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PROOF OF INSURANCE (2015) CLOSEDACORD DATE (MM/DDIY M. CERTIFICATE OF LIABILITY INSURANCE 1 9/29/2014 i PRODUCER Phone: 714 -533 -7089 Fax: 714 - 533 -8873 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION EG INSURANCE AGENCY, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 616 S. EUCLID ST. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ANAHEIM CA 92802 ALTER THE COVFRAPE AFFORDED OY THE POLICIES BELOW,. INSURERS AFFORDING COVERAGE I NAIC # Agency Lic#: Oe39093 INSURED INSURER A: MT. HAWLEY INSURANCE COMPANY 37974 HARRY H. JOH CONSTRUCTION INC. INSURER 5: 7303 SOMERSET BLVD. INSURER C: PARAMOUNT CA 90723 INSURER D: INSURER E: COVERAGES 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, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR INSR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR T .DATE FRdDDvYY GENERAL LIABILITY MGLO181114 10/09/14 10109/15 EACH OCCURRENCE $ 1700,000 DAMAGE DAMAGE TO RENTED $ 50,600 X COMMERCIAL GENERAL LIAB LIABILITY CLAIMS MAOEE] OCCUR F_a 4rccuae ngrr MED, EXP (Any one person) '$ 1,000 A 5...... '.. $0.00 Deductible PERSONAL & ADV INJURY ',$ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS- COMP /OP AGG. $ 2,000,000 rxi POLICY LE PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) '$ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) "$ PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑ CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STA—MT OTHER TORY LIMITS EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUINE E.L., EACH ACCIDENT $ OFFICERMEMBER EXCLUDED? „ E.. L. DISEASE -EA EMPLOYEE $ ff y*%w Clele ba under SPECIAL PRDMMONS Wow E, L, DISEASE - POLICY LIMIT $ OTHER: DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS General Contractor / Certificate holder shall be named as an Additional Insured on General Liability Coverage regards to Project Name: Project Name: RSIP Group 56 / Primary and Non Contributory, Waiver of Subrogation are applied per Endorsement CG 24 04 05 09 / 30 days non -payment cancellation applied. ACORD 26 (2001/08) Certificate # 8533 © ACORD CORPORATION 1988 Policy Number: MGL0180113 Mt. Hawley Insurance Company 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 PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: All persons or organizations where required by written contract. Information 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 05 ( 0 © Insurance Services Office, Inc., 2008 Page 1 of 1 Insured Policy Number: MGLO180113 Mt. Hawley Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS (FORM C) - This endorsement modi if es insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART (If no entry appears below, information required to complete this endorsement will be shown in the Declarations as appli- cable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Sched- ule, but only with respect to liability arising out of "your work" for that insured by or for you. To the extent required under contract, this policy will apply as primary insurance to additional insureds scheduled below and other insurance which may be available to such additional insureds will be non - contributory. Section IV., Condition 4., of this policy is amended accordingly. SCH L Name of Person or Organization: All persons or organizations where required by written cntr .s ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. CGL 216 (04/98) Page 1 of 1 Insured AC40 "" =DAE01 IYYYY) 4 CERTIFICATE OF LIABILITY INSURANCE 14 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 N'IA Stephanie Park NAMM ISU Good Friend Insurance Services PHONE (213) 388 -7979 FpX (213) 674 -4353 INC NO Ext), 3530 Wilshire Blvd Ste 1285 N 0)caStephaniePark @ugfriend.com Los Angeles CA 90010 INSURERA;United Financial CasualtV Co. 11770 INSURED INSURERB :GRANITE STATE INSURANCE CO HARRY H JOH CONSTRUCTION INC INSURERC; 7303 SOMERSET BLVD INSURER D: INSURER E PARAMOUNT CA 90723 1 INSURER F: rtnvFlzer_FC rI= RTIFIreTF NI IMRFR•CL1493007845 REVISION NIIMRFR! THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED., NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE 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 L POLICY EFF POLICY EXP TR TYPE OF INSURANCE INSR VJVD POLICY NUMBER .......................................... . LIMITS GENERAL LIABILITY EACH OCCURRENCE: $ COMMERCIAL GENERAL LIABILITY .- $ I M CLAIMS- MADE 0 OCCUR D EXP (Any one per son) $ PERSONAL & ADV INJURY $ GENERALAGGREGATE $ PRODUCTS - COMP /OP AGG $ GEN L AGGREGATE LIMIT A}"PUES. PER: POLICY t"RO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE. LIMIT ¢.aw srrco-deN 2 000 0 X ANY AUTO BODILY INJURY (Per person) $ A BODILY INJURY(Peraccident)',$ ALL OWNED X SCHEDULED 02450509 -1 10/16/201410/16 /2015 AUTOS AUTOS I NON -OWNED 11ROPENIY'DAMAGE $ HIRED AUTOS _, AUTOS "1 Uninsured motorist combined $ 2,000,000 UMBRELLA LJAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE ..... $ DEO RETENTION $ B WORKERS COMPENSATION WC STA TU- OTH- AND EMPLOYERS' LIABILITY N 157M S ^ " ANY PROPRIETOR/PARTNER /EXECUTIVE - E.L EACH ACCIDENT $ 1. 000 O OFFICER /MEMBER EXCLUDED? N/A 0005643569 1/1/2014 1/1/2015 (Mandatory in NH) E L DISEASE - EA EMPLOYEE.. $ 1 000 000 If yes, describe under DESCRIPTION OF OPERATIONS below E,L.. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED ON THE POLICY PER WRITTEN CONTRACT * DENOTES 10 DAY GIVEN NOTICE OF CANCELLATION FOR NON - PAYMENT OF PREMIUM. Project Name: RSIP Group 56 CERTIFICATE HOLDER CANCELLATIONI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of El Segun ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo, CA 9 AUTHORIZED REPRESENTATIVE James Chong /DDNG ACORD 25 (2010/05) © 1988 -2010 ACORD CORPORATION. All rights reserved.. INS026 (201005) 01 The ACORD name and logo are registered marks of ACORD 0 I� BLANKET WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement, effective 12:01 AM 01 / 10/2014 forms a part of Policy No. WC 005 -64 -3569 Issued to HARRY H._..JDH_.CONSTRUCTI -ON 1-VC -. (A CORP)," By GRANITE STATE INSURANCE COMPANY We have a right to recover our payments from anyone liablkfor # injury covered by this policy. We will not enforce our right against any person or organization with whom you have a written contract t t requires you to obtain this agreement from us, as regards any work you perform for such person or organization. The additional premium for this endorsement shall be 2.00 % of the total estimated workers compensation premium for this policy. z r WC 04 03 61 Countersigned by ..... _ .. . _ _ _... . ..-. .. . . _ _ ®. _..- _ . . . . a... .. . (Ed. 11/90) Authorized Representative . TRIAL MODE - a valid license will remove this message. 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