PROOF OF INSURANCE (2011) CLOSEDOP ID: D1
'`;` °SRO CERTIFICATE OF LIABILITY INSURANCE I DATE 03 /23 //YYYY)
1 03/23/11
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. 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).
CONTACT
PRODUCER
888 -400 -5880 NAME: Diane Medina
United Agencies, Inc. (N) PHONE IFAX
CA License #0252636 888 -400 -5881 Wc,_N_e11-t-626- 535 -8359 L1AICN1 626 -577 -1346 —_
301 E. Colorado Blvd. Ste. 200 E-MAIL - --
Pasadena, CA 91101 ApDRESS: dm_edina c�u -_ .. —�enci _ ._m_ _ __ -- — — — —
0.9.M PRODUCER KALBA -1
Richard C. Norton S�U3LQM€SJ�.— _— .— . - -.. —. — _— ._- -_ - -.— _ —.-
- — IN8UREl�81 AFFORDING_ COVERAGE _ -- NAIL N
INSURED Kalban, Inc. INSURER A: Navigators Insurance Co.— — - -- — _
9075 Glenoaks Blvd. INSURER e_Unigard Insurance Compa— _ — 102.5747 _
Sun Valley, CA 91352 INSURER C: National Union Fire Insurance _
INSURER D: Imperium Insurance Company —
INSURER E: — — -- — — —
INSURER F:
CMVFRAGFS CFRTIFIr'-ATF NJ JURFR- 1 DFVlQlf%N oil IuRCD. 4
THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
City of El Segundo
Attn: City Clerk
to TYPE I — -- TYPE OF INSURANCE — — �g�w -- - - -- — — — — -- _T POLICY 0F ^POLICY EXP — — — - -- --
POLICY NUMBER M/D /YYYY MM/DD LIMITS
— — —
GENERAL LIABILITY I I
i � �
EACH OCCURRENCE S
-- --�-- —
1,000,00
-- - --
A X COMMERCIAL GENERAL LIABILITY X X ISF09CGL01456901 j 12/01H0 12/01/11
�AMA�`iFfi6}FERTE6
�PaEMISES (Ea ocq!gknce $
CLAIMS -MADE rJ OCCUR I I
I MED EXP (Any one person) I $
—..
5,00
- �-- - --
P ERSONAL 8 ADV INJURY $ —
1 000,00
— , 00 —
GEN f RA , GGREGATE S
2,000,00
�_PEN'L AGGREGATE LIMIT APPLIES PER: I
I
` PRODUCTS - COMP /O AG—G $
2,000,00
POLICY I PRO- LOC I
—P .-
- -- — — $ - --
AUTOMOSILE LIABILITY I
B I X�• ANY AUTO I �CM011188 I 06/01/10 06/01/11
COMBINED SINGLE LIMIT
(Eaeccident) —I}—
S
1 OOO OO
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INJURY (Per
I $
ALL OWNED AUTOS I I I I
SCHEDULED AUTOS
rBODILY person)
BODILY INJURY (Per accident)
$
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I PROPERTY DAMAGE
X HIRED AUTOS I I
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(Per accident)
�$
S
X NON -OWNED AUTOS I I
—
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- - - --
$
— —
X UMBRELLA LIAR X OCCUR
EXCESS LIAR
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EACH OCCURRENCE j $
^�pppp - -I - - -
2,000,000
-
CLAIMS -MADE
C r — — — —' —I
I IBE025406589 12/01110 I 12101/11
��I I AGGREGATE — — —�
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2,000,00
DEDUCTIBLE
X RETENTION
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i — ..— -- -- — —• $
.-
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY I I
X WC STATU- OTH-
4_ _--- TQRYAdMffS I E
D ANY PROPRIETOR/PARTNER/EXECUTIVE YIN I .01 DKRM12008759 04/05/10 I 04/05/11
OFFICER/MEMBER EXCLUDED? ❑ I N/A X
(Mandatory In NN) I
E.L. EA_CH_ACCIDENT S
— —. --
E L OISEASE EA EMPLOYEE�—
_
1. 000 00
-- !
1,000,00
It yes. describe under I
- S
— -- -- —
— —
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT $
1,000,00
B Leased/Rented
I CM011188 06/01110 06/01111
JEquIpment
75,
DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
'Except 10 days notice for non - payment of premiums. Project #PW 11 -01
Annual Contract for P.C.C. Curb, Gutter, Sidewalk & Minor Improvements
The City of El Segundo, its officers, officials, employees, agents and
Additional
volunteers are named as Insureds as their Interests may appear as
reguired per written contract.
LA-K I IFICATF HUM nFR rAUrcr 1 ATIAeI
ELSEGUN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of El Segundo
Attn: City Clerk
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
A THORIZED PRESENTATIVE
El Segundo, CA 90245
Richar on ;
CU 1968 -2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED ENDORSEMENT
(EXCLUDING RESIDENTIAL)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS (FORM B)
CG 20 10 1185
SCHEDULE
Name of Person or Organization:
Any person or organization that the named insured is obligated by virtue of a
written contract or agreement to provide insurance such as is afforded by this
policy.
WHO IS AN INSURED (Section II) 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 by or for you.
The following additional provisions apply to any entity that is an insured by the terms of this
endorsement:
1. Primary Wording
If required by written contract or agreement: Such insurance as is afforded by this policy
shall be primary insurance, and any insurance or self- insurance maintained by the above
additional insured(s) shall be excess of the insurance afforded to the named insured and
shall not contribute to it.
2. Waiver of Subrogation
If required by written contract or agreement: We waive any right of recovery we may have
against an entity that is an additional insured per the terms of this endorsement because
of payments we make for injury or damage arising out of "your work" done under a
contract with that person or organization.
3. Neither the coverages provided by this insurance policy nor the provisions of this
endorsement shall apply to any claim arising out of the sole negligence of any additional
insured or any of their agents/ employees.
4. This endorsement does not apply to any work involving or related to properties intended
for permanent residential or habitational occupancy (other than apartments).
The words "you" and "your" refer to the Named Insured shown in the Declarations.
"Your work" means work or operations performed by you or on your behalf; and materials, parts
or equipment fumished in connection with such work or operations.
ANF -ES 160 (5/ 2006)
Insured Copy