PROOF OF INSURANCE (2014) CLOSED Agreement No 4682
Backflow Testing & Maintenance Co.
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CERTIFICATE OF LIABILITY INSURANCE 9/3/20TDArll,amm14
THIS CERTIFICATE 15 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
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REPRESENTATIVE PRODUCER,AND THE CERTIFICATE HOLDER..
-IMPORTANT: If Out csetlflcats holder Is an ADDITIONAL INSURED,fins palky(kwa must he e . If SUBROGATION IS WAIVED,srdbjW to
the tavnas and conditions as the policy,caetaln poitctas may require an mulorssmmiL A statavrasrat on this csrdNcata chess not confer roghts to the
conificattO hokler In livu of such (s),
PRODUCER �.
CARROLL HARRISON INSURANCE AGENCY pYa grlL 27,09 Diu aa,,,t310-9"°
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4825 TORRANCE BL SUITE 10 3 310„5477
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DBA: BACK FLOW TESTING N NdI uR 14
21405 MARJORIEalRr
TORRANCE, CA 90503 N t�Q+SRI
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COVERAGES CERTIFICATE N'UMBER'. REVISION NUMBER'
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN I$SUEIDI 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.
rvEXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS
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CERTIFICATE HOLDER IS A ADDITIONAL INSURED
a;I;IR11F&"ATE HOLDER (A,NCFLIATION
.....CITY OF EL SEGUNDO ,/ SHOULD ANY OF TIME ABOVE DESCRGEo IPOL.ICIE.S BE CANCELLED BEFORE
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400 LOMITA ST v I +T, THE', EXPRATION DATE 'l`HERIF0F. NOTIOE WILL BE DELIVERED W
EL SEGUNDO, CA 90245 L �,' ACCORDANCE WITH THE POI ICY PRI:IVI!IOINS
N=n ALd IBdr?Bdu,A tlR'LPR&'.EE'WIf&TIfO)E
IL"D Iq88-2009AC,0440 CORPORATION All Iighis reserved
AC0RID25 p()0 i09) The ACORD nam and logo are registered matt of ACCORD
POLICY NUMBER: 09376-44-88 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
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This endorsement modifies insurance provided under the following
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Oroa nizationisl: Location(s)Of Covered Operations
CITY OF EL SEGUNDO 350 14AIN STREET
ITS OFFICIALS, AND EMPLOYEES EL SGUO, CA 90245
gnl'odmat n required to com fete this Schedule, if not shown abar'w+e, will ..� �i
_--� -�-�� shown m the Declarations,
A. Section II Who Is An Insured is amended to M 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 s not apply to "bodily injury' or
damage" or "personal and advertising injury'
caused,in whole or in part,by: "property " occurring after:
1. All work, including materials, parts or equip-
1. Your acts or omissions;or ment fumished In connection with such work,
2. The acts or omissions of those acting on your on the project (other than service, mainte-
behalf; nance or repairs) to be performed by or on
be-
in the performance of your ongoing operations for half of the additional insured(s) at the location
the additional insured(s) at the location(s) deslg- of the covered operations has been completed;
nated above, or
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 en-
gaged in performing operations for a principal
as a part of the same project
CG 20 10 07 04 m ISO Properties, Inc.,2004 Page 1 of 1
Customer Copy- WELLS, CLARK E Page 1 of 3
Customer name:WELLS, CLARK E&ANITA Company: SF Mutual
DBA BACKFLOW TESTING Servicing Agent: CHARLINE ESPINOZAw,
Address:21405 MARJORIE AVE Eff date: 08-17-2014 to 02-17-2015
TORRANCE, CA 90503-5445 Description:2002 DODGE DAKOTA PICKUP
Policy: 0309210-1317-75Y VIN: IB7GL32N12S640578
Status: PAID IN FULL
FPP#: POLICY NOT ON
�d
Premium/Billing Information
Amount Due: 0.00
Total premium: 478.33
Last amount paid: 478.33
Date paid: 07-02-2014
Previous premium: 462.64
Premium refund: 0.00
Dividend amount: 76.80
Dividend date: 08-17-1998
Dividend amount: 80.80
Dividend date: 08-17-2000
Dividend amount: 81.50
Dividend date: 02-17-2007
Additional Policy Details
Policy form: 9805B
Coverage Details
The premium amounts shown reflect a six-month policy term.
Code Description Amount
A Liability Coverage 286.90
Limit-Each Accident
$1,000,000
C Medical Payments Coverage 39.90
Limit-Each Person
$25,000
D Comprehensive Coverage 25.37
G Collision Coverage-$100 Deductible 98.84
H Emergency Road Service Coverage 2.22
U Uninsured Motor Vehicle Coverage 24.62
Bodily Injury Limits
Each Person, Each Accident
$100,000$300,000
U1 Uninsured Motor Vehicle Property Damage Coverage 0.48
Total: 478.33
Vehicle Details
Year: 2002
Make: DODGE
https:H sfnet.opr.statefarm.org/sysapv/printOptionsAction.do 9/3/2014
Customer Copy - WELLS, CLARK E Page 2 of 3
Model: DAKOTA
Body Style: PICKUP
VIN: 1B7GL32N12S640578
MSRP base: 0.00
MSRP additional equip: 0.00
Odometer Information
Odometer reading: 36,572
Odometer date: 12-2005
Vehicle Usage
Annual miles: 12,001
Use of vehicle: BUSINESS
Additional Interests
Lienholders
XCEED FINANCIAL CREDIT UNION
888 N NASH ST
EL SEGUNDO CA 90245-2826
Additional Insured/Lessors
TIDELANDS PRODUCTION COMPANY
ATTN JAMES P CONNOLLY
301 E OCEAN BLVD
LONG BEACH CA 90802
VALERO ENERGY GRP WILMINGTON
REFINERY CONTRACTS GROUP/PROD
BLDG ATTN: KATHY HOUGH
SEN CONTRACT ADMIN
2402 E ANAHEIM ST
WILMINGTON CA 90744
LP&REALTY CENTER MANAGEMENT
CORNERSTONE PLAZA
1990 S BUNDY DR STE 785
LOS ANGELES CA 90025
TISHMAN SPEYER PPTY L.P.
MANAGING AGENT FOR GRAND AVE
OOURTYARD L.P.
1960 E GRAND AVE#520
EL SEGUNDO CA 90245
MAR VENTURES, INC
ATTN: ROSEMARY RAMIREZ
2050 W 190TH ST#201
TORRANCE CA 90504
COUNTY SANITATION DISTRICT
OF LOS ANGELES
ATTN: ROSE PIMENTEL
PO BOX 4998
WHITTIER CA 90607
Insurance Certificates
HYATT CORPORATION & DELAWARE
HG INC
200 SOUTH PINE AVE
LONG BEACH CA 90802
CITY OF EL SEGUNDO
ATTN: CITY CLERK
350 MAIN ST
EL SEGUNDO CA 90245
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Customer Copy - WELLS, CLARK E Page 3 of 3
The information on this document is presented for general informational
purposes only and is not intended to serve as a declaration page or policy.
State Farm Mutual Automobile Insurance Company,Bloomington, Illinois
https://sfnet.opr.statefarm.org/sysapv/printOptionsAction.do 9/3/2014
FROM :BAWLDW TESTING & MAIK FAX NO. :13103744214 � 16 2014 01:29PM P2
P.O.BOX$45 • HERMOSA BEACH,CALIFORNIA 90254
(310)316-1717 FAX(310)374-4214
CALIFORNIA
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FROM :BACKFLOW TESTING & MAINT. CO FAX NO. :13103744214 Sep. 08 2014 10:02AM P1
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P.O.BOX 545 • HERMOSA BEACH,CALIFORNIA 90254 �, d
(310)316-1717 • FAX(310)374-4214 4w"
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Attn:City of El Segundo
Re:Workers'Compensation Insurance
I, CIO*Wells, sole owner of Sacldlow Testing snd Maintenance Co. certify that I
am Self-empjayW with no arnployees. For this reason, i do not have a Workers'
Comperisaltion InsuMnao COrtifioate.
Sincerely,
Clerk Wells
owner
Backflow Testing and Maintenanco Co.
Shillin , Mona
From: Garcia, Angelina
Sent: Monday, September 08, 2014 2:58 PM
To: Hegvold,Julie
Cc: Shilling, Mona
Subject: RE: Backflow Testing Agmt - Please Expedite
Approved.
Angelina Garcia
From: Hegvold, Julie
Sent: Monday, September 08, 2014 1:10 PM
To: Garcia, Angelina
Cc: Shilling, Mona; Cummings, Lucienne
Subject: Backflow Testing Agmt- Please Expedite
Hi Angie,
Attached are the auto and GL insurance policies and endorsements, and statement of no employees. Please let us know
if you need any additional information in order to sign off. Thanks!
Julie Hegvold,Management Analyst
CITY OF EL SEGUNDO I Public Works Dept.
350 Main Street,El Segundo,CA 90245
TeL(310)524-2365 1 jhegyold @elsegundo.org
CITY11ALLIS CLOSED ON l.R.I.D.A S
From:Garcia,Angelina
Sent:Thursday, August 28, 2014 4:20 PM
To: Hegvold,Julie
Cc:Shilling, Mona;Turner,James; Cummings, Lucienne; Katsouleas,Stephanie
Subject: RE: Backflow Testing Agmt- Please Expedite
Hi Julie,
This is missing the CGL Endorsement on CG 10 10 1185, auto insurance, workers' comp and waiver of subrogation.
Angelina Garcia
From: Hegvold, Julie
Sent: Thursday, August 28, 2014 3:48 PM
To: Garcia, Angelina
Cc: Shilling, Mona; Turner, James; Cummings, Lucienne; Katsouleas, Stephanie
1