUP
I DESCRIPTION OF OPERATIONS -
Hoary International, Inc.
999 Peachtree St., N.E.
Atlanta GA 30309
City of El Segundo
Department of Public Works
350 Main Street
,El Segundo CA 90245 -3813
RE: Project # 0525700; Installation of ADA Compliant Automatic Doors for City of El Segundo.
7065491172 P.03
City, Its officials, and employees are included as additional insureds with regard to General Liability and Auto Liability, but
to the extent of the Insured's negligence. The Insurance afforded Is primary and non - contributory.
The referenced General Liability is written on form CG 00 01 1012001.
referenced Auto policy is written on form CA 00 0`110-01 -
TOTAL P.03
Sep 07 2005 10:55AM HP LRSERJET 3200
(Ed. 011011)
CNA Policy No. C2058095688
for A0 the C.Mwh e"U *V M& V
IMPORTANT: THIS ENDORSEMENT CONTAINS DUTIES THAT APPLY TO THE ADDITIONAL
INSURED IN THE EVE TSE OCCURRENCE, OFFENSE, CLAIM OR SUIT. SEE PARAGRAPH
C.I. OF THIS ENDORSEMENT
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CONTRACTOR'S SCHEDULED AND BLANKET ADDITIONAL INSURED
ENDORSEMENT WiTH PRODUCTS - COMPLETED OPERATIONS COVERAGE
This endorsement modifies Insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or organization: Desigriated Project:
City of ED Segundo ' Project #0525700; Installation of A13A
Department of Public %brks Coupliant AuUmtic Doors for City of
El Segundo.
(Coverage under this endorsement Is not affected by an entry or lack of entry In the Schedule above.)
The coverage provided to the additional insured
by this endorsement and paragraph f. of the
definition of "insurad contract' under
DEF1NmONS (Section Y) do notappy to ' bodily
Injury' or "property damage' artcing out of the
'products - completed operations hazard' unless
required by the written contract or written
agreement
The Insurance provided to the additional insured
does not apply to 'bodly Injury.` 'property
damage," or 'personal and advertising Injury'
arising out of an architect's,, onginsees, or
surveyor's rendering of or laltun b render any
professional services including:
A. WHO IS AN INSURED (Section IQ Is amended 10
Include as an insured any person or organization,
including any person or organization shown In the
schedute above, (called additional Insured) whom you
are required to add as an additional Insured on this
policy under a writien contract or written agreement;
but the written contract or written agreement must be:
1. Currently In effector becoming effective during the
term of this policy,, and
2. Executed prior to the "bodily injury; "property
damage,' or "personal and advertising Injury".
S. The Insurance provided to the additional insured Is
limited as follows:
1. That porson or organization Is an additional
Insured solely for liability due to your negligence
speclflcalty resultng from "your work' for the
additional Insured which is the subject of the
written contract or writton agreement. No
coverage applies b liability resulting from the solo
negrigenco of the additional Insured
2. The Umits of Insurance applicable 10 the
additional insured are those specified in the
written contract or written agreement or in The
Declarations of this policy, whichever Is lass.
These Limits of Insurance are Inclusive of, and not
in addition to, the Limits of insurance shown In the
Dectarations-
G- 140331 -A
(Ed. 01/01)
f.
a. The preparing, approving, or talOng to prepare
or approve maps, shop drawings, opinions,
reports, surveys. field orders, change orders
or drawings and specificationr, and
b. Supervisory, or Inspection actvities performed
as part of any related amhhedural or
engineering Activities.
C. As respects the coverage provided under this
endorsement. SECTION N - coMMEACiAL
GENERAL LIABl1..iTY CONDITIONS are amended as
follows:
1. The following is added to the Dubs In The Event
of Occurrence. Otiense, Claim orSult Condition:
Page 1 of 2
P.2
SEP -07 -2005 10:46 97% P.02
E
s
s
Sep 07 2005 10:55RM HP LRSERJET 3200
s. An additional Insured under this endorsement
will as soon as practicable:
(1) Give written notice of an occurrence or an
offense to us which may result In a claim
or "suit' under this insurance;
(2) Tender the defense and Indemnity of any
claim or "sui' to any other Insurer which
also has insurance for a loss we cover
under this Coverage Part; and
(3) Agree to make available any other
Insurance which the additional insured
has for. a loss we cover under this
Coverage Part.
f. We have no duty to defend or indemnity an
additional insured under this endorsement
G- 140331 -A
(Ed. 01/01)
SEP -07 -2005 10:46
p.3
G- 140331 -A
(Ed. 01 /01)
until we receive written notce of a claim or
"suit" from the additional insued.
2. Paragraph 4.b. of the Other insunnce Condition Is
deleted and replaced with the folkwing:
4. Other insurance
b. Excess insurance
This Insurance is excess over any other
Insurance naming the additional insured
as an insured whether primary, excess,
contingent or on any othv basis unless a
written contract or wrken agreement .
specifically requires that his Insurance be
either primary or primary and
noncontributing,
Pago2of2
97% P.03
Page 1 of 1
Shilling, Mona
From:
Shilling, Mona
Sent:
Wednesday, September 07, 2005 3:44 PM
To:
Stewart, Jeffrey
Cc:
Domann, Cathy
Subject: Contract #3506 - Henry International, Inc. - Insurance
Jeff,
Maryam Jonas submitted a Professional Services Agreement for Heery International, Inc. for the Design &
Construction Plans for Installation of ADA Compliant Automatic Doors. The total dollar amount not to exceed
$9,975.00.
The cancellation clause does not meet the required 30 -day notice of cancellation. Karl stated you had OK'd the
waiving of the required cancellation clause.
Please confirm via email.
Thank you,
Mona F. Shilling
City Clerk's Office
(310)524 -2307
�I
1
9/7/2005