PROOF OF INSURANCE (2011) CLOSED,ncCRi;f CERTIFICATE OF LIABILITY INSURANCE 02/01/2011 '�'
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 DOER NOT CONSTITUTE A CONTRACT, BETWEEN THE ISSUING INSURER(S), AUTHOR=
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT, if the certificate holder is an ADDITIONAL INSURED, the policyjles) must Ise endorsed. N SUBROGATION IS WAIVED, subject to
the term* and oonditions of the POlIcy, certain policies maY require an endorsement A statement on this certificate does not confer rights to the
certificate holder in Ileu of such sndcrsemenrt * .
PRODUDER 1.866 -220 «4625
Holmes tiurpby and Associates - OVAU* p
L
2637 South 138th Plexa
Suite 200 OR
Omaha, NB $0130
e RERte) AfPO O tjOti�iRAGE -.,-, NIUC 0
INSURED .. MA: Zt7RZfr8 AMUTCAN INSURAM COEQ➢ANY 16535
Post, eucklay, Schuh rr'Teraigan, Inc, MURVRS.. AWILICAN QgAVA7IM R L%ASTLITY YNBURAM 26747
d/b /a PBOW
2001 NM 107th Avenue U c R=XDPAST INSV tM9 CORDPANY 28387
RE
kismi, FL 33177 -2507 w..,�e..
m1hlOCCS. IOR46R9V RAVIAInN MIIEORPR-
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,
Type OFINSURANON
AUDI. SUaR
NU Be P
UhflfS
A
pENERAt UAGN -ITY
OLD 9599458 -04
09/30/1
09190/11
EAW0OCURRLNCH
$ 1,000,000
s 1, D00, 000
X COMMERCIAL oRNERAL [ABILITY
MED EXP An onm
3 25,000
CLAIMS-MADE X� OCOUR
PMONAL & Any INXRY
$ 1,000,000
X Contractual Liability
GENERAL. AGGREGATE
s 2,000,000
GEWL AGGREGATE LIMIT
PRODUCTS,
s 2,000,000
s
X POLCY LOD
B
AUTOMOBILEUABRITY
BAP 9139457 -04
09 30 l
0 ll
eowpNEO SINGLE LIMIT
(as stGdsnDl
$2,000,000
X
ANY AUTO
8001LY INJURY (Per paean}
Ii
ALL OWNED AUTOS
BODILY INJURY (Par 2=V9m)
S
PROPEMOAIAAOE
:
X
SCHEDULED AUTOS
FIRED AUTO*}
S
X
NONAM M AUTO*
s
X
Contractual Liabilit
C
X
tIMSRELLA1Nte
X
OCCUR
AOC 508767106
09/30/1
09/30/11
EACH OCCURRENCE
3 25,000,000
AGGREGATE
25,000,000
E7rCEastlAe
GLMA4fiMADE
DEDUCTIBLE
s
X
0
A
WORI(naCONPBNSATIOR
AND BMALOYOta' LIASMI TY Y E N
Any PRORETWOPARTNBRMXECUTNE�NIA f n NER FCLUOED9 I
�,-f
mwxw v II
yep
pE dpTlq V'QpM-nQ M bgg
WC 9139459 -04
09/30/1
09/30/11
X WCB A - N
ER
EL EA ACCIDENT
1,000,000
E.L 018FASE• EA GMAI.OYE
S 1,000,000
C.DISE"O - POLICY LIMIT
$ 1,000,000
DESCRIPTION OF PIP ERA FoRs I COAT 7 V2 8 (Attach );-CORD tot, 0 roarllt 84 v a mmv spsee rsqu
R6t City of Ul Segundo Is{perial School site Assisted Diving /Seaioz Housing Savironmental Services.
City of ml Segundo, its officals and saaployess are Additional Insureds on the General Liability and Automobile Diabilit
on a Primary bests, if required by contract, with respect to the operations of the insured on the above listed project.
See attached for additicinal wording.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
it Segundo, City of THE EXPIRATION DATE THEREOF, NOTICE WILL OR DELIVERED IN
AttA+ Kimberly Christensen, ACCORDANCE WITH THE POLICY PROVISIONS,
A;cp, planning Manager
350 Main Street
AUTHORIZED 0ARF.8ENTATIVE
8l Segundo, CA 90245 km / C 41ze
edornne ®1988.2009 ACORD CORPORATION, All rights reserved,
annon oe 11nenN16% Thor aCnRn name and Inan are realstsred marks ofACORD
19984583 ^ -
0
0
U
oars~
SUPPLEMENT TO CERTIFICATE OF INSURANCE 02/01/2011
kAME OF IN •O: post, Buckley, Schuh i Jeruigen, Tno.
d /b /s, VBSW
There are uo Deductibles or Sett- Insured Retention on the t}eneral i+iability, Automobile 7iiability and Workers
Campensaticn and Umbrella coverages.
Steadfast Snsursnae Company/ #26367 - AM Best Rating + A XV
Zurich American Xnsuranoe Company/ #15535 - AM Best Rating a A XV
(American Quaraatea cad Liability Insurance Company/ #76247 AM Best Ratiag . A XV
Additional insured -- Automatic - Owners, Lessees Or
Contractors - Broad Form
.. r_, ankle vRCR..i
0
ZURICH
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance- provided under the:
Commercial General Liability Coverage Part
A, WHO IS n INSURED Section II) is amended to include as an insured any person or organ' ion whom you are required
to add as an additional insured on this policy under a written contract or written agreement.
B, The insurance provided to additional insureds plies only to "bodily injury", "property damage" or "personal and advertis-
ing injury" covered under Section D ADVERTISING INJURY LIABILITY, but PROPERTY DAMAGE LIABILITY an
Coverage B, PERSONAL AN /
I. The "bodily injury" or "property damage" results from your negligence; and
2, The "bodily injury", "property damage" or "personal and advertising injury" results directly from:
a. Your ongoing operations; of
b. "Your work" completed as included in the "products - completed operations hazard ",
performed for the additional insured, which is the subject of the written contract or written agreement
C, However, regardless of the provisions of paragraphs A. and B, above:
1, We will not extend any insurance coverage to 70r additional insured person or organization:
a. That is not provided to you in this policy,
b. That is any broader coverage than you are required to provide to the additional insured person or organization in the
written contract or written agreement; and
2, We will not provide Limits of Insurance to any additional insured person or organization that exceed the lower of
a, The Limits of insurance provided to you in this policy; ar
b. The Limits of Insurance you are required to provide in the written contract or written agreement.
D, The insurance provided to the additional insured person or organization does not apply to:/
1, ,Bodily injury ", "property damage" or "personal and advertising injury" that results solely from negligence of the addi•
tional insured; or
engineering sincluding-,
out of the rendering or fariure to
2, "Bodily injuy", or hdama e "personal a d adv
render any professional a i, o 3 g services
a. The preparing, approving, or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field
orders, change orders or drawings and specifications; and
1)•OL•1175•A CW (9103)
Page i ot2
Indudes copyrighted material of insurance Services Office, inc, with fts permission,
b. SuperviSM' inspection, architectural or en8u'eering activities,
E, 'tire additional insured must see to It that:
r"'JIt in a clailn!
1. We arc SOOT' as soo as practicable of an "accurrenoe" or offense that �Y
Z We receive written notice of a claim or "suit" as soon as practical romptly
be brought against any policy issued by
nest far defense and indemnity of the claim or "Suit' p
3 A rmq is as an insured or additional insured. other fin -
another insurer under which the additional insured also and d we wiloither seek nc aril contribution ft by a contractor
I?. The insurance provided by this endorsement is primary the method de-
surance available to any additional insured person or organization unless the
other then You far the same operations and Job ioeand1B� Ali will share 1
RAL)JABILI TY CONDO ONS.
scribed in paragraph q.c. of SECTION IV � CO
apart not changed by the arms and oanditions of this endorsement continua to apply as writ"
Any provisions in this Co vera $
ten.
Noma of P .rsor or Organization:
City of EI Segundo, its officals and employees
350 Main Street
El Segundo, CA 90ZA5 -3813
I Site Assisted Living/Senior Noustng Environmental Services,
fiB: tatty of El Segundo Imperial Schoo
U -0L- 1173 -A CW i93J
page 2 o!2
COMMERCIAL INSUR CE
insurenga for this ooveraae part provided byt
American Guarantee and Liability Insurance Company
ADDITIONAL INSURED
COMMERCIAL
AUTO INSURANCE
a Schuh
miganI Inc, d /b!h PIRW
Policy Number: BAP 9139457 04
policy tcfflExp, 9l30i to - 9130f 11
Renewei of Number BAP 9138487.03
THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED BY THE FOLLOWING'
BUSINESS AUTO CO'IERAGE PART
SCI-IEI3xULS
NAME:
City of El Segundo, its officals and employees
350 Main Street
El Segundo, CA 90245 -3813
IRE., City of El Segundo Imperial School Site Assisted Living/Senior Housing Environmental Sorrlccs.
WHO IS AN INSURED (SECTION 11) IS AMWIN IN ' SCHEDULE BUT ONLY WA's E
PERSON (S) OR ORGANIZATION (S) SHO
RESPECT TO THEIR LIABILITY ARISING OUT OF:
A) YOUR WORK FOR THE ADDITIONAL INSURED(S) AT THE LOCATION
DESIGNATED, OR
B} ACTS THEIR OMISSIONS 01~ OO YOUR WORK' AT THE LOCTION
WITH THE1R GBNERAL SUPERVISION
SHOWN IN THE SCHEDULE.
FOR CLAIMS ARISING OUT OF OPERATION, E PRIMARY INS RANCE OVER ANY 0 HER INSURANCE
AUTO, THIS INSURANCE SHALL B
AVAILABLE TO THE SCHEDULED INSURED.
U-CA -388 -A (07.94)
Blanket rTotiflcatlon to others of Cancellation
ZURICHi
OLO9138458 -04
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.
dorsement modifies insurance provided under the foiiowing:
This en
Commercial General liability Coverage PaR a part has been cancelled to each person or
Part by written notice to the first Named insured for any reason other than nonpayment
Al. if we cancel this
Coverage
of premium, we will deliver electronic notification that such Co
aon shown in a schedule provided to us by the First Named Ensured, Such Schedule.
organization
I, Must be initially innng provided he policy periods own in the Declarations; or
a, After the beginning notification that
b, After this endorsement has been added to policy; or organizations requiring
2. Must contain the names and e-mail addresses of only the persons
such Coverage Part has been cancelled;
3. Must be in an electronic format that Is acceptable to us; and the policy period. Such
4, Must be accurate.
Such Schedule may be updated and provided to 3 the
nnd 4First ba e. insured during
updated Schedule must comply with paragraphs , 01 this endorsement
of the electronic notification as described In puce of ran eclat on is mailed or delivleredbosthe first as
B, Our delivery A. of this endorsement will be completed
most recent Schedule in our records as of the date the n
Named insured. Delivery of the n °cif +Cati to of cubed in paragraph we have complied with Paragraphs A. and B.
soon as practicable after the effective date o itcancellation tproofithat a have Insured.
e, Proof of emaiting the electronic notification w
of this endorsement.
O.
Our delivery of electronic notification described In of electronic noti cation w will nor�dorsement is intend as a
courtesy only. Our failure to provide such delivery ry
1. Extend the Coverage Part cancellation date;
2. Negate the cancellation; or
3. Provide any additional insurance that would not h linbeen d validitylof information containeddinrethe Schedule
E, We are not responsible for the accuracy, integrity, time
provided to us as described in Paragraphs A. and !3. of this endorsement.
•' 30 DAYS NOTICE OF CANCELLATION"
ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED.
City of Ei Segundo, Its officials and employees
35o Main Street
El Segundo, CA 90245.3813
RE: City of El Segundo imperial School Site Assisted Living/Sanlor Housing Environmental Services.
U- GL- 1114 -A CW (10102)