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PROOF OF INSURANCE (2015) CLOSED___"N HADR0-1 OP ID: ED '4i RO' CERTIFICATE OF LIABILITY INSURANCE ° 0916/2014Y' 09/16/2014 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 Brouwer Insurance Agency License # 0454226 725 E. Valley Parkway Escondido, CA 92025 Jack Brouwer, CIC INSURED Hadronex, Inc. 2067 Wineridge Place ##E Escondido, CA 92029 Jack Brouwer, CIC ti :760-745-5151 INSURERA Atain Specialty Company INSURER B United Financial Casua4 COT ....- .. INSURERC:State Compensation Ins Fund .............. 1: 760-741-9308 NAIC Pr 17159 11770 INSURER D INSURER E INSURER F: 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. aY�WSR ,,,,, ........... ADGL sUBR L'TR J TYPE OFINSURANCE �OLI�"R"�F�� F4�LI�GYEXF fL POLICY NUMBER jmDOPYYYY MM100l69Y,,,) LIMITS GENERAL LIABILITY EACH OCCURRENCE S 2,000,00 A X... COMMERCIAL GENERAL LIABILITY X CIP206175 02/02/2014 02/02/2015 DA GP AGO R NTEO b 5 100,00_. R.( Lr1PSlam Ca oa�uarrrrruy CLAIM &MADE X " OCCUR X Y p _ a.. 00 P1LD EXP (Are one orronl � 57 PERSONAL & ADV INJURY S excluded ., e .. GENERAL AGGREGATE 5 2,000,000 GENIAGGREGATE LIMIT APPLIES PER: PRODUC'7S- COMPIOPAGG S excluded POLICY 1'9n LOC ®, 5 AUTOMOBILE LIABILITY UO14.1 -14.1 8111OLF LIMI "9" „ (Lrr nrx;id�zaatp 4 __ 1,0001000 B ANYAUTO 06264245 02/01/2014 02/01/2015 BODILY INJURY (Per person) 5 ALLOWNED [ SCHEDULED .... ....... — — ®„ AUTOS X e AUTOS BODILY INJURY (Per accidonl) $ X HIRED AUTOS P X NON -OWNED P'ROP'ERLY DANi tA.' AUTOS (P7 R AC-CID11 N7,), $ UMBRELLA LIAR OCCUR EACH a C'7GURRENCr EXCESS LIAR CLAIMS MADE AGGREGATE S OLQ RETENTIONS S WORKERS COMPENSATION E1, F EACH ACCIDENT , (It S } } 1,000 "0O AND EMPLOYERS' LIABILITY C ANY PROPRIETOR/PARTNER/EXECUTIVE YIN X 1875457 -2014 0110112014 01/01/2015 OFFICERIMEMBER EXCLUDED? F—] NIA (Mandatory In NN) f E L DISEASE EA LfrfPLOYLI? S 1,000.,00 q7 eS, iW SC�'rkNYl arwldot _. _ ..... ,,,, ,, ._,.. .... ... - --- D$OF'tIPT "9017 OFOPERA'r7OlSkroeCP�u EL DISIaAaI_ POLdCYLIMIT S 1,000,00 DESCRIPTION OF OPERATIONS / LOCATIONS! VEHICLES (Attach ACORD 101, Addldonal Remarks Schedule, if moro space Is roqulrod) Certificate holder is named as additional insured per attached CG 2010 04 13. Insurance is primary as per attached AE 001 397 0712 Waiver of subrogration endorsement also included CERTIFICATE HOLDER bANCELLATION w C 0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE �r. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 4 I�I ACCORDANCE WITH THE POLICY PROVISIONS, City of El Segundo Wastewaters 150 Illinois St 1 �� El Segundo, CA 90245-3813 Ir 7„ AUTHORIZED REPRESENTATIVE 01988 -2010 ACORD CORPORATION. All rights reserved.. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: CIP206175 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 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 Name Of Additional Insured Person(s) Or Oranization(s) City of El Segundo Wastewater 150 Illinois Street El Segundo CA 90245 -3813 Information required to complete this SCHEDULE Locations) Of Covered Operations LOCATION(S) AS REQUIRED BY WRITTEN CONTRACT, not shown a A. Section Il Who Is An Insured is amended to B 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: 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. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2» If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional Insured, ove„ will be shown in the Declarations. 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 wore, including materials, parts or equipment furnished In connection with such work erl 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. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 ENDORSEMENT This Endorsement Changes the Policy- Please Read it Carefully PRIMARY AND NON - CONTRIBUTING INSURANCE (Third- Party's SON/ Negligence) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LJABILITY COVERAGE PART OWNERS AND CONTRACTORS PROTE-CIIVE LIABILITY COVERAGE PART PRODUCTWOOI' PLETE'D OPERATIONS LIABILITY COVERAGE PART RAILROAD LIABILITY COVERAGE PART BUSINESSO"v'1INEER8 LIABILITY' COVERAGE FORM The following Is added to >ection IV - Commercial General Liability Conditions, Paragraph 4: Section IV: Commercial General Liability Conditions 4. Other Insurance° d. Notwithstanding the provisions of sSrlrparagraphs a, b, and c of this paragraph 4, with respect to the Third Party shown below, it is understood and agreed that in the event of a claim or "suit' arising out of the Named Insureds sole negligence, this Insurance shall be prim -,rry and any other insurance maintained by the acklitional insured named as the Third Party below sirail be excess and noncontributory, The Third Party to whom this endorsement applies is: ANY PERSON OR ORGANIZATION WITH WHOM THE INSURED HAS AGREED BY WRITTEN CONTRACT TO PERFORM ;SERVICES AND PRIOR TO ANY LOSS THAT ARE WITHIN THE TERMS AND CONDITIONS OF THIS POLICY TO WHICH THIS FORM IS ATTACHED, Absence of a specifically named Third Party above means that the provisions of this endorsement apply "as required by written contractual agreement with any Third Party for whom you are performing work," All other terms and conditions of this policy remain unchanged. This endorsement is effective on the inception date of the policy unless otherwise stated herein. (The information below Is required only when this endorsement Is issued subsequent to preparation of the policy.) Policy Number; CIP206176 Named Insured; HADRONEX INC Endorsement Effective Date; 02/0212014 Endorsement Serial No, AF 001 397 0712 Includes copyrighted material of Insurance Services Office, Inc„ with its permission Copyright, insurance Services Office, Inc, 1994 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION STATE 1875457 -14 CONAFIEW,ATION RENEWAL FUNDd SD 5- 42 -41 -52 PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 13, 2014 AT 12.01 A.M. ALLEFFECTIVE DATESARE AND EXPIRING JANUARY 1, 2015 AT 12.01 A.M. AT 12 :01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME HADRONEX, INC ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING. IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF EL SEGUNDO WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, HADRONEX, INC IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER, IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03 %. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT, COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: JANUARY 15, 2014 AUTHORIZED REPRESENTA IVE SC1F FORM 10217 (REV.7-2012) PRESIDENT AND CEO 2570 OLD DP 217 Shilling, Mona From: Garcia, Angelina Sent: Thursday, September 18, 2014 5:44 PM To: Hegvold, Julie Cc: Shilling, Mona; Busick, Gil Subject: RE: Hadronex Arndt Good to go. Angelina Garcia From: Hegvold, Julie Sent: Thursday, September 18, 2014 8:02 AM To: Garcia, Angelina Cc: Shilling, Mona; Busick, Gil Subject: FW: Hadronex Arndt 3rd Arndt — Exhibit C From: Hegvold, Julie Sent: Wednesday, September 17, 2014 1:03 PM To: Garcia, Angelina Cc: Shilling, Mona; Busick, Gil Subject: Hadronex Arndt Hi Angie, Attached for your review & initials is the Third Amendment with Hadronex and the applicable insurance /endorsements. (Orig agreement /ends are also attached as reference.) Please let me know if acceptable and I'll bring the originals by your office. 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 jhegvold @elsegundo.org