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PROOF OF INSURANCE (2014) CLOSED ACO
CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYW)
L/1512014,
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 pollcy(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 NAME: Key Helmick
Alliant Insurance Services, Inc. PHONE q JFAX
701 B Street,6th floor re/r�uo r en1,7Rn_"1n,d_7_&?1.... .. .- -�.w.. n.N«I� rO.. 4 ^. ..,.,
MAIL
San Diego CA 92101 ADDRs11t(lTt18N1i8171. k11Y _...
NAIC#
w. ,S AFFORt�INC'�CG�VIE„m ,
A:VallPv Fnrr1P Inc,i,Jrnpce QQmnanv n5n�
INSURE,R.... .�
INSURED DOWNSER-01 .� , R
INSURER B ('�nntmPntal Inc�iranrP(�mm�anv 59RA
Downstream Services, Inc. INSURER C:
2855 Progress Place INSURER D:
Escondido CA 92029
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER:1064623616 REVISION NUMBER:
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.
INSR AOISL SUlki LIC
POY EFF POLICY E%P
LTR TYPE OF INSURANCE !N-SR WVn I POLICY NUMBER (MM!DDfYYYY1 (MM1DnnYYY1 LIMITS
A GENERAL LIABILITY Y 'Y 2094163615 11115/2013 ...1/1512014 EACH OCCURRENCE $1.000.000'
X COMMERCIAL GENERAL LIABILITY PRFMIRFS fFa nrrurranrPl $100 000
j N ...R .._-Fa ,. ,.
q CLAIMS-MADE R X .I OCCUR MED EXP(Any one person) $5.000
PERSONAL BADVINJURY $1,000,000
j GENERAL AGGREGATE $2.000,000
_ ...............................................................
_9f;'N1.AGGRE'.GATE.LIMIT APPLIES.PER: PRODUCTS-COMPIOPAGG $1,000,000
—1-POLICY X PR�7. LOC PD deductible $$5,000
B AUTOMOBILE LIABILITY Y Y 5091396971 /19/2014 1115/2014
1,000 OOn
.... fFa arririanfl� A_., _.........
X ANY AUTO BODILY INJURY(Per person) $
ALL OWNED - SCHEDULED BODILY INJURY(Per accident) $
X HIRED AUTOS X NON-OWNED PROPER^'DAMAGE $
_...,,,.,., AUTOS
$ .
A X UMBRELLA LIAB X OCCUR 2094163629 11/15/2013 11/15/2014 EACH OCCURRENCE $1,000.000
EXCESS LIAR CLAIMS-MADE AGGREGATE $1 000 000
DED .X RETENTION$10.000 $
, WC U-WORKERS COMPENSATION y I OTH
aT PR
AND EMPLOYERS'LIABILITY Y 1 N
,
ANY PROPRICTORIPARTNER&-,XTC!U'rVVr l—j NIA A E L.EACH ACCIDENT $
r°dF''FICEMMEMBER EXCI..UDFO? ] .. ..... .........
(Mowlototy lei NH) E.L.DISEASE-EA EMPLOYE I" S"1 11 Ifyre.'r descrrkte tUl Idl'lr ,,.., .......... ,.�„h,... ���������,.
I;dE..SCRIPT OWN OF OPERAT IONS.6elew E,L.DISEASE-POLICY LIMIT $
I
I
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required)
I
RE: MAINTENANCE AGREEMENT,CITY WIDE LOCATIONS INSTRUMENTATION MAINTENANCE.CITY OF EL SEGUNDO, ITS
OFFICIALS AND EMPLOYEES ARE NAMED AS ADDITIONAL INSURED,WAIVER OF SUBROGATION APPLIES.30 DAY NOC APPLIES.
i
i
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY OF EL SEGUNDO ACCORDANCE WITH THE POLICY PROVISIONS.
PUBLIC WORKS
` 350 MAIN STREET AUTHORIZED REPRESENTATIVE
EL SEGUNDO CA 90245-3813 /
©1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
G-140331-A
E INSURED: Downstream Services, Inc. (Ed. 01/01)
POLICY NO. : 2494163615
IMPORTANT: THIS ENDORSEMENT CONTAINS DUTIES THAT APPLY TO THE
ADDITIONAL INSURED IN THE EVENT OF OCCURRENCE, OFFENSE, CLAIM OR SUIT. SEE
PARAGRAPH CA. OF THIS ENDORSEMENT FOR THESE DUTIES.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CONTRACTOR'S SCHEDULED AND BLANKET ADDITIONAL INSURED
ENDORSEMENT WITH PRODUCTS-COMPLETED OPERATIONS COVERAGE
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization: Designated Project:
WHERE REQUIRED BY WRITTEN CONTRACT
(Coverage under this endorsement is not affected by an entry or lack of entry in the Schedule above.)
A. WHO IS AN INSURED (Section II) is amended to not in addition to,the Limits of Insurance shown
Include as an insured any person or organization, in the Declarations.
including any person or organization shown in the 3. The coverage provided to the additional insured
schedule above, (called additional Insured) whom by this endorsement and paragraph f. of the
you are required to add as an additional Insured on definition of "insured contraof under
this policy under a written contract or written DEFINITIONS (Section V) do not apply to
agreement; but the written contract or written "bodily injyry" cr_"prQp,@rt_y damage" ail log o rt,
agreement must be: f r�� �� pl a erration hazard!$ "
1. Currently In effect or becoming effective during rnless required by the wten contract or
the temp of this policy; and written agreement.
2. Executed prior to the "bodily injury," "property 4. The insurance provided to the additional
damage,"or"personal and advertising Injury". insured does not apply to "bodily injury,"
"property damage,"or"personal and advertising
B. The insurance provided to the additional insured is injury" arising out of an architect's, engineer's,
limited as follows: or surveyor's rendering of or failure to render
1. That person or organization is an additional any professional services including:
insured solely for liability due to your a. The preparing, approving, or failing to
negligence specifically resulting from " WL prepare or approve maps, shop drawings,
work" for the additional insured which is the opinions, reports, surveys, field orders,
su6j ct of the written contract or written change orders or drawings and
agreement. No coverage applies to liability specifications; and
resulting from the sole negligence of the
additional insured. b. Supervisory, or inspection activities
performed as part of any related
2. The Limits of Insurance applicable to the architectural or engineering activities.
additional insured are those specified in the
written contract or written agreement or in the C. As respects the coverage provided under this
Declarations of this policy, whichever is less. endorsement, SECTION IV — COMMERCIAL
These Limits of Insurance are inclusive of, and GENERAL LIABILITY CONDITIONS are amended
as follows:
G-140331-A Page 1 of 2
(Ed. 01101)
G-140331-A
(Ed. 01101)
1. The following is added to the Duties In The f. We have no duty to defend or indemnify an
Event of Occurrence, Offense, Claim or Suit additional Insured under this endorsement
Condition: until we receive written notice of a claim or
e. An additional insured under this "suit"from the additional insured.
endorsement will as soon as practicable: 2. Paragraph 4.b. of the Other Insurance
(1) Give written notice of an occurrence or Condition is deleted and replaced with the
an offense to us which may result in a following:
claim or'suit" under this insurance; 4. Other Insurance
(2) Tender the defense and indemnity of b. Excess Insurance
any claim or "suit" to any other insurer This Insurance is excess over any other
which also has Insurance for a loss we nsu m n enaI-
cover under this Coverage Part; and Insured-a"n-insuM wwhe er
(3) Agree to make available any other excess, contingent or on any other
insurance which the additional insured basis unless a written contract or
has for a loss we cover under this written agreement specifically requires
Coverage Part. that this insurance be either primary or
primary and noncontributing.
G-140331-A Page 2 of 2
(Ed.01/01)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
AMENDMENT OF OTHER INSURANCE CONDITION
INSURED: Downstream Services, Inc. POLICY NO. 2094163615
This endorsement modifies Insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A. The following is added to provision a. Primary Insurance of paragraph 4.Other Insurance under SECTION IV—
COMMERCIAL GENERAL LIABILITY CONDITIONS:
However,when an additional insured has been added to this Coverage Part by attachment of an endorsement,we
will not seek contribution from the "additional insured's own Insurance"provided that:
(1) You and the additi al insured have agreed in a written contract that this insurance is primary and non-
contributory; and
(2) The"bodily injury"or"property damage"occurs, or the"personal and advertising injury"is committed,
subsequent to the execution of such contract.
B. For the purposes of this endorsement the following is added to SECTION V—DEFINITIONS:
"Additional Insured's own insurance" means other insurance for which the additional insured is designated as a
Named Insured.
Iuclndes copyrighted material of Insurance Services Office,Inc.,with its permission.
22-111 (01107) Page 1 of 1
INSURED: Downstream Services, Inc.
POLICY NUMBER: 2094163615 COMMERCIAL GENERAL LIABILITY
CO 24 04 06 08
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Person Or Organization:
CITY OF EL SEGUNDO, ITS OFFICIALS AND EMPLOYEES
Infom ation required',to complete this Schedule if not shown above will be shown in the Declarations..
The following is added to Paragraph 8. Transfer Of
Rights Of Recovery Against Others To Us of
Section IV—Conditions:
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.
CG 24 04 06 09 0 Insurance Services Office, Inc.,2008 Page 1 of 1 O
INSURED: Downstream Services, Inc.
Policy No: 2094163615
111.42700907
THIS OMRSEMENT CHANGES THE POLICY.PLEASE READ ff CAREFULLY.
CALIFORNIA CHANGES - CANCELLATION
AND NONRENEWAL
This vftraerwt mcdfies Insurance provided undet the following;
CAPITAL.ASSETS PROGRAM(OUTPUT POLICY)COVERAGE PART
COMMERf7IAL.AUTOMOBILE COVERAGE PART
COMMERCIAL GENERAL LIABILITY COVERAGE PART
COMMERCdAL INLAND MARINECOVMAGE PART
COMMERCIAL.PROPERTY COVERAGE PART
CRIME AND FIDELITY COV'ERAGTc PART
EMPLOYMENT-RELATED PRAC nCES I.Mall-1TY COVERAGE PART
EQUIPMENT BREAKDOWN COVERAGE PART
FARM COVERAGE PART
LIQUOR LIABILITY COVERAGE PART
POLLUTION LIABILITY COVERAGE PART
PRODUCTSCOMPLETED OPERATIONS UABIL.ITY COVERAGE PART
PROFESSIONAL-LIABILITY COVERAGE PART
A Pamagra phs Z and 2.of tha Canreffedon Common (2) Dlscavery of fraud or materiel
Poky Condban are replaced by the fallowing` misrepreaertitaticrt by.
2. AD PaHelAar In ii flat For 00 Days Or Laos (a) Any Insured or his or her
It this pol!*has been In ~for 60 clays or represontoWe in obtainft this
%so, and is not a renewal of a polls► we have insurance;or
b pmvlot*issued,we may caramel this poll by (b) You or pour ritiprasan1a0ve in
meting or delivering to ttm first Named Insured pursukV a daim under this policy.
at#tie malling address shown in the policy and (3) A jW met by a court or an
to the producer of retard,advance written notice edr irWrative tribunal that you have
of cancellation, stating fttia reason for vi lead a California or Federsi law.
cancellatiarti,at least havino as one of NN nwressary
a. 110 days before the effective dale of sWro is an amt which' materially
carmlfotion'lwocancelfor Increases arty of ft rim insured
(1) NorrE ayff mt of prarniurn;or against.
(2) Disc wery of freed by: (4) Diecovary of urllt A or grossly neogent
(a) Any insured or his or ht+r Rots or omiesions, or of arty violations
representative
in obtaining this of std a laws or regtfttions aft Wishing
safely sta ndwds, by you or your
Insurance;or rapreaertifafivs, which materially
(b) You or your mpnw4fdafiva in increase any of the risks insured
_ pursuing a claim under this poky, against
b. 30 days before ttm effeowe slate of (5) Fadlure by you or yaw naprasw tatnre to
ca"ceilation if we cancel for any other ImpiwW1 reasonswe loss control
reason. rowernm9k woo to by you as a
pl. lUI IPalicia>o lkr l�ffaCt For flAorre Tlwrr 84 E3oara
condition of policy Imuance, or which
were conditions precedent to our use of
a. If this poficy hale bw in effect for mm a park u* rate or raft plan, if that
than 60 days,or Is a renewal of a poNay we failure ma hoidy inavasee any of the
Issued,we may cancel this poft s>*upon risks["owed against.
the occurrence, after the affactiva dais of (g) A deterrminoWn try ft C-m missionar
e ft policy,of stria or More of Ute fotic�rrfnp: of lnsur Mm that the:
(1) Nonpayment of premium, including
payment due on a prior policy we (a) LOSS of, or ohanges In, our
Issued Wd due alining tttie current rainswance coverft all or pad of
paN4y term Covering to$am risks.
NL 02 7'0 00131 Copyrtgfrt,ISO Properfies,Inc.,2006 Pads!Of 3
the risk would threaten our linanc W However, we shall cancel this policy t fits
Integrity or solvency;or first Named Insured has accepted a now or
(b) Continuation of the poilcy coverage renewal policy limned by the CEA that
,would, includes an earthquake policy prentiurn
(l), Place violation of surcharge but falls to pay the earthquake
California law or #fie laws of CEA.premium shtrohatrge authorized by ills
the state where we are c, We ma not cancel such covers sole
domiciled,or Y g° �`
(l!} Threaten,or solvency. because carrosive sot conditions exist on
#to prenvess. Tftls Reslnctton (o,) applies
(7) A change by you or your reprowrieWe only if coverage Is strf W to one of the
In the aoNvities or property Of tho iolow% which exclude loss or damage
commercial or industrial enterprise, caused by or resWOM from corrosive soli
which results in a materially added, aonditions:
increased or o l ngsd risk, unless the (1) Ca 1 Assets am Coverage
added, lrweased or changed risk is Fond((OuVut PoIW—. r
included In the policy. Cornmerciel dY Coverage Part –
b. We will mail or delhw advarics written � Pa
Causes Of Lass-Special Form;or
notice of cancellation,staling the reason for (3) Farm Coverage Bart– Causes Of toss
cancalialion, to the ftrat Narned Insured, at
the mailing address shown, In the policy, Form –Farm Property, Paragraph Q.
wn,
and to the producer of record.at least: Covered Causes Of lass dell,
(1) 10 days before the effective cute of C• The fallowing is added mild ewpersod" any
cancellation K we cancel for provisions b the contrary:
nonpayment of pT&mlum or digoovery of NONRENEWAIL
fraud;or 1. Subjed to the p harm of Paragraphs C.2.
(2) 30 days before #A eihK*e date of and C.S. below, if we elect not to renew this
cancellation If we cannel for any other policy, we will mail or deliver written notIce
reason fisted in Paragraph 8.a6, stattng the reason for norverwmal to the first
B. The following provision Is added to to Carmelliation Narned Inwzed shown in the Declarations and
unman Pokey Condition: to lire producer of reowd, at least 60 days, but
7. 1 Ider01s1 not more than 120 days,before the expiration or
� ► annivereary date.
This pmtavWon applies to coverage on read We wig mail or deliver our notice to the first
property which Is t4w predominantly for Named Ins ed. and to the producer of record.
r r"purposes and consisting of not morn at the mailing address shown in the policy,
than four dwelling units, and to coverage on 2. Residenl[W
nts" household p l property in aY
ntiai unit,If such coveme,Is wAtlen under This provision allies to covetous on real
one of the following: properbr used pmdominantly for residential
Cornmarcial Property Coverage Part Purposes and corgi of not more than four
Farm Coven Part –farm dwelling units, and to c iwarage on tenant,,'
Property –Farm household property contained in a residential
Household Appurtenant Structures And unit~If such coverage is written under one of the
i�auselhold Pers>snal Property Coverage Farm
folkrwvirrg:
b If such coverage has been in effect for 80 Capital Asset Program (Output Palley)
days or lass, and is What a renewed of
coverage we previously issued, we may Coverage Part
cancel this coverage for any reason.except Comrrhercial Property Coverage Part
as provided in b.and et.WOW. Farm Cmmage, Part –Farr, Property –Farm
b. Ww may not cancel this policy solely Dwellings. Appurtenant Structures And
because ft first Named Insured hw Wousohdd Personal Property Coverage Form
(1) Ameptatl an offer of earthquake a. We may AW.'t not to renew such coverage
coverage;or for any reason, except as provided in b.,a.
and d.Wow:
(2) Canceled or did not romwv a pokey b. We will not retwo to renew such coverage
Issued by the Cattomia Earthquake riot because the first Named Insured has
Authority (CEA) that Included an ac oopted an offer of
earthquake policy prorrtium aurcfrarprt, aa►thquske cxweraQe-
However, tfrs fakawirrg atpplies only, to
insurers who are associate participating
Pep 2 d 3 CoPydght,ISO Properties,Inc.,2006 IL 02 70 09 07
insurem as established by Cal. Ins. Coda included an earthquake policy premium
Section 100136.16. We may elect not to surcharge,
renew suob coverage after tho first Named d We will not'refuse to t~ouch coverage
oft has accepted an o of solely. because owcslve soil conditions
earthquake coverage, It one or mom of the exist on the premises. This Restriction (d.)
fong reasons applies: applies only if coverage is subject to one of
(1) The nonronewal is based on sound the following,which exclude loss or damage
undwwriihtg prirrcgles that relate to the caused by or resulting tram corrosive soil
coverages provided by this policy and conditions:
that are consistent with tfta approved (1) Capital Assets Program Coverage
raWg plan and related doodrrmo to filed Form(Output Policy);
with the Departmem of Insurance as
required by existing law; (�) Corrrrnrarciel Prcpergr Coverage Part -
(2) The Commissioner of Insurance finds Causes Of Loss pedal Form;or
OW the exposure to potential losses (3) Farm Coverage Part-Causes Of Loss
wilt threaten our solver or place us It Form -firm Property, Paragraph D.
a hazardous condition. A hazardous covered Causes Of Lase-Saedal.
owdition includes,but Is not limited to, S. We are not required to send notice of
a condition In which we make claims nonrenewal in flue following eiWations:
payments for losses resulting fro rr an d, If the transfer or renewal of a policy,
earthquake flat occurred within the l s, without
preceding two yam and that required a Is chorus is totals, conditiana, dx rotas,
reduction In policyhoidor surplus of at Is between us and a rnatnbar of our
least 26%for payment of Itme dalrns; Insurance prcup,
or b. If the poWy has been extended for tae days
(S) We bava: ar lass.provided that notice has been given
in accordance with Paragraph C.I.
(A) trawl or socperi The a sut1elantiar o. It you have ollMned topiacement coverage,
redaction m tre coverage; or or d the 1W Named Insured has agreed, In
scope of raimsurx�nas coverage:ar writing,within 60 days of the termination of
X (b) Bdpetienoad a substantial increase] the policy,to obtain that coverage,
In the premium charged for d if the
reMrsurance coverage of our Ply��a ie"0d of no more than
minsantial propera insurance 60 days and you are noMed at the time of
policies;and Issuance that It will not be renewed,
file QMvY isskwW has approved a plan e. c the I not Named insured requests s
for the nanreme�wals that � lair and ctra<tge In fine terms-or conditions or rises
equitable, and that is responsive to the end of �the pperi WiUtih ti0 hays d1i the
changes in cur reinsduarrae position. aloft at life po11C�r period.
If we have
a. We wig not refuse to redrew Rh coverage made a written offer to the:flrs
uc t
solely becakm the first Named Irwumd has beet rd Insured. in Paragraph the
cwxxilled or did cad renew a policy, issued tirmelratrtres shown ht Paragraph term or
by the California Earthquake Autlto*that c npw lhre policy under d urngerd iu mr; e,
donditior+s or at an increased premium rate,
when 1hs increase axoseds 26%.
am
W
MOM
IL alit?0 W ttI GopyriQilt,ISQ Properties,ft.,2006 Pugs 3413
CNA63359XX 0412
DOWNSTREAM SERVICES, INC.
MR
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CONTRACTORS EXTENDED COVERAGE ENDORSEMENT
- BUSINESS AUTO PLUS -
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
I. LIABILITY COVERAGE
A. Who Is An Insured
The following is added to Section II, Paragraph A.1.,Who Is An Insured:
I. a. Any incorporated entity of which the Named Insured owns a majority of the voting stock on the
date of inception of this Coverage Form; provided that,
b. The insurance afforded by this provision A.1. does not apply to any such entity that is an
"insured"under any other liability"policy" providing"auto"coverage.
2. Any organization you newly acquire or form, other than a limited liability company, partnership or joint
venture, and over which you maintain majority ownership interest.
The insurance afforded by this provision A.2.:
a. Is effective on the acquisition or formation date, and is afforded only until the end of the policy
period of this Coverage Form,or the next anniversary of its inception date, whichever is earlier.
b. Does not apply to:
(1) "Bodily injury" or "property damage" caused by an "accident" that occurred before you
acquired or formed the organization; or
(2) Any such organization that is an "insured" under any other liability "policy" providing "auto"
coverage.
3. Any person or organization that you are required by a written contract to name as an additional
insured is an "insured" but only with respect to their legal liability for acts or omissions of a person,
who qualifies as an"insured"under Section II—Who Is An Insured and for whom Liability Coverage is
afforded under this policy. If required by written contract, this insurance will be primary and non-
contributory to insurance on which the additional insured is a Named Insured.
4. An "employee" of yours is an "insured" while operating an "auto" hired or rented under a contract or
agreement in that "employee's" name, with your permission, while performing duties related to the
conduct of your business.
"Policy,"as used in this provision A.Who Is An Insured, includes those policies that were in force on the
inception date of this Coverage Form but:
1. Which are no longer in force; or
2. Whose limits have been exhausted.
B. Bail Bonds and Loss of Earnings
Section Il, Paragraphs A.2.(2)and A.2.(4)are revised as follows:
1. In a.(2), the limit for the cost of bail bonds is changed from $2,000 to$5,000; and
2. In a.(4), the limit for the loss of earnings Is changed from $250 to$500 a day.
C. Fellow Employee
Section II, Paragraph B.5 does not apply.
Such coverage as is afforded by this provision C. is excess over any other collectible insurance.
II. PHYSICAL DAMAGE COVERAGE
A. Glass Breakage—Hitting A Bird Or Animal—Falling Objects Or Missiles
CNA63359XX 0412
The following is added to Section III, Paragraph A.3.:
With respect to any covered "auto," any deductible shown in the Declarations will not apply to glass
breakage if such glass is repaired, in a manner acceptable to us, rather than replaced.
B. Transportation Expenses
Section III, Paragraph AA.a. is revised, with respect to transportation expense incurred by you, to
provide:
a. $60 per day, in lieu of$20; subject to
b. $1,800 maximum, in lieu of$600.
C. Loss of Use Expenses
Section III, Paragraph A.4.16. is revised,with respect to loss of use expenses incurred by you,to provide:
a. $1,000 maximum, in lieu of$600.
D. Hired "Autos"
The following is added to Section III. Paragraph A.:
5. Hired"Autos"
If Physical Damage coverage is provided under this policy, and such coverage does not extend to Hired
Autos,then Physical Damage coverage is extended to:
a. Any covered "auto"you lease, hire, rent or borrow without a driver;and
b. Any covered "auto" hired or rented by your "employee" without a driver, under a contract In that
individual "employee's" name, with your permission, while performing duties related to the
conduct of your business.
c. The most we will pay for any one "accident" or "loss" is the actual cash value, cost of repair, cost
of replacement or$75,000, whichever is less, minus a$500 deductible for each covered auto. No
deductible applies to"loss"caused by fire or lightning.
d. The physical damage coverage as is provided by this provision is equal to the physical damage
coverage(s) provided on your owned "autos."
e. Such physical damage coverage for hired "autos"will:
(1) Include loss of use, provided it is the consequence of an "accident" for which the Named
Insured is legally liable, and as a result of which a monetary loss is sustained by the leasing
or rental concern.
(2) Such coverage as is provided by this provision will be subject to a limit of$750 per"accident."
E. Airbag Coverage
The following is added to Section III, Paragraph B.3.:
The accidental discharge of an airbag shall not be considered mechanical breakdown.
F. Electronic Equipment
Section III, Paragraphs B.4.c and B.4.d.are deleted and replaced by the following:
c. Physical Damage Coverage on a covered "auto" also applies to 'loss" to any permanently installed
electronic equipment including its antennas and other accessories.
d. A$100 per occurrence deductible applies to the coverage provided by this provision.
G. Diminution In Value
The following is added to Section III, Paragraph B.6.:
Subject to the following,the"diminution in value"exclusion does not apply to:
a. Any covered "auto" of the private passenger type you lease, hire, rent or borrow,without a driver
for a period of 30 days or less, while performing duties related to the conduct of your business;
and
b. Any covered "auto" of the private passenger type hired or rented by your "employee" without a
driver for a period of 30 days or less, under a contract in that individual "employee's" name, with
your permission,while performing duties related to the conduct of your business.
c. Such coverage as is provided by this provision is limited to a "diminution in value" loss arising
directly out of accidental damage and not as a result of the failure to make repairs; faulty or
incomplete maintenance or repairs; or the installation of substandard parts.
d. The most we will pay for"loss"to a covered"auto" in any one accident is the lesser of:
CNA63359XX 0412
(1) $5,000; or
(2) 20%of the"auto's"actual cash value (ACV).
III. Drive Other Car Coverage—Executive Officers
The following is added to Sections II and III:
1. Any "auto" you don't own, hire or borrow is a covered "auto" for Liability Coverage while being used by,
and for Physical Damage Coverage while in the care, custody or control of, any of your "executive
officers,"except:
a. An"auto"owned by that"executive officer"or a member of that person's household; or
b. An "auto"used by that"executive officer"while working in a business of selling, servicing, repairing or
parking"autos."
Such Liability and/or Physical Damage Coverage as is afforded by this provision.
(1) Equal to the greatest of those coverages afforded any covered "auto"; and
(2) Excess over any other collectible insurance.
2. For purposes of this provision, "executive officer" means a person holding any of the officer positions
created by your charter, constitution, by-laws or any other similar governing document, and, while a
resident of the same household, Includes that person's spouse.
Such "executive officers"are"insureds"while using a covered "auto"described in this provision.
IV. BUSINESS AUTO CONDITIONS
A. Duties In The Event Of Accident,Claim,Suit Or Loss
The following is added to Section IV, Paragraph A.2.a.:
(4) Your "employees" may know of an "accident" or "loss." This will not mean that you have such
knowledge, unless such "accident"or"loss" is known to you or If you are not an individual, to any
of your executive officers or partners or your insurance manager.
The following is added to Section IV, Paragraph A.2.b.:
(6) Your "employees" may know of documents received concerning a claim or "suit." This will not
mean that you have such knowledge, unless receipt of such documents is known to you or if you
are not an individual, to any of your executive officers or partners or your insurance manager.
B. Transfer Of Rights Of Recovery Against Others To Us
The following is added to Section IV, Paragraph A.5.Transfer Of Rights Of Recovery Against Others
To Us:
We waive any right of recovery we may have, because of payments we make for injury or damage,
against any person or organization for whom or which you are required by written contract or agreement
to obtain this waiver from us.
This injury or damage must arise out of your activities under a contract with that person or organization.
You must agree to that requirement prior to an"accident"or"loss."
C. Concealment, Misrepresentation or Fraud
The following is added to Section IV,Paragraph B.2.:
Your failure to disclose all hazards existing on the date of inception of this Coverage Form shall not prejudice
you with respect to the coverage afforded provided such failure or omission is not intentional.
D. Other Insurance
The following is added to Section IV, Paragraph B.5.:
Regardless of the provisions of Paragraphs 5.a. and 5.d. above, the coverage provided by this policy
shall be on a primary non-contributory basis. This provision is applicable only when required by a written
contract.That written contract must have been entered into prior to"Accident"or"Loss."
E. Policy Period, Coverage Territory
Section IV, Paragraph B. 7.(5).(a). is revised to provide:
a. 45 days of coverage in lieu of 30 days.
V. DEFINITIONS
Section V. Paragraph C. is deleted and replaced by the following:
"Bodily injury" means bodily injury, sickness or disease sustained by a person, including mental anguish,
mental injury or death resulting from any of these.
AC CERTIFICATE OF LIABILITY INSURANCE m"`'
" � 1 0 DATE(MMIDD
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 Beecher Carlson Insurance Services CONTACT NAME: RApn:hpr ClnrlSnn InSIIrAnr:A Anrvlrac
21650 Oxnard Street, Suite 1600 wa `. x .Y A
Woodland Hills, CA 91367 PHONE IAI[ N F e1 St1R SaR-49nn FAXlAICA No) A1A-s a0-5Ron
F-MAIL ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A ACP Amprinnn InSllranf`P Co. A+XV
w Barrett Business S.:. _... ... - -
o .
INSURE
NE Parkway, Re. -
I Services, Inc.
Vancouver WA 98662 te 200 INSURER c .
INSURE _
. ..,. .
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER: 19297195 REVISION NUMBER:
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.
�......,
IpYSR.,,.... .. ,,.ADDL SU9R ...------- ----..... .........POLICY JEFF ' POLICY EXP .... LIMITS
LT•,R TYPE OF INSURANCE use unm POLICY NUMBER fMMInn.hrr Y1 !MM/ODIYYYYI
GENERAL LIABILITY EACH OCCURRENCE $
DARMEMA ISE ES T O!E RY a EooNnce cT uEpl7D
COMMERCIAL GENERAL LIABILITY
�CLAIMS-MADE [ ]OCCUR eer
P
ERSONA &ADV INJURY $
GENERAL AGGREGATE $......... ...... .......
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $
....,I POLICY PROs LOG $JErIT
AUTOMOBILE LIABILITY G:�MStlNPO SING LE LIMIT
a acedplemwt) $
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED ' SCHEDULED BODILY INJURY(Per accident)
'AUTOS AUTOS $
NON-OWNED PROPERTY DAMAG E - --
HIRED AUTOS AUTOS (Per accident) $
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
........ .. ....
f EXCESS LIAB AGGREGATE $
CLAIMS MADE _....... - _
DED --- RETENTION$ $
WORKERS COMPENSATION WCSTATU- OTry- �1•�_nnn_ -- --•L'
A WCLC47118219 12/1/2012 1/1/2015 Tn1RYl_IMIT.R ✓ ER
AND EMPLOYERS'LIABILITY Y/N `--`—' --------.
ANY PROPRIETOR/PARTNER/EXECUTIVE """"" E.L.EACH ACCIDENT OFFICERIMEMBER EXCLUDED? NIA AC C $ .2.000,000--- --
(Mandatory in NH) E L DISEASE-EA EMPLOYEE'. $ n0f1 M0.
If yes,describe under Covered states: -- 2,_-9
DESCRIPTION OF OPERATIONS below CA,;DE,,OR,;WA E.L.DISEASE-POLICY LIMIT $ 2,000.000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Sebodute,if more space is required)
In the event of any payment under this policy for a Loss for which the named insured has waived the right of recovery in a written contract entered
into prior to the Loss,insurer hereby agrees to also waive our right of recovery but only with respect to such Loss.
sall-ins r : r r)i n
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
This Section Intentionally Left Blank THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
(WDHLS)Pam Brooskin
©1988-2010 ACORD CORPORATION. All rights reserved,.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
CE':RT NO 1%1,97195 (VIDTH's) Raheri. ;c:k:.wa xtx 2/20/201A 4:I39:::03 PkI Pe.q. 1 u$ :I-
902838
A Hmm R ce
April 14, 2014
DOWNSTREAM SERVICES, INC
2855 PROGRESS PL
ESCONDIDO, CA 92029-1516
Re: Barrett Business Services, Inc. ("BBSI")
Letter of Self-Insurance for Workers' Compensation Coverage
For DOWNSTREAM SERVICES, INC, CSLB license number 807953
As the named addressee of this Letter, your company's required workers'compensation coverage is provided through
BBSI's state approved Self-Insured Workers' Compensation Plan. As a party to a co-employment contract with BBSI,
which is effective from 1/1/2014 until 12/3112014, California Labor Code §3602 allows DOWNSTREAM SERVICES, INC
to obtain its workers'compensation coverage from BBSI.
BBSI's California customers can also verify BBSI's state certification at http://www.dir.ca.gov/osip/PrivateRoster.pdf;then
scroll down to Barrett(the list is alphabetical by company name). Additional in(ormati n is as follows:
State: California Workers'Compensation Limits: Em�yer L bility Limits:.
Self Insurance Certification #: 2246 Statutory $5,000,000.0 Each Accident
$5,000,000.0 Disease Coverage Limit by Client
$5,000,000.0 Disease; Each Employee
Notice of Termination: In the event the contract between BBSI and DOWNSTREAM SERVICES, INC is terminated, BBSI
must provide notice of the termination within seven (7)days to the California Contractors State License Board ("CSLB").
Other Comments (place an "X" if applicable):
o SERVICES, INC agree to waive their right of subrogation
benefit f:
Waiver of Subrogation: BB I and D DOWNSTREAM M
for the
City of El So undo- Public Works it's officers and em to ees at"All O erasions"
X Named"Letter Holder": City of El Segundo- Public Works, it's officers and employees 350 Main Street El
Segundo, CA 90245
® Other: "All Operations"
Additionally, BBSI's self-insured program is further supported by an excess workers'compensation insurance policy with
ACE American Insurance Co. Copy of certificate is available upon request.
For additional information, please contact your local BBSI office at: TEMECULA
(951)296-3770
_.. One Ridge Gate Drive Suite 100
Temecula, CA 92590
Very truly yours,
doe:Lasl-3
Michael L. Elich
President and Chief Executive Officer