PROOF OF INSURANCE (2000) CLOSEDC
L
PRODUCER
SHIPKEY INSURANCE AGENCY, INC.
15375 BARRANCA PKWY. SUITE B -201
IRVINE, CA 92618
(949)453 -1115
FAX (949)453 -1244
INSURED
PAVEMENT COATINGS COMPANY
P.O. BOX 1491
CYPRESS, CA 90630
Cert# 2487 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
COMPANY
A GOLDEN EAGLE INS. CORP.
COMPANY
B EMPLOYERS MUTUAL INSURANCE COMPANY
COMPANY
C ROYAL INS. CO. (NELSON, GORDON,JAMES)
COMPANY
D
OVERAGES
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 KtUUGtU UT rmu
O
TR
TYPE OF INSURANCE
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
POLICY NUMBER
CCP637876 -00
POLICY EFFECTIVE
DATE (MM /DD/YY)
OCT 1 99
POLICY EXPIRATION
DATE (MM /DD/YY)
OCT 1 00
LIMITS
GENERAL AGGREGATE $ 2,000,000
_
PRODUCTS- COMP /OP AGG.
$ 2,000,000
PERSONAL & ADV INJURY
$ 1,000,000
LAIMS MADE
" OCCUR.
EACH OCCURRENCE
$ 1,000,000
A
I
OWNER'S & CONTRACTOR'S PROT.
FIRE DAMAGE(Any One Fire)
$ 100,000
—
$2500 PROPERTY DAMAGE
DEDUCTIBLE PER OCCURRENCE
MED. EXPENSE(Any One Person)
$ 5,000
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
$ 1,000,000
X ANY AUTO
0X81588 00
OCT 1 99
OCT 1 00
ALL OWNED AUTOS
_
BODILY INJURY
(Per Person)
$
- --
SCHEDULED AUTOS
— —
BODILY INJURY
$
B
HIRED AUTOS
NON -OWNED AUTOS
(Per Accident)
PROPERTY DAMAGE
El
i
$
AUTO ONLY - EA ACCIDENT
$
GARAGE LIABILITY
OTHER THAN AUTO ONLY:
�--
ANY AUTO
--
EACH ACCIDENT
$
AGGREGATE
$
C
EXCESS LIABILITY
X UMBRELLA FORM
PHN203745
OCT 1 99
OCT 1 00
EACH OCCURRENCE
$ 1000000
$ 1000000
AGGREGATE
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION AND
EMPLOYERS' LIABILITY
THE PROPRIETOR/ INCL
PARTNERS /EXECUTIVE REXCL
OFFICERS ARE:
STATUTORY LIMITS
EACH ACCIDENT
--
$
DISEASE - POLICY LIMIT
_
DISEASE -EACH EMPLOYEE
$
OTHER
UE5GKIY I IUN Ur UYCrtH1IUwJ�LVIiM�wivm vu •wow..,, •••�•• -•••-
SLURRY COATING OPERATIONS- 1999 -2000 SLURRY SEAL, SPECIFICATIONS NO. PW 00 -11
ADDITIONAL INSURED PER CG2010 ATTACHED.
30 DAYS NOTICE COMPANY ELECTION EXCEPT FOR NON - PAYMENT WHICH IS 10 DAYS
Ij CERTIFICATE HOLDER -� — CANCELLATION•:. -
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL MAIL 30 DAYS
CITY OF EL SEGUNDO WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.
PUBLIC WORKS DEPARTMENT
EL SEGUNDO CITY HALL
350 MAIN STREET AUTHORIZED REPRESENTATIVE
EL SEGUNDO, CA 90245 ---A � �(
s Software 25S 9/93 �
GOLDEN EAGLE INSURANCE CORPORATION
P.O. BOX 85826 - SAN DIEGO, CA. 92186 -5826
ADDITIONAL INSURED - OWNERS, LESSEES Policy No: CCP637876 -00
OR CONTRACTORS (FORM 8)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. .
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
WHO IS AN INSURED (Section II) is amended to Include as an insured the person or
organization shown In the Schedule, but only with reipect to liability arising out of "your
work" for that Insured by or for you.
The coverage afforded the additional' insured does not apply to any project on which
"your work" was completed prior to the effective date of this endorsement
SCHEDULE
THE CITY OF EL SEGUNDOi ITS OFFICERS, AGENTS AND EMPLOYEES
ARE INCLUDED AS ADDITIONAL INSURED WITH REGARD TO LIABILITY
AND DEFENSE OF SUITS ARISING FROM THE OPERATIONS AND USES
PERFORMED BY OR ON BEHALF OF THE NAMED INSURED REGARDLESS
OF WHETHER LIABILITY IS ATTRIBUTABLE TO THE INSURED OP. A
COMBINATION OF THE NAMED INSURED AND THE ADDITIONAL INSURED.
RE: 1999 -2000 SLURRY SEAL, SPECIFICATIONS NO. PW 00 -11
CO 20 10 (114UP WdWad
GHCG 601 0"1)
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a
GOLDEN EAGLE INSURANCE CORPORATION
P.O. BOX 85826 - SAN DIEGO, CA 92186 -6826
PRIMARY INSURANCE ENDORSEMENT . Policy No: CCP637876 —00
Endorsement No. (if Issued after the effective date):
Endorsement Effective: 8/29/00
(At 12:01 A.M. Standard Time)
Named Insured: pAVEMENT COATINGS COMPANY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies the following policy coverage forms:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
PRODUCTSICOMPLETED OPERATIONS LIABILITY COVERAGE FORM
The insurance provided by this policy for the benefit of the Additional Insured shown in the
Schedule shall be primary insurance, and any other insurance maintained by the additional insured
shall be excess and noncontributory with the Insurance provided by this policy, but only as
respects any claim, loss or liability arising out of the ongoing operations of the named insured or
its subcontractors, and only if such claim, loss or responsibility of the named Insured.
Name of Person or Organization:
SCHEDULE
CITY OF EL SEGUNDO
PUBLIC WORKS DEPARTMENT
EL SEGUNDO CITY HALL
350 MAIN STREET
EL SEGUNDO, CA 90245
RE: 1999 -2000 SLURRY SEAL, SPECIFICATIONS NO. PW 00 -11
SCIF 10262 (REV. 3 -95)
WENT HAS A BLUE PATTERNED BACKGROUND e ,