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PROOF OF INSURANCE (2010) CLOSEDAcORQ. CERTIFICATE OF LIABILITY INSURANCE 3 p Ord 3 , �AbIM o3 09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Meier Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 10308 NE 183rd Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 1727 (98041 -1727) Bothell WA 98011 Phone:425- 481 -9007 Fax:425- 489 -9947 INSURED Professional Building Contractors, Inc. 125 Sheldon Street E1 Segundo CA 90245 INSURERS AFFORDING COVERAGE NAIC # INSURER A: United Specialty Insurance Co. INSURER B: American States Insurance Co. 19704 INSURER C: Hartford Fire Insurance INSURER D: INSURER E: 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. INSR ADD'L LTR INSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE MMIDOIYY DATE MMIDOIYI EACH OCCURRENCE $1,000,000 GENERAL LIABILITY A X X COMMERCIAL GENERAL LIABILITY FEC61000285 DAMAGE TO RENTED 03/01/09 03/01/10 PREMISES (Ea occurence) $ 50 000 r CLAIMS MADE X OCCUR MED EXP (Any one person) s5,000 X $5,000 DEDUCTIBLE PERSONAL BADVINJURY $1,000,000 GENERAL AGGREGATE s2,000,000 PRODUCTS - COMP /OP AGG s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $2,000,000 C X ANY AUTO 52UECIV4361 03/01/09 03/01/10 (Ea accident) ALL OWNED AUTOS BODILY INJURY (Per person) $ SCHEDULED AUTOS X HIRED AUTOS BODILY INJURY (Per accident) $ X NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ S WORKERS COMPENSATION AND _ TORY LIMITS ER . EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ II Yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER B Property & IM Cov 01CH6845584 03/01/09 03/01/10 Sched Equ $52,326 BLK Bldg $1,.043,38 Deduct $1,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS RE: Proj #RSI 09 -06 Residential Sound Insulation Program - Goup 31. Contract #3941. E1 Segundo, its officers, officials, employees, agents & volunteers are included as primary non - contributory additional insured if required in written contract per attached CG2033 07/04. Waiver of Subrogation applies per attached CG2404 10/93. Per Proj Agg. Applies per attach. CG2503 3/97 %,cn r ma,r r c Fl— . " City of El Segundo City Clerk 350 Main Street E1 Segundo CA 90245 -3 Arnpn 7F r7nnvnxi CITYELS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO' DATE THEREOF, THE ISSUING INSURER WILL MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, AUTHORIZED REPRESENTATIVE n 1 39 4 1 ° , ali • ONO a0t 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(s). 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 policies listed thereon. ACORD 25 (20011081 39 4 1 POLICY NUMBER: FEC61000285 COMMERCIAL GENERAL LIABILITY CG 20 33 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS -- AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section 11 — Who Is An Insured is amended to include as an additional Insured any person or organization for whom you are performing operations when you and such person or organization have agreed In writing in a contract or agreement that such person or organization be added as an additional Insured on your policy. Such person or organization Is an additional Insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the Insurance afforded to these additional Insureds, the following additional exclusions apply: This Insurance does not apply to: f. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. 2. "Bodily injury" or "property damage" occurring after: a. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional Insured(s) at the location of the covered operations has been completed; or b. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged In performing operations for a principal as a part of the same project. CG 20 33 07 04 © iSO Properties, Inc_, 2004 Page 1 of 1 POLICY NUMBER: FEC61000285 COMMERCIAL GENERAL LIABILITY . IL 12 01 11 85 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGES Policy Change Number POLICY NUMBER POLICY CHANGES COMPANY FEC61000285 EFFECTIVE United Specialty Insurance Company 03/01/09 NAMED INSURED AUTHORIZED REPRESENTATIVE Professional Building Contractors, Inc. COVERAGE PARTS AFFECTED: Commercial General Liability Primary Insurance ! Excess & Non - Contributory Wording This endorsement modifies insurance provided under the following: The Additional Insured Endorsement — BLANKET ADDITIONAL INSURED — OWNERS, LESSEES OR CONTRACTORS AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU (CG2033 07104) is amended to Included the following: C: Coverage provided by this policy to the Additional Insured(s) shown in the Schedule shall be primary insurance and any other insurance maintained by the Additional Insured(s) shall be excess and non - contributory, but only if required of the Named Insured by an 'insured contract ". IMG 4001 01/08 Page 1 of 1 Revised 4 -25 -08 POLICY NUMBER: FEC61000285 1� Ck COMMERCIAL GENERAL LIABILITY CG 24 0410 93 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: All clients of the Insured where required by written contract. (if no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for Injury or damage arising out of your ongoing operations or "your work done under a contract with that person or organization and included in the "products- completed operations hazard ". This waiver applies only to the person or organization shown In the Schedule above. Page 1 of 1 POLICY NUMBER: FEC61000285 COMMERCIAL GENERAL LIABILITY CG 25 03 03 97 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE The General Aggregate Limited Is $2,000,000 per project with an absolute General Aggregate Limit of $5,000,000 all projects for this policy. no entry appears above, information required clarations as applicable to this endorsement.) A. For all sums which the Insured becomes legally obligated to pay as damages caused by "occurrences" under COVERAGE A (SECTION 1), and for all medical expenses caused by accidents under COVERAGE C (SECTION 1), which can be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. A separate Designated Construction Project General Aggregate Limit applies to each designated construction project, and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2. The Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under COVERAGE A, except damages because of "bodily injury" or "property damage" included In the "products - completed operations hazard ", and for medical expenses under COVERAGE C regardless of the number of: a. Insureds; b. Claims made or "suits' brought; or endorsement will be shown c. Persons or organizations making claims or bringing "suits ". 3. Any payments made under COVERAGE A for damages or under COVERAGE C for medical expenses shall reduce the Designated Construction Project General Aggregate Limit for that designated construction project. Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Designated Construction Project General Aggregate Limit for any other designated construction project shown in the Schedule above. 4. The limits shown in the Declarations for Each Occurrence, Fire Damage and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applIcable Designated Construction Project General Aggregate Limit. CG 25 03 03 97 Copyright, Insurance Services Office, Inc., 1996 Page 1 of 2 B. For an sums which the Insured becomes legally obligated to pay as damages caused by "occurrences" under COVERAGE A (SECTION 1), and for all medical expenses caused by accidents under COVERAGE C (SECTION 1), which cannot be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. Any payments made under COVERAGE A for damages or under COVERAGE C for medical expenses shall reduce the amount available under the General Aggregate Limit or the Products - Completed Operations Aggregate Limit, whichever is applicable; and 2. Such payments shall not reduce any Designated Construction Project General Aggregate Limit C. When coverage for liability arising out of the "products- completed operations hazard" is provided, any payments for damages because of "bodily injury" or "property damage" Included in the "products - completed operations hazard" will reduce the Products - Completed Operations Aggregate Limit, and not reduce the General Aggregate Limit nor the Designated Construction Project General Aggregate Limit. D. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restarted, or if the authorized contracting parties deviate from plans, blueprints, designs, specifications or timetables, the project will still be deemed to be the same construction project. E. The provisions of Limits Of Insurance (SECTION Ill) not otherwise modified by this endorsement shall continue to apply as stipulated. CG 25 03 03 97 Copyright, Insurance Services Office, Inc., 1996 Page 2 of 2 DATE CERTIFICATE OF LIABILITY INSURANCE 39 4 j • Q6/A3D2009) PRODUCER (951)736 -9477 FAX (951)736 -9478 Orion Risk Management Insurance Services, Inc. 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 Ca. Li c . #OD28764 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 2280 Wardlow Circle, Suite 250 Corona, CA 92880 INSURERS AFFORDING COVERAGE NAIC # INSURED Professional Building Contractors, Inc. INSURERA: Insurance Company of the West 27847 INSURER B: DBA: PBC INSURER C: EACH OCCURRENCE 125 Sheldon Street INSURER D: $ El Segundo, CA 90245 INSURER E: PERSONAL & ADV INJURY $ 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. INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE Y1 POLICY EXPIRATION DATE (MMIDDIYY) LIMITS GENERAL LIABILITY G COMMERCIAL GENERAL LIABILITY CLAIMS MADE F—] OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO JECT LOC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO H AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC AUTO ONLY: AGG $ $ EXCESS /UMBRELLA LIABILITY OCCUR F-1 CLAIMS MADE DEDUCTIBLE RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER /EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below OTHER ert does not address overage limitations/ xclusions WSD5000211 04/01/2009 04/01/2010 X WC sTATU- 1 oTH- E.L. EACH ACCIDENT $ 1.000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,0 Orion does not warrant that coverage may exist for any specific purpose or situation DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS e: Project #RSI 09 -06 Residential Sound Insulation Program - Group 31 aiver of subrogation in favor of the City, its officers, officials, employees & volunteers will be issued by the carrier pending underwriting approval. 0 Day Notice of Cancellation for Non - Payment of Premium/ Non - Reporting of Payroll City of E1 Segundo City Clerk 350 Main St. E1 Segundo, CA 90245 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL *MX00M MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, CORPORATION 1988 i 39 4 • r :: 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(s). 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 policies listed thereon. ACORD 26 (2001/08) W0lRKtRS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 37 (Ed. 5-02) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the schedule. The additional premium for this endorsement shall be 5% of the California Workers' Compensation premium otherwise due on such remuneration, subject to a minimum premium of $50.00. Schedule Person or Organization City of El Segundo its officers, officials, employees and volunteers 350 Main Street El Segundo, CA 90245 Job Description Project # RSI 09 -06 Residential Sound Insulation Program Group 31 Policy Number: WS 5000211 -01 Insured: Professional Building Contractors, Inc. Endorsement Effective: 06 -03 -2009 Issue Date: 06 -04 -2009 WC 99 06 37 (Ed. 5 -02) Coverage Provided by: Insurance Company of the West Countersigned by: