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PROOF OF INSURANCE (2014) CLOSEDAgreement No. 4628 American Asphalt South, Inc. A CERTIFICATE OF LIABILITY INSURANCE (MMIDD/YYYY) [,,DATE 25/2014 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). PRODUCER NAME J-oa,.nne C .d:. .r ttt InterWest Insurance Services PHONE #0601094 .a j T r AAX P.O. Box 255188 _ADDRs) 81t( i�(N4t:IC( �rq. .... Sacramento CA 95865-5188 INSURER(S)AFFORDING COVERAGE NAIC# --- .-.-. INSURER A:FinAnrial Pnrifir.Inc rmmnanv 14fiR INSURED AMERI26 INSURERB Arrh InC1lrAnrP("mmnAnv 111,F(1 American Asphalt South, Inc INSURER 14436 Santa Ana Avenue Fontana CA 92337 wsuRERD. INSURER E: ''....... INSURER F t. COVERAGES CERTIFICATE NUMBER:1460940927 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. INS ADOI,"SUr'�:'R POLICY EFF POLICY EXP T LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER IMMIDDIYYYYi IMM/DD/YYYYI LIMITS A GENERAL LIABILITY Y Y 50423382 12/31/2013 12/31/2014 EACH OCCURRENCE $2,000,000 OAIRAI:rI. °01,L �+)'I"". .. ..... x $100,000........ ......... G MME�Rw r1Al.,GENERAL LIABILITY FxFaEMISES,(Ee occa rrertz�al CLAIMS-MADE �x OCCUR I MED EXP(Anv one oerson) $5,000 X Contractual Liab ; PERSONAL&ADV INJURY $2,000,000 X Ded,$5,000 GENERAL AGGREGATE $4,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $4,000,000 r C7LLG:a M x PROW _ C.00 $.JECT 4 AUTOMOBILE LIABILITY Y Y 12/31/2013 12/31/2014 60423382 (Ea accweni) $1 000,,00 0 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED ... .- -------------------------------- AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE " HIRED AUTOS x AUTOS (Pa arrd fl ..:.--- --------- -------- -. _ $ A UMBRELLA LIABX OCCUR 60423382 12/31/2013 12/31/2014 EAGH OCCURRENCE $5 000 000 X EXCESS LIAB CLAIMS MADE .AGGREGATE $5 000 000 DED x RETENTION$None $ B WORKERS COMPENSATION Y AWC19316500 /1/2014 /1/2015 X WCSTATU- OTH- AND EMPLOYERS'LIABILITY Y/N ,TnRV..!innir.$F. -- FR ......... .............- .,.,..... ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? NIA ,_. ... ... ...... ............. .. .......... (Mandatory in NH) E L,DISEASE-EA EMPLOYEE; $1,000,000 If yes,describe under .,.,. .,.,. .,.,,.,., .....,. .........m DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $1,000,000 I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Re: 2013-2014 Slurry Seal Furnishing/Application-Various Streets, City Of El Segundo, Its Officers, Officials, Emplooyees,Agents, Volunteers Are Included As Additional Insured (GL/AU)Acting Within The Scope Of Their Duties Controlled/Supervised By The Primary (First)Additional Insured, Primary Wording, Per Project Aggregate, GL/AU/WC Waivers Attached. 30-Day Notice Of Cancellation Except 10-Day Notice For Non-Payment Of Premium Applies Per Policy Provisions. CERTIFICATE HOLDER CANCELLATION p " P SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo G a' ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street ✓ ?' El Segundo CA 90245 V AUTHORIZED REPRESENTATIVE r S ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Re: 2013-2014 Slurry Seal Furnishing/Application - Various Streets. City Of E1 Segundo, Its Officers, Officials, Emplooyees, Agents, Volunteers Are Included As Additional Insured (GL/AU) Acting Within The Scope Of Their Duties Controlled/Supervised By The Primary (First) Additional Insured, Primary Wording, Per Project Aggregate, GL/AU/WC Waivers Attached. 30-Day Notice Of Cancellation Except 10-Day Notice For (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization is held liable for "your work" for that person or organization by or for you. This endorsement applies to the following work: Description of Job: See Above Location of Job: See Above Al only Effective from: Effective Date:12/31/2013 Expiration Date: 12/31/2014 When this endorsement applies, such insurance as is afforded by the general liability policy is primary and any other insurance shall be excess and shall not contribute to the insurance afforded by this endorsement. CG 20 10 11 85 Modified (07-01) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission, POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY CG 24 04 10 93 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Re: 2013-2014 Slurry Seal Furnishing/Application - Various Streets. City Of E1 Segundo, Its Officers, Officials, Emplooyees, Agents, Volunteers Are Included As Additional Insured (GL/AU) Acting Within The Scope Of Their Duties (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMMER- CIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: 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 10 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 POLICY NUMBER:60423382 ASDA AU 07 01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM SCHEDULE NAMED INSURED:American Asphalt South, Inc 14436 Santa Ana Avenue Fontana CA 92337 ADDITIONAL INSURED:Re: 2013-2014 Slurry Seal Furnishing/Application - Various Streets. City Of El Segundo, Its Officers, Officials, Emplooyees, Agents, Volunteers Are Included As Additional Insured (GL/AU) Acting Within The Scope Of Their Duties WHO IS AN INSURED (SECTION II) is amended to include as an insured the organization shown in the Schedule above, but only with respect to the operation of vehicles owned by the named insured and operated on behalf of the named insured. This endorsement does not apply to any operations for other than the named insured. Each person or organization named above is an insured for liability coverage, but only to the extent that person or organization qualifies as an insured under the Who Is An Insured provision of Section II Liability Coverage. The additional insured is not required to pay for any premiums stated in the policy or earned from the policy. Any return premium, if applicable, declared by us shall be paid to you. You are authorized to act for the additional insured in all mailers pertaining to this insurance. We will mail the additional insured notice of any cancellation of this policy. If the cancellation is by us, we will give thirty days notice to the additional insured. The additional insured will retain any right of recovery as a claimant under this policy,. ASDA AU 07 01 Page 1 of 1 POLICY NUMBER:604233 82 ASDA AU 07 02 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM SCHEDULE Name of Person or Organization:Re: 2 013-2 014 Slurry Seal Furnishing/Application - Various Streets. City Of E1 Segundo, Its Officers, Officials, Emplooyees, Agents, Volunteers Are Included As Additional Insured (GL/AU) Acting Within The Scope The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV BUSINESS AUTO CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above be- cause of payments we make for bodily injury or property damage arising out of losses or accidents which occur during the policy period. This waiver applies only to liability you assume pursuant to a contract with the person or organization shown in the schedule. ASDA AU 07 02 Page 1 of 1 POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY CG 25 03 03 97 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Projects: ALL PROJECTS WITH THE POLICY PERIOD, (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. For all sums which the insured becomes legally 4. The limits shown in the Declarations for Each obligated to pay as damages caused by Occurrence, Fire Damage and Medical Ex- "occurrences"under COVERAGE A(SECTION pense continue to apply. However, instead of 1), and for all medical expenses caused by acci- being subject to the General Aggregate Limit dents under COVERAGE C (SECTION 1), which shown in the Declarations, such limits will be can be attributed only to ongoing operations at a subject to the applicable Designated Con- single designated construction project shown in struction Project General Aggregate Limit, the Schedule above: B. For all sums which the insured becomes legally 1. A separate Designated Construction Project obligated to pay as damages caused by General Aggregate Limit applies to each "occurrences"under COVERAGE A(SECTION designated construction project, and that limit 1),and for all medical expenses caused by acci- is equal to the amount of the General Aggre- dents under COVERAGE C(SECTION 1), which gate Limit shown in the Declarations cannot be attributed only to ongoing operations 2. The Designated Construction Project General at a single designated construction project shown Aggregate Limit is the most we will pay for in the Schedule above: the sum of all damages under COVERAGE 1. Any payments made under COVERAGE A A, except damages because of"bodily injury" for damages or under COVERAGE C for or"property damage" included in the medical expenses shall reduce the amount "products-completed operations hazard",and available under the General Aggregate Limit for medical expenses under COVERAGE C or the Products-Completed Operations Ag- regardless of the number of: gregate Limit,whichever is applicable;and a. Insureds; 2. Such payments shall not reduce any Desig- b. Claims made or"suits" brought;or nated Construction Project General Aggre- c. Persons or organizations making claims gate Limit. or bringing "suits". C. When coverage for liability arising out of the 3. Any payments made under COVERAGE A "products-completed operations hazard"is pro- for damages or under COVERAGE C for vided, any payments for damages because of medical expenses shall reduce the Desig- "bodily injury"or"property damage" included in nated Construction Project General Aggre- the "products-completed operations hazard"will gate Limit for that designated construction reduce the Products-Completed Operations Ag- project. Such payments shall not reduce the gregate Limit, and not reduce the General Ag- General Aggregate Limit shown in the Decla- gregate Limit nor the Designated Construction rations nor shall they reduce any other Des- Project General Aggregate Limit. ignated Construction Project General Aggre- gate Limit for any other designated construc- tion project shown in the Schedule above. CG 25 03 03 97 Copyright, Insurance Services Office, Inc., 1996 Paae 1 of 2 D. If the applicable designated construction project E. The provisions of Limits Of Insurance(SECTION has been abandoned, delayed,or abandoned III)not otherwise modified by this endorsement and then restated,or if the authorized contract- shall continue to apply as stipulated. ing parties deviate from plans, blueprints, de- signs, specifications or timetables, the project will still be deemed to be the same construction project. 1132.,o 7 of 2 ( nnvriaht Insurance Services Office. Inc.. 1996 CG 25 03 03 97 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 POLICY NUMBER: ZAWC19316500 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2 % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION AS REQUIRED BY WRITTEN CONTRACT ALL JOBS UNDER CONTRACT PRIOR TO A LOSS This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated,. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 04-01-14 Policy No. ZAWC19316500 Endorsement No. Insured AMERICAN ASPHALT REPAIR Premium $ INCL. Insurance Company ARCH INSURANCE COMPANY Countersigned By DATE OF ISSUE: 03-25-14 ©1998 by the Workers'Compensation Insurance Rating Bureau otCaliromia. All rights reserved. From the WCIRB's California Woriters'Compensation Insurance Forms Manual© 1999. Shilling, Mona From: Garcia, Angelina Sent: Wednesday, July 02, 2014 4:03 PM To: Hegvold, Julie Cc: Shilling, Mona; Bola, Arianne Subject: RE:American Asphalt PW 13-15 Agmt Hi Julie, The power of attorney is not acceptable.The County Clerk Cert. is required. All other insurance looks good. Angelina Garcia From: Hegvold, Julie Sent: Tuesday, July 01, 2014 7:39 AM To: Garcia, Angelina Cc: Shilling, Mona; Bola, Arianne Subject: American Asphalt PW 13-15 Agmt Good Morning Angie, Here are the contract documents for the PW 13-15 project agreement for your review and intial: • Contract Agreement • Project Specifications • Insurance Certificate • Endorsements • Waiver of Subrogation • Bonds—Notarized • Power of Attorney with Seal for Surety Is the Power of Attorney form with seal acceptable, or do we need to return the bonds to them in order to obtain the County Clerk Certification as well? Please let me know. Thanks, ®c Hegvold,Management Analyst CITY OF EL SE UNDO I public Works Dept. 350 Main Street,E1 Segundo,CA 90245 Tel,(310)524-2365 I the of @else n cs.or C.➢.".1 ' is L IS CLOSED ON .FRIDAYS 1