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PROOF OF INSURANCE (2011) CLOSEDFrom Rock 10 Insurance Services 1.866.376.2511 Thu Feb 17 11:05:18 2011 PST Page 2 pfy4� �..., ({ 1 OP ID:TB' ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDOIYYYY) `, 02/17111 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: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. 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). PRODUCER 866- 376 -2510 CONTACT . Rock 10 Insurance Services 866 -376 -2511 PHONE Fax _(A/C, No, Exq'._.._ AIC No P.O, Box 15608 San Diego, CA 92175 INSURED Brubec Construction Co. Doug Brubec P.O. Box 987 Moreno Valley, CA 92556 rn%I nAr_Ce f`CDTICI(%ATC Kit IM12CD- r'nV u-n BRUBE -1 CUSTOMER ID Y: INSURER (S) AFFORDING COVERAGE T NAIC N INSURERA:NaviClators Insurance Company 142307 INSURER C : INSURER D INSURER E: RFVISIAN NIIMRFR- 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 INSHRANCF 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. INSR LTR TYPE OF INSURANCE A OL ACCORDANCE WITH THE POLICY PROVISIONS. POLICY NUMBER POLICY f EFF POLICY MI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00q A X COMMERCIAL GENERAL LIABILITY X X 04- NO015006 11/05110 11/05/11 PREMISS Ea occurrence 3 50,00 MED EXP (Any one person) $ 5,00 CLAIMS -MADE D OCCUR PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,00 3 X POLICY I PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Es accident) $ BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED AUTOS PROPERTY DAMAGE (Per accident) $ SCHEDULED AUTOS HIRED AUTOS - $ NON -OWNED AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ _ AGGREGATE $ EXCESS LUIS CLAIMS -MADE DEDUCTIBLE $ $ RETENTION $ WORKERS COMPENSATION WC STATU- OTH- " IMITS FR AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YF E.L. EACH ACCIDENT $ E.L. DISEASE -_EA EMPLOYEE $ OFFICER/MEMBER EXCLUDED? (Mandatary hi NH) NIA E.L. DISEASE - POLICY LIMIT $ 0 yas, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) City of Ell Segundo, Its officers, em toyees, agents and vounteers are included as Additional Insured under Commerclal GL policy per attached endorsement (ANF -ES 043 6/2006), subject to written contract between the Named Insured and Additional Insured. GL coverage a piles on a primary and non-contributory 's G Waiver of S ati a 'es. Re: Various rrooTtClr -Arc tJr%I ncD / PAAIr`FI I ATInM CITYOEL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CI of El Segundo City g ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Recreation & Par 350 Main St El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ®1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD From Rock 10 Insurance Services 1.866.376.2511 Thu Feb 17 11:05:18 2011 PST Page 4 of 4 4128., .. BLANKET ADDITIONAL INSUREDS - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Policy Number: 04- NO015006 Endorsement Effective: 2/17/2011 NaWPM* ed Insur Countersigned By: MUTION SCHEDULE Name of Person or Organization: CITY OF EL SEGUNDO, ITS OFFICERS, EMPLOYEES, AGENTS AND VOUNTEERS ATTN: RECREATION & PARKS 350 MAIN ST EL SEGUNDO, CA, 90245 Location: THROUGHOUT THE CITY OF EL SEGUNDO, CA. (if no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section II — Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization shown in the Schedule is held liable for your acts or omissions arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions 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 site 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. C. The words "you" and "your" refer to the Named Insured shown in the Declarations. D. "Your work" means work or operations performed by you or on your behalf; and materials, parts or equipment furnished in connection with such work or operations. Primary Wordinq If required by written contract or agreement: Such insurance as is afforded by this policy shall be primary insurance, and any insurance or self- insurance maintained by the above additional insured(s) shall be excess of the insurance afforded to the named insured and shall not contribute to it. Waiver of Subrocfation If required by written contract or agreement: We waive any right of recovery we may have against an entity that is an additional insured per the terms of this endorsement because of payments we make for injury or damage arising out of "your work" done under a contract with that person or organization. ANF- ES 043 (5/2006) 2011.02- 2211:23 Bruli Const 9514860592» 310 647 4223 P 212 4128 � 7 . 0 Interinsurance Exchange of the Automobile Club Automobile Insurance Policy Coverages and Llmlts Renewal Declarations We are pleased to offer you a renewal for your automobile insurance policy. To renew your policy, send at least the minimum payment on or before the due date. Insurance is in effect only for the vehicles, coverages, and limits of liability shown on this declarations page and as set forth in the insurance policy and endorsements. These declarations, together with the contract and the endorsements in effect, complete your policy. If any change to your policy or to the information we have on file results in a premium decrease during the policy period, the Interinsurance Exchange reserves the right to apply any refund due to your outstanding balance. r r a n a NAMED INSURED (Item 1.) AUTO POLICY NUMBER: G 5774461 POLICY PERIOD (PACIFIC STANDARD TIME) 11944 VENETIAN DR POLICY EFFECTIVE DATE: 02 -08 -11 1201 A M. MORENO VALLEY CA 92557 -6519 POLICY EXPIRATION DATE: 02 -08 -12 12:01 A.M. VEHICLES VEHICLE YEAR MAKE MODEL IDENTIFICATION NUMBER VEHICLE GARAGE ANNUAL USE 21P CODE MILES VERIFIED MILEAGE NUMBER 1 2001 FORD F250 SUPER DUTY 1FTNX20L1IED91316 BUSINESS 92557 20,001 •25,000 VERIFIED 2 2001 MERC GRAND MARQUIS LS 2MEFM75W51X677938 PLEASURE 92557 10,001 -15,000 VERIFIED COVERAGES AND LIMITS ANNUAL PREMIUMS Coverage Is not In effect unless a premium or the word "Included" Is shown, COVERAGES LIMITS OF LIABILITY Vehicle 1 Vehicle 2 Vehicle Vehicle Vehicle Liability Bodily Injury $100,000 each person $300,000 each occurrence S 322 : S 188 Property Damage $50,000 each occurrence $ 236 :S 131 Medical Medical Payments $2,000 each person $23 $20 Physical Damage (rctuai cash value unless otnerwlee stated, less deducl,04) I Vehicle 1 Vehicle 2 Vehicle Vehicle Vehicle Comprehenaive ACV ACV S 73 ' S 31 (Less Deductible) $1.000 $1,000 Collision ACV ACV .8318 i 111208 (Less Deductible) $1,000 $1,000 Car Rental Expense (Per Day) $30 $30 •, S 61 ;$32 Uninsured Motorist Bodily Injury 330,000 each person/ $60,000 each accident ; S JO S 26 Uninsured & Underinsured Vehicles Uninsured Deductible Waiver :Included ': Included Uninsured Collision NA NA Total Premium s love s 831 "NA" indicates coverage not purchased. PREMIUM DISCOUNTS Please refer to the enclosed document entitled "Premium Discounts Applied to Your Automobile Policy" Total Annual Premium• S 1686 (Includes all applicable discounts.) 'If at any time you choose to pay leas than the full balance outstanding. Less Policyholder Savings Dividend $ 139 finance charges of up to 1.5% per month of the balance outstanding will apply $ 1547 as explained In your billing statements, which are part of these declarations. Not Premium' ITS0019A PROCESS DATE 01 -04 -11 PLEASE ATTACH TO YOUR POLICY (SEE REVERSE) ROUPaI I Fax Server 2/16/2011 3:56:22 PM PAGE 2/003 Fax Server ` + CERTHOLDER COPY SK P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 02 -16 -2011 GROUP: POLICY NUMBER: 1932349 -2010 CERTIFICATE ID: 14 CERTIFICATE EXPIRES: 05 -01 -2011 05- 01- 2010/05 -01 -2011 CITY OF EL SEGUNDO SK DEPT OF BUILDING a SA 350 MAIN ST EL SEGUNDO CA 90245 -3513 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for Lhe policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions,, and conditions, of such policy. { ' `HrNtaa L tAhorized Representative President and CEO UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' COMPENSATION LAW. EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT 80015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2011 -02 -16 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF EL SEGUNDO ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 02- 16-2011 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER 11944 VENE MORENO VALLEY CA 92557 PAT,CSj PRINTED : 02 -16 -2011 (REV.&•2010)