No preview available
PROOF OF INSURANCE (2015) CLOSEDC CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 4/2/2014 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). CONTACT PRODUCER Ed ewood Partners Insurance Center (EPIC) NAME: 19000 MacArthur Blvd. PH Floor PHONE 1e r " 5 ,�� ; (.9.49)-2 63 0606 � FA 'A O)• (949) 2163-0191,061, Irvine, CA 92612 [EWAIL r:(i1/FRAr;FA CERTIFICATE NUMBER: 107911AA"t 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 INSURERISI AFFORDING COVERAGE NAIC p www.edgewoodins.com ........ ......... INSURER A : Peerless Insurance Co. — - _. 24198 ...- .. INSURED INSURER B --- -------- —.. ............. Robert's Liquid Dispposal 14018 Carmenita Rd. - ... --- ' "SORER° ACCORDANCEIW TH HE POLICY PROVIS IONS. Santa Fe Springs CA 90670 INSURER o . $ 1,000,000 r:(i1/FRAr;FA CERTIFICATE NUMBER: 107911AA"t 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. J SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE E WILL BE DELIVERED IN . .... ... _ .. .... . EFF POLICY ILTR -- - ---- ---- --- -------- —.. ............. TYPE OF INSURANCE POLICY IPOLICY INSO .-D I XP LIMITS ACCORDANCEIW TH HE POLICY PROVIS IONS. A ✓' COMMERCIAL GENERAL LIABILITY ✓ GL9568472 3/5/2014 3/5/2015 EACH OCCURRENCE $ 1,000,000 El Segundo CA 90245381, DAMAGE YO RENTED CLAIMS -MADE ✓ OCCUR P)7 FMISFC lF rP $ 100 000 ,r..s MED EXP (Anv one Derson) S 5,000' PERSONAL &ADVINJURY S 1,000,000 , , . . _ GEN'LAGGREGATELIMITAPPLIESPER: GENERAL AGGREGATE - .---- -------- - - --- 000 000 S 2,, P RO- ✓ POLICY FRO- ....,.,� LOC PRODUCTS - COMP /OP _ AGG ............. .. $ 2 000 000 OTHER, $ AUTOMOBILE LIABILITY F IT ..0 f Pf�:I�1P 8 IM.... ... $ .. m... ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ A AUTOS UT OS -wy NON -OWNED i'ROPF DAMAGE $ ---' HIRED AUTOS AUTOS; . !P"OComsmuil ... .., A UMBRELLA LIAB ,/ OCCUR CU8638902 3/5/2014 3/512015 EACH OCCURRENCE $ 1.000.000 EXCESS LIAB CLAIMS -MADE AGGREGATE $ 1,000,000 DFD I ✓ I RFTENTIQN$NIL i $ WORKERS COMPENSATION PER ORH AND EMPLOYERS' LIABILITY YIN ITF ' ....... .........•:, ........� _:........ ANY PROPRIETOR/PARTNER /EXECUTIVE E..L EACH ACCIDENT $ OFFICER /MEMBER EXCLUDED? NIA . ".� . .... ........ . .._,.,.. . (Mandatory in NH) E DISEASE- EA EMPLOYEE $ If yes, describe under - -- -- -- DESCRIPTION. OF OPERATIONS below E.. L- DISEASE - POLICY LIMIT $ ''.. DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required( Certificate holder is named as additional insured as respects the general liability, but only if required by written contract with the named insured, prior to an occurrence, per form GECG 602 09/04. Subject to all policy terms and conditions. r...'FRTIF'Ir".ATF wni nFR CANCELLATION (9 1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD CBRT NO.: 19720666 Jan Schwartz 9/2/2019 3:06:26 PM Page 1 of 11 City of El Se Undo J SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE E WILL BE DELIVERED IN of Public'WWorks�' a ACCORDANCEIW TH HE POLICY PROVIS IONS. 150 Illinois Street �w, El Segundo CA 90245381, AUTHORIZED REPRESENTATIVE Tony D "Asaro (9 1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD CBRT NO.: 19720666 Jan Schwartz 9/2/2019 3:06:26 PM Page 1 of 11 AGENCY CUSTOMER ID: rte' C>1?V ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED Robert's Liquid Disposal Edgewood Partners Insurance Center (EPIC) 14018 Carmenita Rd. POLICY NUMBER Santa Fe Springs CA 90670 CARRIER ADDITIONAL REMARKS NAIC CODE EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability (01/14) ........ . .......... . ........... . .. ..... CERTIFICATE HOLDER: City of El Segundo Department of Public Works ADDRESS: 150 Illinois Street El Segundo CA 902453813 ........ .. ...... ............. City of El Segundo, its officials, and employee as "additional insureds" with respects to general liability ACORD 101 (2008/01) @ 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ADDENDUM CERT NO.: 19720686 Jan Schwartz 4/2/2014 3:06:26 Pm Page 2 of 11 4/2/2014 COMMERCIAL LIABILITY GOLD ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SECTION I - COVERAGES COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY 2. Exclusions Item 2,g. 2) is replaced with the following: 2.g. 2) A watercraft you do not own that is: a) less than 50 feet long; and b) Not being used to carry persons or property for a charge. Item 2.g. 6) is added. 6) An aircraft in which you have no ownership interest and that you have chartered with crew. The last paragraph of 2. Exclusions is replaced with the following: Exclusions c„ through n. do not apply to damage by fire, explosion, sprinkler leakage, or lightning to premises while rented to you, temporarlly occupied by you with the permisslon of the owner, or managed by you under a written agreement with the owner. A separate limit of insurance applies to this coverage as described in Section III - Limits of Insurance. SECTION I - COVERAGES COVERAGE C. MEDICAL PAYMENTS If Medical Payments Coverage is provided under this policy, the following is changed: 3. Limits The medical expense limit provided by thls policy shall be the greater of: a. $10,000; or b. The amount shown in the declarations. Coverage C. Medical Payments is primary and not contributing with any other insurance, even if that other insurance is also primary. 03C O, (102 (09 /0) hicludes crapyric htcd ;naterkd 01' Sn'91mmce services offices fnc. Willi its p ermk5iolt Page .1 of I CRRT NO.: 19720686 Jan Schwartz 9/2/2019 3:06:26 PM Page 3 of 11 I he following is added: COVERAGE D. PRODUCT RECALL NOTIFICATION EXPENSES Insuring Agreement We will pay "product recall notification expenses" incurred by you for the withdrawal of your products, provided that: a, Such withdrawal is required because of a determination by you during the policy period, that the use or consumption of your products could result in "bodily injury" or "property damage "; and b. The "product recall notification expenses" are incurred and reported to us during the policy period. The most we will pay for "product recall notification expenses" during the policy period is $100,000. SUPPLEMENTARY PAYMENTS - COVERAGES A AND B Item b. and d. are replaced with: b. The cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds. d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or "suit" including actual loss of earnings up to $500 a day because of time off from work. SECTION II -MIO IS AN INSURED Item 4. is replaced with: 4. Any subsidiaries, companies, corporations, firms, or organizations you acquire or form during the policy period over which you maintain a controlling interest of greater than 50% of the stock or assets, will qualify as a Named Insured if: a) you have the responsibility of placing insurance for such entity; and b) coverage for the entity is not otherwise more specifically provided; and c) the entity is incorporated or organized under the laws of the United States of America.. However; coverage under this provision does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed the entity, or "personal injury" or "advertising injury" arising out of an offense committed before you acquired or formed the entity. Coverage under this provision is afforded only until the end of the policy period, or the twelve (12) month anniversary of the policy inception date whichever is earlier. SECTION III - LIMITS OF INSURANCE Paragraph 2 is amended to include. The General Aggregate Limit of Insurance applies separately to each 'location" owned by you, rented to you, or occupied by you with the permission of the owner. GCCG 602 (0W04) Include; col }yt° ghIell Inworial oI! Instirance Services Ullices Inc. uvi Ili its liermissimi llagu 2 oF2 CSRT NO.: 19720686 Tan Schwartz 4/2/2014 3:06:26 PM Page 4 of 11 Paragraph G. is replaced with the following. 6. Subject to 5. above, the Fire Damage Limit is the most we will pay under Coverage A for damages because of "property damage" to premises while rented to you, temporarily occupied by you with permission of the owner, or managed by you under a written agreement with the owner, arising out of any one fire, explosion or sprinkler leakage incident. The Fire Damage Limit provided by this policy shall be the greater of: a. $500,000. or b. The amount shown in the Declarations. SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS Item 2. a.is replaced with: 2. Duties In The Event of Occurrence, Offense, Claim or Suit a. You must promptly notify us. Your duty to promptly notify us is effective when any of your executive officers, partners, members, or legal representatives is aware of the "occurrence ", offense, claim, or "suit ". Knowledge of an "occurrence ", offense, claim or "suit" by other employee(s) does not imply you also have such knowledge. To the extent possible, notice to us should include: 1) How, when and where the "occurrence" or offense took place; 2) The names and addresses of any injured parsons and witnesses; and 8) The nature and location of any injury or damage arising out of the "occurrence ", offense, claim or "suit ". Item 4. b. 1) bf is replaced with: b. Excess Insurance 1) b) That is Fire, Explosion or Sprinkler Leakage insurance for premises while rented to you, temporarily occupied by you with permission of the owner, or managed by you under a written agreement with the owner; or Item 6. is amended to include: 6. Representations d. If you unintentionally fail to disclose any hazards existing at the inception date of your policy, we will not deny coverage under this Coverage Part because of such failure. However, this provision does not affect our right to collect additional premium or exercise our right of cancellation or non - renewal. Item 8. is replaced with: 8_ Transfer of Rights Of Recovery Against Others To Us a. If the insured has rights to recover all or pall of any payment we have made under this Coverage Part, those rights are transferred to us. The insured must do nothing after loss to impair there. At our request, the insured will bring suit or transfer those rights to us and help us enforce them. GLCG 602 (09/04) 1 tic ludes Copyrighted material or [murance Services O lice;; Inc. witli is perniission Page 3 or i CERT NO.: 19720606 Jan Schwartz 4/2/2014 3:06:26 PM Page 5 of 11 b, If required by a written "insured contract`, we waive any right of recovery we may have against any person or organization because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under that written "insured contract" for that person or organization and included in the "products - completed operations hazard ". Item 10. and Item 11. are added: 10. Cancellation Condition If we cancel this policy for any reason other than nonpayment of premium we will mail or deliver written notice of cancellation to the first Named Insured at least 60 days prior to the effective date of cancellation. 11. Liberalization If we adopt a change in our forms or rules which would broaden your coverage without an extra charge, the broader coverage will apply to this policy. This extension is effective upon the approval of such broader coverage in your state, SECTION V- DEFINITIONS The following definitions are added or changed: 9. 'Insured contract' a, is changed to a. A contract for a lease of premises. However, that portion of the contract for a lease of premises that indemnifies any person or organization for damage by fire, explosion or sprinkler leakage to premises while rented to you, or temporarily occupied by you with permission of the owner, or managed by you under a written agreement with the owner is not an "insured contract ". 23 and 24 are added: 23. "Location" means premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway, waterway or right -of wey of a railroad. 24. "Product recall notification expenses" means the reasonable additional expenses (including, but not limited to, cost of correspondence, newspaper and magazine advertising, radio or television announcements and transportation cost), necessarily incurred in arranging for the return of products, but excluding costs of the replacement products and the cash value of the damaged products. The following Provisions are also added to this Coverage Part: A. ADDITIONAL INSUREDS - BY CONTRACT, AGREEMENT OR PERMIT 1. Paragraph 2, under SECTION 11 - WHO 1S AN INSURED is amended to include as an insured any person or organization when you and such person or organization have agreed in writing in a contract, agreement or permit that such person or organization be added as an additional insured on your policy to provide insurance such as is afforded under this Coverage Part, Such person or organization is not entitled to any notices that we are required to send to the Named Insured and is an additional insured only with respect to liability arising out of: a. Your ongoing operations performed for that person or organization; or b. Premises or facilities owned or used by you,. CY;C G 602 {09 /0,I'} h1audes copyrigli Lett material of lu:akrnuce services oldies hie. widh ils permission Pate 1 or CERT NO.: 19720606 Jan Schwartz 9/2/2019 3:06:26 PM Page 6 of 11 With respect to provision 1.a. above, a person's or organization's status as an insured under this endorsement ends when your operations for that person or organization are completed. With respect to provision 1.b. above, a person's or organization's status as an insured under this endorsement ends when their contractor agreement with you for such premises or facilities ends. 2. This endorsement provision A. does not apply: a. Unless the written contract or agreement has been executed, or permit has been issued, prior to the "bodily injury ", "property damage" or "personal and advertising injury "; b. To "bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equlprnent rurnished lil connection with Such work, in 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. To the rendering of or failure to render any professional services including, but not limited to, any professional architectural, engineering or surveying services such as: (1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surreys, field orders, change orders or drawings and specifications; and (2) Supervisory, inspection, architectural or engineering activities; d. To "bodily injury ", "property damage" or "personal and advertising injury" arising out of any act, error or omission that results from the additional insured's sole negligence or wrongdoing; e. To any person or organization included as an insured under provision S. of this endorsement; f. To any person or organization included as an insured by a separate additional insured endorsement issued by us and made a part of this policy. S. ADDITIONAL INSURED —VENDORS Paragraph 2. under SECTION II -WHO IS AN INSURED is amended to include as an insured any person or organization (referred to below as "vendor ") with whom you agreed, in a written contract or agreement to provide insurance such as is afforded under this policy, but only with respect to "bodily injury" or "property damage" arising out of "your products" which are distributed or sold in the regular course of the vendor's business, subject to the following additional exclusions: 1. The insurance afforded the vendor does not apply to: a. "Bodily injury" or "property damage' for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; b. Any express warranty unauthorized by you; c. Any physical or chemical change in the product made intentionally by the vendor; GECG 602 (09 /04) tnetaades copyrighted material of 1119mai.aco services or iccs hic, ",R4 its percnimicni Page 5 or 5 CERT NO.: 19720686 Jan Schwartz 4/2/2014 3:06:26 PM Page 7 of 11 d Repackagmg, uniess unpacked solely for the purpose apt inspection, demonstration, testing, or sr.a bslltulion of parts under instructions frOrn the rnarlUfaC[Urer, and then repackaged in the origin"A container; e. Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to aialke or norn-wHy undertake,% to rnAe in the course of business, in connection with the clsthbution or sale of the products: f. Dernonstration, installation, servicing of, repair operations, except such operations perforrried at the venclor's premises in connection with the sale of the product; U. Products which, after distriblUtinn or sale by you have been labeled or relabded or used as as container, part or lngredient of any other thing or substance by or for the vendor; ar. h To "bodify injury" or "property danriage" @rising out of any act, error or orHssion that resufts frCm1 the additiorml insured's sole negfigence or wrongdoing. 2. This insuraince does not apply to any incur person or organization, from whorn you have acquired such products, or any ingredient, part or container, entering Infra, accompanying or containing such products, 602 (4 "9A14) jjdLkkjp_q p pr a '[1, j njj�meliM gar his I'll vI ntrv, Smiv%�s Offict!S hlc� WirAl its ngv Ci o CERT NO.. 19720686 Jan Schwartz 4/2/2014 3,06:26 PM Page 0 of 11 POLICY NUMBER:GL9568472 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location And Description Of Completed Opera - Or Oruanization(s): tions Any person or organization, trustee, estate or gov- COMMERCIAL WORK ONLY ernment entity to whom or to which the Named Insured is obligated, by virtue or written contract or agreement to provide Insurance, Such As Is Afforded By This Policy. Information required to complete this Schedule if not shown above, will be shown in the Declarations. 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 liability for "bodily injury" or "property damage" caused, in whole or in part, by 'your worK' at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products - completed operations hazard CG 20 37 07 04 m ISO Properties, Inc., 2004 Page 1 of 1 0 CERT NO.: 19720686 Jan Schwartz 4/2/2014 3:06:26 PM Page 9 of 11 Robert's Liquid Disposal 4/2/2014 POLICY NUMBER: GL9568472 COMMERCIAL GENERAL LIABILITY CG 20 10 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 I=1P1114M Name Of Additional Insured Person(s) Location(s) Of Covered Operations Or Oraanization(s): City of El Segundo Department of Public Works 150 Illinois Street El Segundo CA 902453813 Information reauired to complete this Schedule. if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional exclu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage or personal and advertising injury "property damage" occurring after: caused, in whole or in part, by: 1. Your acts or omissions; or 1. All work, including materials, parts or equip- ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project (other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) desig- covered operations has been completed; or nated above. 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a princi- pal as a part of the same project. CG 2010 07 04 © ISO Properties, Inc., 2004 CERT NO.: 19720686 Jan Schwartz 4/2/2014 3:06:26 PM Page 10 Of 11 Page 1 of 1 13 Forming a part of Policy Number: GL 9568472 .... ................ _ ........... ......._ Coverage Is Provided In PEERLESS INSURANCE COMPANY - A STOCK COMPANY Named Insured: Agent: HERRICKS ROBERT (INDIVIDUAL) EDGEWOOD PARTNERS INS CENTER (DBA) ROBERT'S LIQUID Agent Code: 4295098 Agent Phone: (949)- 263 -0606 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 Additional Insured Person(s) Or Oroanization(s): Location(s) Of Covered Operations THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS AND VOLUNTEERS CITY OF EL SEGUNDO DEPARTMENT OF PUBLIC WORKS 150 ILLINOIS STREET EL SEGUNDO, CA 90245 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 organization(s) shown in the Schedule, but 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(s) 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 location 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. © ISO Properties, Inc., 2004 CG 20 10 07 04 Page 1 of 1 03105/2012 9568472 NEUSXJPC1308 PGDM060D J02388 GCAFPPN 00013924 Page 13 CERT NO.; 19720656 Jan Schwartz 9/2/2019 3:06:26 PM Page 11 of 11 .$L. I "J DATE(MWDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 04/03 /2014 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 terns 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 endomement(s). CONCT PRODUCER BETH BETTGER NAME AMANDA HANSEN 20220 STATE RD. AIC, Ho, Ent): 562 -809 -9500 �i�C. No) : 562 -809 -9559 _ t -MAIL StateFarm CERRITOS, CA 90703 ADDRESS: AMANDAOBETHBETTGER.COM _ ,INSURER(S) AFFORDING COVERAGE INS NAIL N � . ,,,,, A. _ ,.... ......._ _.. , ..... , INsuRER A. State Farm Mutual Automobile Insurance Company 25178 INSURED ROBERT & PEGGY HERRICKS INSURER DBA ROBERTS LIQUID DISPOSAL IysuRERC: 14018 CARMENITA RD INSURER O: SANTA FE SPRINGS, CA 90670 -4919 INSURERS: INSURER F COVERAGES _ .�_.__... CERTIFICATE NUMBER: mm .. .. ... _....... 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. IL'rR GENERAL.,.,.,,,,,,,_., Abbi. S�� ,.LICY�.,..�.,,,,, -.., �FOLk�" M' �F�f�W D1O0 EXOd4�i�d4.,��"`TOIaEO$LO L TYPE OF INSURANCE I � POLICY NUMBER MMPLIOdYYYY MMtDk"�YYY LIMITS LIABILITY , ,) S COMMERCIALGENERALLIABILITY ru., �^ S f ` , J ;P rxa rata aroi, .e _ ..... CLAIMS -MADE OCCUR MED EXP (Any one person 1 $ PERSONAL-&, ADV INJURY S GENERALAGGREGATE S GEN'L AGGREGATpE� LIMIT APPLIES PER PRODUCTS - COMPIOP AGG S I OUCY U I U+�" _ S Y _ P73 6862- A06 -75M 01!0612014 07/ ... I INdLT Lir3i� "° ...._. _ .._ AUTOMOBILE LIABILITY 014 f 0 IE8 ecadenn Y $ 2,000,000 r Q D _ ANY AUTO Y BODILY INJURY (Per person) S ALL OWNED ° "" SCHEDULED 244 3052- B01 -75E 02/01/2014 08/0112014 BODILY INJURY (Per scat X j AUTOS X, AUTOS 403 0161- D21 -75V 04/2112014 1012112014 s X HIREDAUTOS � X NON-OWNED 'Y'`k&;IWSOUYq,yAMAGE AUTOS I (r�m�x A �rkrvrwll _ f $ 244 3054- B01 -75D 0210112014 08101/2014 1 - UMBRELLA LIAB OCCUR l _.. EACH OCCURRENCE S EXCESS LIAB CLAMS MM L, k:. , AGGREGATE ...... .... S DED �....... R(mMNTtlONS 5 IOP yUMMI _ _ ...__ ..... WORKERS COMPENSATION B"4" o AT &I tid'rpi AND EMPLOYERS' LIABILITY E L DISEASE -EA B Pi I * t' OFFICEANEMBER EXCLUDED? NIA E L EACH ACCIDENT E (Mandat�oryRn NH��ARTNER/EXECUTIVE 1pp..� LM "I.. GL� S R. W, .. II yes, describe under ra PTIn nr roraennuc na,,.,, mm,•, ••,,, &° t, V,'NS• AS)T , PMTI.K,'e UlArT 5 ENOL Poucv Y� 413 8508- B03 -75C 0210312014 08/03/2014 S2 �0 00D DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, U more space is required) Additional Insured Endorsement, and Waiver of Subrogation have been requested and will be mailed directly to the additional insured. CERTIFICATE HOLDER CANCELLATION City of El Segundo THE SHOULD THEREOF, NOTICE I WILL BE CBE CDELIVERED BEFORE IN 350 nMalmrSt Rivera, PW ACCORDANCE WITH THE POLICY PROVISIONS. . w�• AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 "1,J A III ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 1001486 132849.8 01 -23 -2013 5t(ttttlP State Farm Mutual Automobile Insurance Company 900 Old River Road Bakersfield CA 93311 -9501 NAMED INSURED 00085 75- 3357 -1 B A 000085 0058 HERRICKS, ROBERT & PEGGY DBA ROBERTS LIQUID DISPOSAL 14018 CARMENITA RD SANTA FE SPGS CA 90670 -4919 DO NOT PAY PREMIUMS SHOWN ON THIS PAGE. IF AN AMOUNT IS DUE, THEN A SEPARATE STATEMENT IS ENCLOSED. YOUR CAR 10129 -1 -B MATCH 00085 MUTL VOL DECLARATIONS PAGE POLICY NUMBER 244 3054 -BOl -75E POLICY PERIOD APR 03 2014 to AUG 01 2014. 12:01 A.M. Standard Time AGENT BETH BETTGER INS AGENCY INC 20220 STATE RD CERRITOS, CA 90703 -6470 PHONE: (562)496 -1000 2006 FORD F650 TANK 3FRWF65T56V266874 Commercial ,9Jr,�'a „c, ✓ /w; "a�� ,�.ed,,,,,a rP. nu„yu'r� 'n,��nd' f�, r, EJ,,,` 4c�` �. r�i�^ a` ��,,,, r",;, dwvrv:, u'.%. . „Mr,�t;�.ylr,�cJlfl.,a ✓an.:,?, „��� w_;�drr,N�„ Limit -Each Accident ftrp zcbl ib ) v'�':!!r yWJI /gyp ASP IJ /ir r/ ri i9riN /Irrf /ill j7 /rri'l �tl /)Y' ✓f ,,r '0;I d r ° 1JiF vfr r{r Wry ,fi� r 1. ✓�L�, d/ B 9e�r! ,r,,,,✓ ✓, 7 5«�.�� �dl ;Us���;J vd �, f ✓dll �,J r., .l��IJl,�i�r!!J2! ^.i ih�ii'i;ali zr n,,,u N �, v±�./,1 �, r�',,,a � �., � ,Y , .",r;,,, ow' „a fait✓ � ,��,uJ,v.a ,eldl .,,✓ti,.P C Medical Payments overage $8.14 rr� ✓"rs v",?:f,y�' 1 r y r Jyr., gar e ✓ ✓, ✓ rr�w. „r!,;..„,�41N / rrri�,vfdN, ✓ /�NIl1 Lori trl -rri 71iy/ ii ,.��iri Y(ib T✓ r ,l% ✓ ✓/ ✓off i s'✓ /✓ �: e�a�lO 1rr ;� 4lrr a✓ uriFj li r i� i! i ! /✓ rd.. 1( �; �„' �',; v, �` �. S, i��, 1» tSS� `,"��J /s(�1�Jfl���8�'✓3�iI��1W1� U��,,'NoFl�til�� ✓e�.�t�, /,n�la �u�r „ ✓G, ✓w1Y ��, Y�'1, 12 °3'dloY d ✓n. ,V„ „i... ,,.� L�:;� ;a'L twvs �,:,df, Nt,,,o,u� ,;J+✓ v� /��� „v.� � ,d ✓,ti $5,000 i r r b'n�^ y'HN i r r/ J' rrf� >, .� , -:. �, � ✓. , rr�c? p , Y �ru� �, �5, "I 7, r .t + +l w d;Y )' ° i"T !fir !rJ`r /y err //d t a 7'. l /,r �r a J Jn 9 ✓/ ,� ! � � 1 r�3�r „�(��,,!`i,J� �. rdd/r r�] rurrv,, d!✓/ kn����. ��, d' n�+, 1,' NM 4A,> i�✓ 4�hP� .�!��'xa'��fJ ✓lm+ri��r2�i+� ,✓+✓ �,�v.,�:r rx� <�,rri�.!:�r fvwT�Ae�wS,M�o��W,>6, ° ✓immuf +, �t�o¢Jl,�h�./ G Collision Coverage $2 000 Deductible $132.24 PY� w J r l! r r✓ rf l99 arld,rN'Y u.” i ;"� �,r,(�;, �,y r r s �;Ja "� ✓dl rrjr , llilr f ! ✓r ✓1 Y r� ✓1> ''� r > u N+ Y.t /Ii /1>'r /aJirr ✓ X r'y r ✓ ✓ir /-J' ,rU,IF NII+mI� �'9, d.”. G,% /r, �'�(.6 wfi lv�rfin��1MV� .fr;��6L 1 ' 7JA. �W, �n 'a” 'X Am W” ,.re�„k� �� +i w,,w �%rvJ'm`- "�n /�.: t,r�.lL (�. 4.�".a, Bodll Injury Limits !l`h !f`;v✓✓r J +rr'I!r ±l"Yli �l, J'�,p�r ✓� aa✓v¢ -� X190 ri�iri>J/,o �IY�,�(., kiJ ✓o of prf 4:1 FRY'.r ✓NJl�9u al,F!lrl%'i ,�Jrr H.rJy( /!d�%,.^'lrVP ✓rr7d yl r „� ✓I rJia /ir ✓�f�r.YNi��r,' r6;vRrNi�/ l -j r4wu4� ✓u�� -��, -,'��J r,:im�',�,1�l irvf�m �' B' ��i��ffi' �d+ �1S' �AdPA ,���,.e16✓�,:i,�/�4��!u�✓Na /;Ilr %(r l�'� ,dX�m�v Ird�,,.,�u, r, r, ,., t,�A,;�, ✓rlflaw r.�,��ol,>yr „�,oraJ�`,✓�'1 �i�4 ✓d,��b ✓ar �„ann,r�P. $100,000 $300,000 Ir`l /l.n, �: ,i����r� T -� is �„ , ✓wr ;� ,�, .., �F,.✓ rr,;J� r�,rJ✓ � aa;I c ✓�4;";�'l�d ✓ild�d111%n3 ;ii7 /�l /!„ °i,r,P P /friN bn” ri �rdlr /�r2„i JY ✓r�r�l,��r r Replaced policy number 2443054 -75D„ Your total renewal premium for FEB 01 2014 to AUG 012014 is $1,399.80. PMU OL Y CONSISTS 0 H S D C -51 I C LY, IACLUDINGLTHOSEOOISSUED TO YOU � S q� ��YL ENDOS MHN J r" WW MI0 pp HDI& RIS -1 TOE13ERAA TA LMOTCATCAP90405T5232DBA WATT 6'08 (�2A76IOIA{AL�ASUR H'VR01& l� A, N ANpp ITS SUBSIDIARIES b FILI(App}ESp E pMES O�i 220 C NWY AR I2033 -2020. 1 0�8 4IAA� IBg NI�LTO 10� EO CA �A�Y0 C G MOTOR CD F' CERS, A��Ni & HM EH 1850 YSIN EL SEGUNDO CA 90245 -3895. (� WAIVE LSU 0 t1l ' UNDER THE LIABILITY COVERAGE. BN ONST NGpp E Y'OF LI UI'D PRODUCTS. DO C VE pp R ( ( �I HICLE SHARING. g S NGL LIMIT PpA�ILI�Ip �4I�RYta. T 2pMCP E H91 PNO ESSEUEU�HE R 3443052-75 CANCELLATION. EFFECTIVE 2 O16A0VER OF SUBROGATION UNDER THE LIABILITY COVERAGE - CITY OF EL Agent: BETH BETTGER INS AGENCY INC Telephone: (562)496 -1000 02586/01249 See Reverse Side Prepared APR 15 2014 3357 -1385 156.3888 CA.2 06.2002 (81802510) (o10254c) 14SXON (o1 a0251e) This policy is Issued by State Farm Mutual Automobile Insurance Company. MUTUAL CONDITIONS 1. Membership. While this policy is in force, the first insured shown on the Declarations Page is entitled to vote at all meetings of members and to receive dividends the Board of Directors in Its discretion may declare in accordance with reasonable classifications and groupings of policyholders established by such Board. 2. No Contingent Liability. This policy is non - assessable. 3. Annual Meeting. The annual meeting of the members of the company shall be held at its home office at Bloomington, Illinois, on the second Monday of June at the hour of 10:00 A.M., unless the Board of Directors shall elect to change the time and place of such meeting, in which case, but not otherwise, due notice shall be mailed each member at the address disclosed in this policy at least 10 days prior thereto. In Witness Whereof, the State Farm Mutual Automobile Insurance Company has caused this policy to be signed by its President and Secretary at Bloomington, Illinois. Secretary President Important ... California low requires us to provide you with information for filing complaints with the State Insurance Department regarding the coverage and service provided under this policy. Complaints should be filed only after you and State Farm® or your agent or other company representative have failed to reach a satisfactory agreement on a problem. Please forward such complaints to: California Department of Insurance Consumer Services Division 300 South Spring Street Los Angeles, CA 90013 Or call toll free 1 -800 -927 -HELP f43M NOTICE We are required to furnish you with the following information: 1. An automobile liability insurance company may cancel a policy before the end of the current policy period for reasons described in the provision titled Cancellation which is located in the General Terms section of your policy (refer to the Contents in the beginning of your policy forthe page number). 2. An automobile liability insurance company may increase the premium or refuse to renew the policy for any of the following reasons: a. Accident involvement by an insured, and whether an insured is at fault in the accident, h. A change in, or an addition of, an insured vehicle. c. A change in, or addition of, an insured underthe policy. d. A change in the location of garaging of an insured vehicle. e. A change in the use of the insured vehicle. f. Convictions for violating any provision of the Vehicle Code or the Penal Code relating to the operation of a motor vehicle. g. The payment made by an insurer due to a claim filed by an insured or a third parry. An automobile liability insurance company may increase the premium or refuse to renew the policy for reasons that are not listed above but which are lawful and not unfairly discriminatory, nyW 510 °0 '�HP° oo`w' Q��' w,�",`w' z Q� w "'N "� W,� A� aoW�j`"A �W oho w��, ° O wow H�aH a w Id° `Q�o a AA O� d QQ � O ciapy o z o H o° O o J -4 >,U,gopa Up0 A O O dOA° 1 rxff ti �n U HOU °a�U ��W BOA ° un � H a C) f44 �� �U0 w no o� HrxO v v 00p�Zo z p Ov �pW O U� " o C) pO UH o O Z 0 < 0 �a FO °O H,,Aw zUUw 1 owl ~° °OUR U �z U -Oum� .. o n V O y !-' v O> W V H O W1, WOO 0 rD H U T .D C a.� QO¢ w`i' A>.. °°� r�AO�:) c�;ApUO co OOH °Ow 0 y TcJ �a° • v y b � y �D A? o y • _ �°' b °y 00 G c y 3 o .°� b o ❑ O ° UOAO Aa Hw f� � y � �pz �°�' Z ° > y a o 4 A 4�O ° � vZ' Oa m N C m N V , Cl) � H y W O boo Q r U y J O W T c. b w° $ Fi 'C Out V. o W � o o g O O O G - d v O U= 4 GL E o E o a o g J O 2 O C b b V, v = 'o a O Q o `o 4 3oa 3 �?� ca o �.a?� O w o$ .: o C) N.M Z ,OG O iii r O {O H t —; N £ 3o I pops Ial 'Dlootl A3I'I0d 2IIIOA OZ I13VI LV HWHIld gSL-I0g-17S0£ "Z :joq —N AxTod 0 0 0 N C O U G N M O 1 1 0 NC a� a 0 U 0 0 0 N C d O U y ti d .D O wE O a2 ' eb 0 103 WIZ 10IL9930 N 0 O En A p za U Ln ° o x $ � U b z U'' w P4 cn °b A � z a C3 0 u w U 0. CL .0�o CL A W a p a a x P. A � xv ti O cal F� 0 c LL 66 z P4 u o W a A d WdU L G 0 r C O o U �pA E U WA ° 0., ° WQ a s o �^ U WW O aF- LU zzz a O p FW dO � >X' w w o� boo �� o 'ti o a W o w 0 W x W d U. �azp�-p,v �v °4 0 V1 �+ WwW �b o a U d a O OW P4 P4 aoi o> > .G d W O V] `—' O G O 0 'O ZI) dry C 00 � K o o A o0 W ° to ro Q v a sv w a w H v Odd WUO �q �a W p0 V ZZgq �o^^ '3SL-IOg-bSO£ ttZ :IagtunK AoTjod ldd DIOOU AD IOd -UfIOA OZ IIDV,LIV JSVU'Id O 0 C o. 0 U 0 00 0 U ZM 0 ID 0 N c 0 0 U d O 0 c M� P: 'ob 0 u 64Z 40 /L900 u o� >�,� �O ...a �¢ 9, a :, WU �..; F" o O� z�x U U O ° �?4� °' cd 0 x3q �3 ° �q3 :. �. 0 ot.� � � >b C O to >.— E c Fi A a '° w H v M '3SL-IOg-bSO£ ttZ :IagtunK AoTjod ldd DIOOU AD IOd -UfIOA OZ IIDV,LIV JSVU'Id O 0 C o. 0 U 0 00 0 U ZM 0 ID 0 N c 0 0 U d O 0 c M� P: 'ob 0 u 64Z 40 /L900 N �:7 U>o,soc °� >oe• ^3� ul Cc cl m m $� c0 y W o >, °'� ° o c �.0 U v�6�04.- bCU�or° 'WF C CL.•, koa3u�y��L�'-e c ac o ?r 4•� • cam, is A a F• 07A 3 3 a�� � a W a v wti >- c= 0 eon � � R ❑ O W W� O d= t) '° U►� W'm o�.'N ^p Y C7W'x o Hwy co El cC X30 OU`�p OU0UOF V n_ y . zO�F"A> v > 0^ o �y zUA �wu? a vwgW �. �>W Itow N OOUl 1 � yp i o..�a ~N •? C .c2 .6b WLz'�`gW�jc>'"� ° W ° W w° .. v C d m PQ O o w � o .e wUGy�U.v � w .a >a" >�"3w�.^ Q a�i� -e a O WU2 tic �o d cS o� o $ a �,.0 04 w — N0. o °wa�a'A�oa ?:b� ii 1' O cococ� o co ,mac u p O U a.0 a'-:Q Q.� �a °'r��rp `�',w°,? �o��T�o3ci a OA =0cui ' 0 c 1: to O5 CY-4 ►'""i O H U �� W (� � U H U ri .c .° CW7.Or-•�.�°5 ,3 o.� ° �. � CW7�OQOUa•�`�•�•�' ~a w 0UW }' ` ca° p a�`OU� td•� a��-��m y O r. O 3 ' w y anic � LZ ° U �V O .v 7 0. Z = �• .c� In .: OyO y C C '101 a A o 'd >,= > 5 O°° � (Z' o a' c P% � F G v ° J W ° Ww LU > U m r Z ° ri O t° > pp �j N el. a m O O"1'W►i d i - -v ° �� � 2 4 oc b tj uJ k 5 w S� Ur b a °° ° 3 0 0 o •� ° W� WO`� c �0°'>�"° 0. >ca�nc y >UE p° O o ° CQ7�UQj'o 01 ° c �.m E ° s i? V- O of �i fyi `.^ . 'o a " r`s•'a a '� n. ° L� O x`'>?� rO caw ony�o ��o°o'ye3$ c W b 00 �.� °� a c w ° � r O � uJ Oqy ° c �°� � (Z o � . a Ua U ° m `a °•5 �._oo o ° 0.�.� `offs LU V avwiU or. ° o w� hw a��i ° �H G o W�� 1 Dn 'C o y O m e p C; N y •> ra td p O e0 F a £ 3o Z aa4S Ial lvIOOg ADI'IOd HfIOA OZ FIL)V,LZV Hsv HIM HSL-IOS-b50£ ttZ :iagmnll a�od 9 N 0 N 0 V p 0 0 0 CV a� w ;ob U M-i O N Q a. 0 yU �5 m 0 0 00 � C a� 0 U N 103 043 L01899ZO �" 4+ .N Q C� e 2 � � G O !A ^ a+" U CA V1 N oX E,E U U•y�•+ U., �., o Ei r w a c v a a� •Y v ? >•a "0 ;� O G'm b. O RS�^ � O G Um �O+ d W rte•+ O 0 `� O O r7+ 8,- p 30 G '01 O : O O c� dd w to ..�¢ p� J C+.� A E � �w �•O a>> W m U .'�•• '� G cep U U LiJ E1 1 U O O J O Cd �j y0 O J ^•� Pi O to ui «.��'m C pp� A Cd Z r Eq U N� o o ° i a a = -=p= - oN .o H er o.- 40. C� CD y '� y .. ►a 'r fV C+i N O bq o°�+ 4, G h 6i ooQ.. -iocahq U U 0.2 > G O 7 0 C V w N U O • U d U cy0 > d M U P a N � Q W � •� O.C4 ° c v 0.b y 'w OVA r H a n`"ioHo .c HSL-1091750£ "Z :nqianMj(oT .1od Iaa IXOOU ADPIOd 2iII0A 01 HJVIIV USVJ'Id N O N q O U ti m O O W0 O a M� CU a a7 w v 6t,Z 09900 0 m O .Q N pp O � N U y �. aQ W T G. 4 W � UC� O CO a. ld U ❑� O N a N oy b[ y > H Q �• w U >'0 0 cd 'i o C C aco �• b Q\ O N 3�'aoo''oo 'y^ 'i7 • y R. R .14 O O .9 � ti o�aCiyo>3� d cd r-+ ❑ 4 ° E gyp. C13 xi UN _ � _ �y pp a� .. cd O Y •C�' •� ' aFyi.7 W E c o^•� y a� ^ 5- F y 3 :? y C >-o:s aw'S c •E ❑mac T bu c3'� o Z v is Co $o I "o, o oa °O �4ryyd.� vw nq n Elc� u � U-0 O zo b7S O 7 's e �• w U >'0 0 cd 'i o C C aco �• b N > b= d 3�'aoo''oo v > O .� • E U 'i7 .14 O O .9 � ti o�aCiyo>3� d cd y ❑ 4 ° E gyp. o xi UN _ � _ �y pp a� .. cd O Y •C�' •� ' aFyi.7 W E c o^•� y a� ^ 5- F y 3 p � Z W �• � r. p m p p Or, O U '� W U 3 y cd 'i o C C aco �• b N > b= d > 7n » R� v > O .� • E U 'i7 U CpO ,� O TOO yy p •�U^, f+ d cd y w xi UN E _ £ 3O £ IAJ'DIOOn ADI IOd HfIOA OZ II3V.L,LV TSva'Id 35L-i0g-b50£ bbl :zaqumH oraaioS Z d 0 N C U U .Or d p O W O N a� O U 103 6VE l0/699Zo State Farm Mutual Automobile Insurance Company 900 Old River Road Bakersfield CA 93311 -9501 NAMED INSURED 00083 75- 3357 -1 B A 000063 0058 HERRICKS, ROBERT 8 PEGGY DBA ROBERTS LIQUID DISPOSAL 14018 CARMENITA RD SANTA FE SPGS CA 90670 -4919 10129 -1 -B MATCH 00083 MUTL VOL DECLARATIONS PAGE POLICY NUMBER P73 6862 -AO6 -750 POLICY PERIOD APR 03 2014 to JUL 06 2014 12:01 A.M. Standard Time AGENT BETH BETTGER INS AGENCY INC 20220 STATE RD CERRITOS, CA 90703 -6470 PHONE: (562)496 -1000 DO NOT PAY PREMIUMS SHOWN ON THIS PAGE. IF AN AMOUNT IS DUE, THEN A SEPARATE STATEMENT IS ENCLOSED. YOURCAR W......_.._........- ......... ... .- ........ .................................. 1997 FORD VACUUM TRUCK 1 FDZS96D6VVA31257 Commercial �: �� r w,,�w ✓ «r;'n � / /'r „�e,.� ti �.� v��,�ol., �� ,��6 ��:. I,. ✓,.a,«,�«./ �x /:gin �yz,,, err ,� /;„a ��� Ir xi G,G „?, «r. �.d+ . , , �a, nxo�ru��r, x ,v x�� u/ r �iUx ,A Limit -Each Accident /I ,� rp;211� 9 v�� �/ �d ,rrr ^. ,..r r t r / ". lry �r � .:. /f« I ,� � � v T / : r ✓ � � r v � yr �� �, I ,.�:. / � Wp / „ ✓, ✓ «�,.. ”. ,,. ✓f ✓,.r,.PL /1 �N. /, ra.;��:, q AF.�jI�.`��v,/ ,x n� nG�Co 6'r,,,l %„5 „rr �/, /,/, rn» ae'<, .a,.? �1,. ,/u,.:, I, !�fw/.�,, ;rry�,/ c,rv+!n., �,� »:fi G ✓,�r, ;;r .,ldG�lvi.rfi C Medical Payments Coverage V 09 rlr ✓rin lr vrp r»"�d �/:?ro�l rrspl / p d FG �" «i� en /; /ry /1^ /l « / /Oi wY,rx' ✓ f /d/ ✓r/ ^ i�, /� � a / ✓r '� 1 r S u 1 � � a r .,x., /ra,,,,rt r /d „✓ ,'0 «„ ✓r,x i,f:;��F'A �,. �9�vr .�1, ,� „ / /,�,t„ ,.o, � ,r x,�.,, ,nx n, vvw.rvr / /�,a „c <, .,,x / xr��.r 1, ,,,,a^Ar ,,, ,W. n�,v ,nla„ ,ry ,.k 1��, r, /.n,� r yy $5,0�y0,0 b i IM,"Il G / / / /an d ✓f� / / /! //Y /f /��f±9R��t9Ab, /o����A'A ��,MR: ��YAI�4��P'a llv�.r ��.;�. ,. � "l ��r\r;� /ra�x� ✓: r: i3Oi J/, 1.9111ia a, J,f�, x.Y�!4 1, �n�.F7,r �:ry F/ r�,'.i ✓i; i Ai,� /x �/ G Collision Coverage $2,000 Deductible $113.77 fl r / / r y(; «%. // r l d pr y2 /,,,y �yI r< y r, yy t / r`L/ ) / ! i' d N fYf; lr / i ✓�9 /l!5 P Il r r F �' r o`rro h p ✓ %'. / u %%/ a, l!T„ n!a ;a .,L,,,LWt11tt�,��;t` ,1`�'yi°,!110di�;t�1'a0! ��'.�a ,. � •�, vim.,, r� d ✓r..x, � //. �, , �� „/ r , .,�,,, ;. ,: r� Trx,;ul z�nc.,�i, , ,� . /o /�, ,, «, „,. Sodil Injury Limits W// rF 1 / / / .✓ /ir /i j rr ar r� M�4p%W� /a�A�'��N�RN��✓�✓�..xo %� -r+ , %c. ,,, �; r /,/ �� ;,�, r�sr „I�.Tr,��, //� �.�;r �[:an „ r, �, ;>m ¢ , /,xuxx,„ ,rr,cfi/ o.. 24 x „ /tom $100,000 $300,000 V i Xv .✓ a l aka /fir r , ,.�r r•. r �,�- 7r .4 -aa r,,,t Replaced policy number P736862 -75N. Your total renewal premium for JAN 06 2014 to JUL 06 2014 is $1,531.35. YY JOIS SSTS OF THIS DECLARATIONS PAGE THE POLICY BOOKLET - }} ENDORSEMENTS THAT APPLY, INCLUDING THOSE ISSUED TO YOU U° RENEWAL NOTICE. gg,, 2 DDI IO LPARKUBLDVD 1SrE13040ERSANTALMONICATCAP90405 -5232. WATT AO�I O AL INSURED -KT S KITCHENS INC, 1065 E WALNUT ST STE C, L INSURED-AMERICAN HONDA A CO N G 1 TNSUECHVRNIS4I _T LIRD EOUANC /O AMCSPO BOX2020,CONWAY 607T_,2 MC CITY OF EL 02579101247 386 c 1 n.2 06.2002 (00251o) 14SXON (.1.0251.) 3033 OAMAINIST OELESEGUNDODOCAI90245 -3895. 10'N UNDER THH LIABILITY COVERAGE. ICLE SHARING. SION. THEFLIABILLITY COVERAGE - Agent: BETH BETTGER INS AGENCY INC Telephone: (562)496 -1000 See Reverse Side Prepared APR 15 2014 3357 -1385 (01.0254c) This policy is issued by State Farm Mutual Automobile Insurance Company. MUTUAL CONDITIONS 1. Membership. While this policy is in force, the first Insured shown on the Declarations Page Is entitled to vote at all meetings of members and to receive dividends the Board of Directors in its discretion may declare in accordance with reasonable classifications and groupings of policyholders established by such Board. 2. No Contingent Liability. This policy is non - assessable. 3. Annual Meeting. The annual meeting of the members of the company shall be held at Its home office at Bloomington, Illinois, on the second Monday of June at the hour of 10:00 A.M., unless the Board of Directors shall elect to change the time and place of such meeting, in which case, but not otherwise, due notice shall be mailed each member at the address disclosed In this policy at least 10 days prior thereto. In Witness Whereof, the State Farm Mutual Automobile Insurance Company has caused this policy to be signed by Its President and Secretary at Bloomington, Illinois. ern. 4„4.4., Secretary President Important... California law requires us to provide you with information for filing complaints with the State Insurance Department regarding the coverage and service provided under this policy. Complaints should be filed only after you and State Farm® or your agent or other company representative have failed to reach a satisfactory agreement on a problem. Please forward such complaints to: California Department of Insurance Consumer Services Division 300 South Spring Street Los Angeles, CA 90013 Or call toll free 1 -ODO -927 -HELP (4357) NOTICE We are required to furnish you with the following information: 1. An automobile liability insurance company may cancel a policy before the and of the current policy period for reasons described in the provision titled Cancellation which is located in the General Terms section of your policy (refer to the Contents in the beginning of your policy for the page number), 2. An automobile liability insurance company may increase the premium or refuse to renew the policy for any of the following reasons: a. Accident involvement by an insured, and whether an insured is atfault in the accident. b. A change in, or an addition of, an insured vehicle. c. A change in, or addition of, an insured underthe policy, d. A change in the location of garaging of an insured vehicle. e. A change in the use of the insured vehicle. f. Convictions for violating any provision of the Vehicle Code or the Penal Code relating to the operation of a motor vehicle. g. The payment made by an insurer due to a claim filed by an insured or a third party. An automobile liability insurance company may increase the premium or refuse to renew the policy for reasons that are not listed above but which are lawful and not unfairly discriminatory, ce�67 B10 403 LVZ40/089ZO p�O w�ti w O O wUw Hv�daH a °° o umo z�'� OAAa.I A m H x g° N o �d �° �� q�° � W � a c� F' •� ono RWq ��.� � o a A no w 005 b o o o o w w �wA� pWU OA Uwp a Uu.,3: HHH 0g; �Au; o OAd° �� a boa °�A z W O ZxW od P.UMU A U H ~ AvoF" Fho N U ca G Hd HA W p U w F- UV . 2 1 W W O PQ pa U ZZR�UW N > v 9 vi o :c 0 o� zH w"I Wxx Z W �q W [- W� UPu0F oWz�rx� 1) �W4!0z aO��y� w Z�� POWW F �fW ¢ � Fva p a wQWFc �otiv, Ow �p A �PIZ O�°Oa aa " O O�la oo a x O px o H �� pod�Q U U Q P4 u Z �z U >, goo x o � > o H�UN o oo o o ° a Q U w o RwO H H - O w O Wd`i' 4114 2 00 O WW Z Wj W I 00C7PW,� 0 E -Z° U � v ❑ o o w wC7[ -aW aWo vEll 2-0 QQw� 0 o a� Y � o o o CW7QI�O C) � v pxj q yv U � O O pUw�W U'OW C a Uw�p �pAOU o �Z ° � N 22 d5 0 a C 6 c 0 oz ZA c ° o c 1512-0 QA °mow `4 C7O °W WW O WW v o o Sz y wz fQ O y v � QQ OORUH a E��WU Uy � m 1 7 O O c v" •a 40 ° >'-6 'd -:.6 ctl O 0.p C pia W a ° v 3yv o- W v 4 aria P'o 0 °a o 0-0 ooii CL 0 0- � c W ° �o go d 3 bo o i b vEa o J C ,6.E d oh v 5 y E Oi O w n z °q o o Ea U '3 S > °cv v °y� E a 0 O chi .�1.'°�. "POO 0° �m Z .vo m a ao A [� .a Cd 0 Z JOT jaag8 IJIXOOg AD IOd HA02L 01 HDV.L.LV :ISVl'Id OSL-90H-Z989 £Ld aagwn1l AOTIOd O b N � E N Ln 0Up O .0 d U N N L V � t0 T as U � W U� U .Q ° o R. q U N N o o C y •y Ha W -WP4 0.:. bod-� >, . o o � w C7pU0� �.� c o• °y j, �❑❑ U �y p A x O N ^�' C N- O U a 'C 0 R_ o 0 m O 0 pQG�HH O 3 aai 0 a� a ts Po� � 0 ��4 T U W O cW7'"O�O� a� 3'� -o UW a U p� a y >, �>y 4v m cOi zulVugWjo�o�y >�c N ice+ ~��'�i•� Cc�• C O U C C r. O G WW P4 U WW cd N o WOW1��o,N'ao> a N It o -00 m r� a c d UpF o �.0. C.-o o U o O n W~ C-1 �y T� o U a '"�xp� 0.3'J� ❑ y•b a o •� z � !� U N w � N N K o� o � W N ¢w���� ah o 0 W W ►`•, H v a mp b OwQa o 'oy cy� Q o oa �.0 WUp 2:a 0 � d C7 CW7I�wW0 U U a �qrY AO�FU ° ei 0 04 1,4 a O > D Hp • .0 . 3 w U � ,°> o co0 p 0z "8 1) ZO U p - t : W w � U � N °O � Q 4q c c w � V A LYy O ca � •-• � O O �] ^ a w v Q [ry 0. i cd ., .4 Q P: p ° O .�@ L T ti a G ^�� A 41 �0 �U .2 �b v 3 > O �U j 0 w� o ro w s o U O o CA O W y U 0 V o 1 . . . O Cw•- O Nw cOC O > a LA W 7y u 70 m c°�.0 $�E > c `0 4 a•°i E 30� "5 E ca cE vc°iJ.' n ' .0. ,� x ° mil° Lou cC ,=' • bq N w Ua0Ua 0 ��_ cd C U 0 y r ,yr C U S d • a .�T 0 C O u —� T -00 �.04 i tl C °C °w 0 ? z N N U y U N U F 0 '�. Hw 2 R,a. . c o 0 09L-90`d-Z989 £Ld :zogmnK6or L�IDIOOS ADI'IOCI -dfIOA 01 HDV,LJV atsvHIM M O N C a 0 U .G. d p O 0_0 N co �, w� O U U ZM 0 0 N C 0 U q 0 w� 0 0 M� OUQ �tl W� a U LraLao99zo ` •b U m t �0 oyF+y�� C U CL h > c > U cd_a v U N 3 ? r o G yw C ED wo ^y M T U U V R mu •� � a o b00.'� y �•D .V p o � o O w O [- a :oF�•�o rs- o m cCd z 0 V N V S.'U U �,•z, p m t V V •1x' UI o pro V�ti?'� �C G•�n � .�,C r L P. 9'Z3 C C U N� G .,.. y t im o c c CL o T '� •� o a�,G U oq.4t�U��ro W E 14 , oc3v�yA°au° °��r N H v c• 3 3 �� �'w 3 �� U �C a v o W� y 0 0��•���a°i W Wti =a to w U.Z1W•m O'Cw ce �s C Y" 0^ L N V .0 ..� V C O O J �V W � � •� 0. cy � Q v' .� C b OU 4O .� zOW�A TdV o ZUr�yd az1cY a' d -r- - o,_ fYti� C �w C °�i ": O c 'o rfO��Uj 0zz 6 vy°„.oS,3�o °�v .��G CG c?o � �o W oo7Gn > 3 w ww W .. d0.M i �3��y • >,Oeti'Vo�°� � Ud U n mL. tt m r�1 -.4 W =' 9 o 3 ° a o� p eb is vo 0. is m � U � ca d .o � � too � vim• � �:� �� � O 4 a C��yc`w0 ' E > c W� e U M bb Oa W ��w p (Z 1 0 y00U� aki ` T- ,A .14 a o �b a o O a cd � u� o 7 U cti A Z 30 Z aagS IJI 'V1008 ADI'IOd HfIOA OZ H�d.L,LV 71SVI'Id OSL-90V-Z989 £Ld :zagmnN aRod rn 0 N A O U c a 0 0 0 M C V _ as 5 w a O U Ev G 0 N C a 0 U 0 00 N C a5 won 0 U MI 109 LtIM11BBZ0 W C9 O L) J_ m Q J H J W J Z rn co tD 09L-90V-Z989 £Ld :IgqumN XOIlod iari om )oriod mfI0A OZ HDvjuV jSva'Id r N c 0. U V G d 0 w � O O a� w O U 0 Q 00 N N c U U C L O 0 0 a� 5 w m U u cbz 10/ MZ0 o.0 EO =ai 0y� cs�Un� aUa^o =a a ON -6 -2° t - U =^5 N o t= cG0 v : V 'C p . G W +•�••' i0 U N .^ c cCd ai > cOG i E 8 - U •- -G •a"b p O U N O C P y C D 4 Y ? o 4'j r4 $ v,: b U o .D G .D U m •b U d p Ua s U70�5 T o 3 o y w 'n G . y N � y y y � O � G U y sY V r� T 3 'Om U Cw.� O _ w. 3 y U E r 4, �.. 3 3 r. 4 N O _ U U �cd> 4 y C c0 . c0 O �• Q ,$' • c0 rGn cad O U b y t, °c C 9s -o p: %) C O '.� G G U• 0i .ia 4 T c m T p Cd ,b U O «� O G •� C CJ d � OD �' y N O'p f�' ?' �0��, d� � '.T',U �C °Cc°ewsn�c5 cGe moo •� ... co U O 'O OA y N cd y U•y U 3 i F O 4> �''�'^ c0 � eCi N O c0 •� 7 7 4 U a •� O. N G j a O o v m m o G._._ o•- C •b0 �3 'tl cC � � C Imo � � � � Tw Op o c?0•v yE ..2 o N 0 ="O •� O G N G O O r G Uy N C 4cC 0 E yr7 4y L G p yw`� G a r- 00120 C d +•- w t"� O w ;^ y > O T O c0 U � O • T c�0 N � cO' m E C E A ti m E7 N a N W a> O E a� .b o 2 o . 0 •� H o._ '. H cu �b•o u � 09L-90V-Z989 £Ld :IgqumN XOIlod iari om )oriod mfI0A OZ HDvjuV jSva'Id r N c 0. U V G d 0 w � O O a� w O U 0 Q 00 N N c U U C L O 0 0 a� 5 w m U u cbz 10/ MZ0 CERTIFICATE OF LIABILITY INSURANCE °ON1 QO14 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 terns 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 BETH BETTGER CONTACT N PAjt PHONE _QA 20220 STATE RD. ADORE,i I+, API09 9559 --MAIL a.. AtlW1,�kh1l BETHBE'TdI.)fl Ct'I' SfatpFsrsn CERRITOS, CA 90703 n �, tale FaIIn NRSUR KA IIaSURER S A wFFOROIN CI, COVERAGE ( NAIC A Mutual AugORIqIIq C 25178 INSURED ROBERT & PEGGY HERRICKS .._ _ I IfBUIi ER ° : ®. , .. DBA ROBERTS LIQUID DISPOSAL INSURER' 14018 CARMENITA RD !N� ®..., _. __,._m...• .. ....m_.._ _ _ . SANTA FE SPRINGS, CA 906704919 COVERAGES CERTIFICATE NUMBER: 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. ... A00L� ....�....�� POLICY NUMBER_.._.mm.� ... . Y W.. _. _ ......... . .. .... _ e ., ............ _ ...,,,..,... NN"6Pk�� _ TYPE OF INSURANCE 406LS,UOA ILIUM F LIMBS TRk_ GENERAL LIABILITY EACH OCCURRENCE 5 TeiaurcTa RFNTE�- I. COMMERCIAL GENERAL � CLAIMS -MADE C OCCUR 1 _ LIAMLITY S I PRI,".,trM4�SE'Tgrra,;xanma�ep _..,�... MED EXP (Anv one oersor+l M PERSONAL6 ADV INJURY $ P d G GENERAL AGGREGATE IS POLICY LIMITAPPLIES PER. ; PRODUCT$ COMPfOP AGG S _,_. .....w.... ... ... .. .....a,,,....� } EN'L AGGR T �RO � LOC � S Aur0MO91LE LU181L1TY f Y P73 6862- A06 -75M Ovosnola o7r06n014 F ".mom+ I s Z000o 001 ANY AUTO 244 3052- B01 -75E 02!011`2014 0610112014 BODILY INJURY (Per perserr) M " ALL OWNED �x_ SCHEDULED BODILY INJURY (Praccidce)I S _ X ., AUTOS AUTOS 413 8508- B03 -75B 0210312014 , 08/0312014 - ... AUTOS PROPERTY -DAMAGE NON•OWNED � �Pwr amderut __m,. _ .. �p S . -. X� HIRED AUTOS � X I S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS - MADE AGGREGATE S _ m.,.. .,.� r DED @ R.FTF,NTIpN� .. _. _:.. . _.. YIN V CRY iM , 1WI ANY PR PRAETOR LCLU ERI ECUTIVE ? ,E L.�EACH ACCIDENT ER In NN) WORKERS COMPENSATION NIA....,,... „w., , .. It yes as faire urid c 6 M E.YL. OISLA E 4 EMPLOYEE, TM OI E IIyes.RIPTI Eunder P i E DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES IAH"h ACORD 101. Additional Remarks Schedule, U more space la required) 11PPYIPIrATIF wnt nFrt CANCELLATION City of El Segundo Department of Public Works THE SHOULD TON DATE THEREOF. NOTICE �WRL BE AN CDELIVERED RN 150 Illinois St. ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 -3813 AUTNO�RyQED REPRESENTATIVE Y d n f 0 1951E -2010 AC O CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 1001466 132849.8 01 -23 -2013 P.O. BOX B 192, PLEASANTON. CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 12 -31 -2013 GROUP: POLICY NURl.P.ER: 1446891-2013 CERT!FICATE IC]: 212 CERTiF!CAT_ EXPIR ES: 12-31 -2014 4 12 -31- 2013/12 -31 -2014 PEA^ CITY OF EL SEGUNDOµ Sc ATNN: PUBLIC WORKS DEy� 150 ILLINOIS ST EL SEGUNDO CA 90245 - 4311"' d'. T-115 iS to cer:tfy That we have issued a valid V orker; Comoensatlon nsurarco pol!cy to a form approvetl toy the Califorria insu ante Commissioner the employer name: be!ovv for :he Dol;cv penad Indicated. This odic-. JS not suojecl to cancellalien nv me i and except upon 30 da•a advance wfitten not,co to trio ernalo'lor ' Ve wdl also gtve v0u 30 Calls adIJ nOe notice 6nould ihis policy be cancelled prior l0 its normal exp,ralion. This cerlihcate or insurance is not an insurance pdilcy and Coes ^el 'amend, extend or Alter the coverage afforiled by the ziolicy Iistea herein. NClvomstanainC any roqulremen[, rerin or -cOnarion of anti contract or other doc::ment vvrn respect to which this ceruficato of insurance may be issued or :o wnicn : may per.a:n, the insurance afforded by the ooL•cv described herein is subject to all the terms exclusions, and conditions, of such poiicv Aulndnred 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 EMPLOYERS 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: 51.000.000 PER OCCURRENCE., ENDORSEMENT x12065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 12 -31 -1998 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT 42570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2013 -12 -31 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO Et1PL,,') ER HERRICKS. ROBERT LEE (IIi AND HERRICKS. PEGGY LEE OBA: ROBERT'S LIQUID DISPOSAL 14018 CARMENITA RD SANTA FE SPRINGS CA 90670 M0410 PRINTED : 11- 15-2013 ,9EV 1.2012.