PROOF OF INSURANCE (2009) CLOSEDFrom: Jennifer Brumm At. The Wooditch Company FaxID: To: Maryam M. Jonas
Date: 1/162009 09:07 AM Page. 2 of 8
AGORA CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
COLIICD -1 01/16/09
PRODUCER
The Wooditch Company Insurance
Services, Inc.
1 Park Plaza, Suite 400
Irvine CA 92614
Phone: 949- 553 -9800 Fax: 949 - 553 -0670
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIO
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
INSURERS AFFORDING COVERAGE NAIC
INSURED
Southwest Pipeline
Id Trenchless Cor�pp
547 W. 140th St rat
Gardena CA 9024
INSURER A: National union rare Ins. Co. 19445
INSURER 0: Seabright Insurance Cerqany 15563
INSURER old Republic General Ins. core 24139
INSURER
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 CLAMS.
LTR
NSR TYPE OF INSURANCE
I E
POLK:Y NUMBER DATE MMID.
DATE MMIDDIYY
LIMITS
C
GENERAL LIABILITY
X 'IX- COMMERCIAL GENERA- LIA&U-Y
CLAIMS MADE] OCCUR
I
AlCG93330800 10/15/08
10/15/09
EACH OCCURRENCE
$ 1,000,000
1 PREMISES (Ea occurence)
$ 100,000
MED EXP (Any one person)
S 5,000
PERSONAL & ADV INJURY
S 1,000,000
GENERAL AGGREGATE
1$2,000,000
I
I
GEN -L AGGREG ATE LIMIT APPJES PER
PRODUCTS - COMPIOP AGG
1$2,000,000
r— POLICY X — jE O- _7 LOC
C
AUTOMOBILE LIABILITY
X X AN�AUTO
AICA93330800 j 10/15/08
I 10/15/09
COMBINED SINGLE LIVIr
(Eaacadent)
111,000,000
BODILY INJURY
(Per person)
$
`y AL: OWNED AUTOS
SCHEDULED AUTOS
J' HIRED AUTOS
NON -OWNED AUTOS
603IL� INJURY
(Par "cc ldeM)
$
PROPERTY DAMAGE
(Aar ac meet)
$
GARAGE LIABILITY
i
AUTO ONLY - EA ACCIDENT
S
ANA AUTO
OTHER THAN _EA ACC_
AUTO ONLY. AGG
f
EXCESSAMMBRELLA LIABILITY
EACH OCCURRENCE
S 5,000,000
A
IX IOCCJR �CLAIMSMADE
BE 7660913 10/15/08
10/15/09
AGGREGATE
S5,000,000
I
,S
i
I
$
JI DEDUCTIBLE
I
I
IX RETE14T10N $10,000
$
B
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPR ETORIPARTNER/EXECUTIVE
OFFICERIMEMBER EXCLUDED?I
kyac deccobe ender
SPECIAL PROV SIONS bs ow
I
BB1080246 06/01/08
i
06/01/09
X I TORY LIMBS ER
EL.EACHACCIDENT
$1,000,000
E L. DISEASE • EA EMPLOYE
E L. DISEASE - POLICY LIMIT
f 1 , 0 O , OOO
S 1 , 0 0 0 , 000
OTHER
I
DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
RE: SWPiTC Job $514; City of El Segundo- Trenchless Rehabilitation of Sewer
Main on Imperial Hwy.; PW 08 -10. Waiver of Subrogation for Workers'
Compensation: See attached endorsement.
* *SZE NOTES ** glaip /auai /wcwv /x
*THIS VOIDS AND SUPERSEDES THE PREVIOUS CERTIFICATE DATED 12/23/08*
CERTIFICATE HOLDER CANCELLATION
City of El Segundo
Public Works Department
El Segundo City Hall
350 Main Street
El Segundo CA 90245
CI TYEL2 I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATI(
DATE THEREOF. THE ISSUING INSURER WILL MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, romw
ow
JAN -16 -2009 09:00 91% P.02
From: Jennifer Brumm At. The Wooditch Company FaAD: To: Maryam M. Jonas Date: 1/16/2009 09.07 AM Page: 3 of 8
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.
JAN -16 -2009 09:02 91% P.03
From: Jennifer Brumm At: The Wooditch Company FaxID: To: Maryam M. Jonas Date: 1/16/2009 09:07 AM Page: 4 of 8
JAN- 1(i -1U09 09:03 91% P.04
From: Jennifer Brumm At: The Wooditch Company FaxID: To: Maryam M. Jonas Date: 1/16/2009 09:07 AM Page: 5 of 8
POLICY NUMBER: AICG93330800 COMMERCIAL GENERAL LIABUN
Cd 2010 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of AddIdo al Insured Persons)
Or O actions :
Loaatio s Of Covered Opery6ons
WHERE REQUIRED BY WRITTEN CONTRACT.
WHERE REQUIRED BY WRITTEN CONTRACT.
Information required to complete this Schedule if not shown above will be shown in the Declarations.
A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organizations) shown in
the Schedule, but only with respect to lability for "bodily injury", "property damage' or 'personal and advertising injury'
caused, in whole or in part, by.
1. Your ads or omissions; or
2. The acts or onvssions of those acting on your behalf
in the performance of your ongoing operations for the additional insureds) at the location(s) designated above.
B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply:
This insurance does not apply to "bodily injury' or *property damage" occurring after.
1. 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 krcadw of the
covered operations has been completed, or
2. 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.
CO 20 10 07 04 ® ISO PrWertles, Inc., 2004 Page 1 of f
JAN -16 -2009 09:03 91% P.05
From: Jennifer 8rumm At: The Wooditch Company FaAD: To: Maryam M. Jonas Date: 1/16/2009 09:07 AM Page: 6 of 8
OLD REPUBLIC GENERAL INSURANCE CORPORATION
CHANGES ADDITIONAL INSURED PRIMARY WORDING SCHEDULE
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING:
COMMERCLAL GENERAL LIABILITY COVERAGE FORM
Name of Addlbonal Insured Person(s)
Or Organizatlon(s):
As required by written contract:
Location(s) of Covered Operatlons
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
The insurance provided by this endorsement is primary insurance and we will not seek contrbution from
any other insurance of a like kind available to the person or organization shown in the schedule above
unless the other insurance is provided by a contractor other than the person or organization shown in the
schedule above for the same operation and job location. If so, we will share with that other insurance by
the method described in paragraph 4_c. of Section IV — Commercial General Liability Conditions.
All other terms and conditions remain unchanged_
Named Insured
SOUTHWEST PIPELINE & TRENCHLESS CORP.
Policy Number
AICG93330800
Endorsement No.
Policy Period
10/15/2008 to
101151 009
Endorsement Effective Date:
1011512008
Producer's Name:
Producer Number:
AUTHORLZED REPRESENTATIVE
CG EN GN 4029 09 46
DATE
JAN -16 -2009 09:04 91% P.06
From: Jennifer Brumm At: The Wooditch Company FaxID: To: Maryam M. Jonas Date: 1/1612009 09:07 AM Page. 7 of 8
OLD REPUBLIC GENERAL INSURANCE CORPORATION
ADDITIONAL INSURANCE WHERE REQUIRED
UNDER CONTRACT OR AGREEMENT
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
1HIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING:
BUSINFSS AUTO COVFRAGF FORM
The following is added to Section II — Liability Coverage, A. — Coverage, 1 Who Is An Insured
d. Any person or organization to whom you become obligated to include as an additional
insured under this policy, as a result of any contract or agreement you enter into which
required you to furnish insurance to that person or organization o' the type provided by
this policy, but only wlth respect to liability arising out of your operations or premises
owned by or rented to you. However, the insurance provided will not exceed the lessor of:
The coverage or limits of tnis policy, or
2. The coverage or limits required by said contract or agreement.
Named insured
SOUTHWEST PIPELINE & TRENCHLESS CORP.
Policy Number
AICAS3330800
Endorsement No
Policy Period
10/15/2008 to
10115/2009
Endorsement Effective Date: i 10/15/2008
Producer's Name -
Producer Number:
i
AUTHORIZED REPRESENTATIVE DATE
CA EN GN 0020 09 06
JAN -16 -2009 09:05 91% P.07
From: Jennifer Brumm At: The Wooditch Company FaxID: To: Maryam M. Jonas Date: 1/16/2009 09:07 AM Page: t$ OTC
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06
(Ed. 4 -84)
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
due on such remuneration.
Person or Organization
% of the California workers' compensation premium otherwise
Schedule
Job Description
WHERE YOU ARE REQUIRED BY WRITTEN CONTRACT TO
OBTAIN THIS AGREEMENT FROM US, PROVIDED THE
CONTRACT IS SIGNED AND DATED PRIOR TO THE DATE OF
LOSS TO WHICH THIS WAIVER APPLIES. IN NO INSTANCE
SHALL THE PROVISIONS AFFORDED BY THIS
ENDORSEMENT BENEFIT ANY COMPANY OPERATING
AIRCRAFT FOR HIRE.
*The premium charge for this endorsement shall be 2% of the premium developed in the State of California, but not less
than $500 policy minimum premium.
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The Information below Is required only when this endorsement Is Issued subsequent to preparation of the policy.)
Endorsement Effective 06/01/08 Policy No. BB1080246 Endorsement No, 14
Insured Southwest Pipeline & Trenchless Corp. and /or U Policy Effective Date 06 /01/08
Liner West, A Division of ZZ Liner and/or National
Liner West, a Division of ZZ Liner and /or ZZ Liner,
Inc.
Insurance Company SeaBright Insurance Company / l
Countersigned By
WC 04 03 06
(Ed. 4 -84)
(DiM by the Workers' Compensation Insurance Rating Bureau of California. AH rights reserved.
JAN -16 -2009 09:06 91% P.08