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PROOF OF INSURANCE (2011) CLOSED® DAT (MMIDDIYYYY ALC40 ° CERTIFICATE OF LIABILITY INSURANCE OPID 23 09/23/10 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: I the certi icate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. I 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). Raintree Insurance Agency License #0557773 2039 North D Street San Bernardino CA 92405 Phone:909- 881 -2654 INSURED Silvia Construction, Inc. 9007 Center Ave. Rancho Cucamonga, CA 91730 COVERAGES CERTIFICATE NUMBER: 1 rnvvv.. =n SILVI -1 CUSTOMER ID #: INSURER(S) AFFORDING COVERAGE INSURER A: Interstate Fire & Cas. /CRC INSURER B: Nationwide Mutual Insurance Co INSURER C : RSUI Indemnity Company INSURER D: Insurance Company of the West INSURER E: INSURER F: REVISION NUMBER: .�...,� rno Tuc oni iry oFaZlnn NAIC # THIS IS TO CERTIFY THAT THE POLICIES OF INSUKANUC ua i cu 1 , —� ,,,. --- • �- • • •- .. - - -- - - - 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. I'-R LTRI TYPE OF INSURANCE GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR X CONTRACT PROTECT INSR X WVD POLICY NUMBER SGL1002369 XCU INCLUDED EFI (MMIDDIYYYY) 07/03/10 (MMIDD /YYYY) 07/03/11 LIMITS EACH OCCURRENCE $ 1,000,000 A PREMISES(Eaoccurrence) $ 50,00 MED EXP (Any one person) $ Excluded PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 X BROAD FORM PD / PRODUCTS - COMP /OP AGG $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: COMBINED SINGLE LIMIT (Ea accident) $ $ 1,000,000 _ POLICY X JECT LOC AUTOMOBILE LIABILITY B X ANY AUTO ACP7851895282 07/03/10 07/03/11 BODILYINJURY(Perperson) $ BODILY INJURY (Per accident) $ ALL OWNED AUTOS PROPERTY DAMAGE (Per accident) $ SCHEDULED AUTOS X X HIRED AUTOS X NON -OWNED AUTOS C UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE NHA226249 07/03/10 07/03/11 EAZRRENCE $ 10, 000, 000 AG$ 10,000,000 DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIV YIN OFFICER/MEMBER EXCLUDED? (Mandatory in NH) f yes, describe under DESCRIPTION OF OPERATIONS below NIA X WSA5004599 -00 07/03/10 07/03/11 WC STATU ER jj ACCIDENT $ 1 , 0 0 0 , 0 !) ASE - EA EMPLOYEE $ 1 , 0 t) 0 , 0 t) 0 gE.L. ASE - POLICY LIMIT $ 1,000,000 * 10 DAYS NOTICE OF CANCELLATION FOR NON- PAYMENT OF PREMIUM DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Re: Pavement Rehabilitation of Grand Avenue (Sepulveda Blvd to Duley Rd) (Project #PW 10 -03) * See attached for full list of Additional Inusreds CERTIFIGAIt MULUtK - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ELSEG- 2 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISI City of El Segundo AUTHORIZED REPRESENTATIVE Attn City Clerk ' 350 Main St. El Segundo CA 90245 ,noo o wr on . r1DDr10AT1rI All rinhfs reserved. ACORD 25 (2009/09) The ACORD name and logo are registe�) marks 0 A RD Gi Policy Number: SGLI002369 4V 9 ) • ',814 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE, READ IT CAREFULLY ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - (FORM B) This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE PART, SCHEDULE Name of Person or Organization: City of El Segundo, its Officers, Officials, Employees, Agents and Volunteers Any person or organization or 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. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section 11) 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. Co Insurance Services Office, Inc., 1984 ]Page 1 of 1 CG 20 10 Z1 85 Pyn�� t 40 9 1 . , AMENDMENT OF OTHER INSURANCE CONDITION - PRIMARY INSURANCE FOR AUTOMATIC STATUS ADDITIONAL IN THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREMLY. This endorsement modifies insurance provided under the following: COM v ERCIAL GENERAL LIABILITY COVERAGE PART If required under a written "insured contract" with you, paragraph a. Primary Insurance in SECTION IV — CONMRCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance is amended by adding the following paragraph: Not withstanding the foregoing, the insurance afforded to any person or organization who has been added to this policy by an Automatic Status Additional Insured Endorsement is primary and non- contributory insurance, but only as respects "bodily injury" or "property damage" liability arising out of "your work" performed after the effective date of this policy under a written contract between you and such person or organization that requires you to maintain primary and non - contributory insurance and to include such person or organization as an additional insured thereunder. All other terms and conditions of this policy remain unchanged. TCB -8001 04 -05 4 0 9 1. 4, .*-,A Named Insured: Silvia Construction, Inc. CONIIViERCIAL AUTO Policy Number: ACP7851895282 - MS ENDnRSFMEN T C'AANCTF,S t'FT F, P()T.TCY. PIXASE READ IT CARF,FTJT.T. Y DF,8TrNATF,D I SURER This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies perms n (does not alter coverage provided ineds" under th Who Is An Insured provision of the Coverage Form. This endorsement Name of Person(s) or Organization(s): City of El Segundo, its Officers, Officials, Employees, Agents and Volunteers (If no entry appears above, information required to complete this endorsement will be shown in the Declarations or Schedule as applicable to this endorsement.) Each person or organization indicated above is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Section Il of the Coverage Form. The insurance provided to the person(s) or organization(s) shown in the Schedule is Primary Insurance and we will not seek contribution from any other insurance available to that "insured ". includes copyrighted material of Insurance Services Office, Inc. with its permission. Copyright, Insurance Services Office, Inc,, 1996 Farm CA7266 (Ed 7 -97) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY 4 0 9 1 f►- 99006(4 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - BLANKET (Ed. 8 -00) 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 contract thatdrequire you Schedule. obtain'this agreementf om u )y to the extent that you perform work under a written The additional premium for this endorsement shall be 3 % of the total California Workers' Compensation premium otherwise due. Person or Organization ANY PERSON OR ORGANIZATION WHEN REQUIRED BY WRITTEN CONTRACT Policy Number: WSA 5004599 00 Endorsement Effective: 07 -03 -10 Issue Date: 06 -24 -10 WC 99 06 34 (Ed. 8 -00) Schedule Job Description ALL CALIFORNIA OPERATIONS Insured: SILVIA CONSTRUCTION INC Coverage Provided by: INSURANCE COMPANY OF THE WEST Countersigned by: