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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