PROOF OF INSURANCE (2015) CLOSED�1
ACORU® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
kw�" 6/1/2015 8/18/2014
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(les) 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 Lockton Insurance Brokers, LLC
725 S. Figueroa Street, 35th Fl.
CA License #OF15767
Los Angeles CA 90017
-
PHON No ;
-
(213) 669 -0065
INSUBENEIAFFORDIN
INSURANCE LISTED BELOW HAVE BEEN ISSUED TO
INSURER A: Liberty Mutual Firelnsur
INSURED Joe's Sweeping, Inc.
INSURER B: Liberty jtl ur n
1047663 dba: Nationwide Environmental Services
INSURERC: Torus National Insurance
and JNL Building Services
OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
11914 Front St.
MAY BE ISSUED OR MAY PERTAIN,
Norwalk CA 90650
INSURER E
99R 1C C " A
.......... ....... -
'Irl' WON NUM@91R XXXXXXX
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.
l
TYPE OF INSURANCE
A
I kph
I B POLICY NUMBER
Y TB2 -Z91- 449522 -114
Y
6/1/2014
LIMBS
6/112015 EACH OCCURRENCE 1,000,000
A
X
COMMERCIALGENERALLIABILITY
Y
CLAIMS -MADE FX—] OCCUR
D
1,000,000
PREC19USM l...
MED EXP (My one peMnj I 10 000
PERSONAL & AOV INJURY s 1 000 000
GSN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE s 2,000,000
POLICY[_ JECT LOC
PRODtJCTS- COMWOPAGG b 2.000,000
OTHER
$
A
AUTOMOBILE LIABILITY
N
N AS2 -Z91- 449522 -034
6/1/2014
6/1/2015 POL79 I $ 1,000,000
ANY AyUVTO
BODILY INJURY (Per person) $ XXXXXXX
AUTOS NED AUTOSULED
Ix
BODILY INJURY (Per accident $ XXXXXXX
HIRED AUTOS X gOf1OOWNED
33
P TP Y $ XXXXXXX
Comp & Coll Ded s 1,000
B
X UMBRELLA LIAB X OCCUR
N
N TH7 -Z91- 449522 -064
6/1/2014
6/1/2015 EAC'H�URRENCE s 5 000 000
EXCESS LIAR CLAIMS -MADE"
AGGREGATE $ 5,000,000
DED RETENTION $
$ XXXXXXX
C
A D EMPLOYERS' LIABILITY YIN
Y T10140036
6/1/2014
6/l/2015 X I STATUTE I X I TH-
ANY PROPRIETORIPARTNER/EXECUTIVE
IM
OFFICEREMBER EXCLUDED? N❑
NIA
E.L. EACH ACCIDENT 1,000,000
(Myandatory In NH)
IE.L. DISEASE - EA EMPLOYEE 1,000,000
DESCRIPTION OF OPERATIONS below
.. I SE - POLICY LIMIT 11000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, may be attached It more space Is required)
THIS CERTIFICATE SUPERSEDES ALL PREVIOUSLY ISSUED CERTIFICATES FOR THIS HOLDER, APPLICABLE TO THE CARRIERS LISTED AND THE POLICY TERM(S) REFERENCED.
City of El Segundo, Its officers officials, empployees, agents and volunteers are included as Additional Insured to the extent provided by the policy
language or endorselttent issur or approved by the Insurance carver. Coverage provided is primary and non - contributory. Waiver of Subrogation applies
attached endorsement(s) or policy language.
per
CERTIFICATE HOLDER
CANCELL,A"1"ilON See Attachments
O f2
[
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
1876365 r ylA
City of El Segundo�11 v
AUTHORIZED REPRESENTATIVE
Attn: Floriza Rivera, PW Dept.
350 Main St,
El Segundo CA 90245
ACORD 25 (2014/01)
0108-2014,ACORD CORPORATION. All rights reserved
The ACORD name and logo are registered marks of ACORD
Policy Number: TB2 -Z91- 449522 -114
Item 13. BLANKET ADDITIONAL INSURED — PERSON OR ORGANIZATION
A. Section II — Who Is An Insured is amended to include as an additional insured any person or organization to whom
you are obligated by a written agreement to procure additional insured coverage, 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 the acts or omissions of those acting on your behalf:
1. In the performance of your ongoing operations; or
2. In connection with premises owned by you provided that:
(a) The "bodily injury", "property damage" or "personal and advertising injury" giving rise to liability occurs subsequent
to the execution of the agreement; and
(b) The written agreement is in effect at the time of the "bodily injury", "property damage ", "personal injury" or
"advertising injury" for which coverage is sought.
That person or organization shall be referred to as the additional insured.
There is no coverage for the additional insured for "bodily injury", "property damage" or "personal and advertising
injury" arising out of the sole negligence of the additional insured or by those acting on behalf of the additional insured,
except as provided below.
If the written agreement to indemnify an additional insured requires that you indemnify the additional insured for its sole
negligence, then the coverage for the additional insured shall conform to that agreement; provided, however, that the
contractual indemnification language of the agreement is valid under the law of the state where the agreement was
formed. If the written agreement provides that a particular state's law will apply, then such provision will be honored.
B. Waiver Of Subrogation
For any additional insured that obtains insured status on this policy through Paragraph A. above, we waive any right of recovery we
may have against the additional insured because of payments we make for "bodily injury", "property damage" or "personal and
advertising injury" to which this insurance applies.
C. Exclusions
This insurance does not apply to:
1. Any premises or equipment leased to you.
2. Any construction, renovation, demolition or installation operations performed by or on behalf of you, or those operating on your
behalf.
D. Other Insurance
The insurance provided by this endorsement applies only to coverages and limits of insurance required by written agreement,
but in no event exceeds either the scope of coverage or the limits of insurance available within this policy. This insurance shall
be excess over any other insurance available to the additional insured, whether such insurance is on an excess, contingent or
primary basis, unless you are obligated under a written agreement to provide liability insurance for that additional insured on
any other basis. In that event, this policy will apply solely on the basis required by such written agreement. To the extent that
the additional insured has the right to pursue any other insurance carrier for coverage, including a defense, we shall share that
right with the additional insured.
SCHEDULE
City of El Segundo, its officers, officials, employees, agents and volunteers
LG 32 37 09 07
Attachment Code: D449136
Certificate ID : 1876365
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06
Ed. 4 -84
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 * % of the California workers' compensation premium otherwise
due on such remuneration.
Schedule
Person or Organization
Job Description
WHERE YOU ARE REQUIRED BY WRITTEN CONTRACT TO
OBTAIN THIS AGREEMENT FORM US, PROVIDED THE
CONTRACT IS SIGNED AND DATED PRIOR TO THE DATE OF
LOSS TO WHICH THIS WAIVER APPLIES. IN NO INSTANCE
SHALL THE PROVISIONS AFFORDED BY THIS
ENDORSEMENT BENEFIT ANY COMPANY OPERATING
AIRCRAFT FOR HIRE.
*The premium charge for this endorsement shall be 2% of the premium developed in the State of California, but not less
than $500 policy minimum premium.
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 6/1/2014 Policy No. T10140036 Endorsement No. 12
Insured Joe's Sweeping, Inc. Policy Effective Date 6/1/2014
Insurance Company Torus National Insurance Company
WC 04 03 06
(Ed. 4 -84)
1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved.
Attachment Code: D448503
Certificate ID : 1876365
Shillin Mona
From: Hegvold, Julie
Sent: Thursday, September 11, 2014 4:28 PM
To: Shilling, Mona
Cc: Katsouleas, Stephanie; Fajardo, Ron
Subject: Nationwide (Joe's) 5th Amendment
Attachments: Nationwide 5th Amendment. Street Sweeping 3168.pdf; Nationwide Insurance.pdf;
Nationwide Street Sweeping Agmt.AG initials.pdf; Nationwide Street Sweeping
Agmt.CM.pdf
Hi Mona,
Here is the 5th Amendment to contract with all signatures for finalization. This was approved by City Council on June 3rd
— Item E -16.
I will drop the originals off to your office today. Please also send finalization email to the vendor at:
Ani Samuelian ani@nes- sweeping.com.
Please let me know if you need anything additionally. Thank you..
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.or
11111" 11 L L IS ('1L0 1q,'1) ON 11 "l?1DAYS
Cc: Shilling, Mona
Subject: RE: Nationwide (Joe's) 5th Amendment
i
04/ra" BUBO, 1 % %ir 401101101501 r
From: Hegvold, Julie
Sent: Monday, September 08, 2014 9:49 AM
To: Garcia, Angelina
Cc: Shilling, Mona
Subject: Nationwide (Joe's) 5th Amendment
Importance: High
Hi Angie,