PROOF OF INSURANCE (2015) CLOSED�y r» 0 DATE (MMIDDIYYYY)
L CERTIFICATE OF LIABILITY INSURANCE 014
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).
CONTACT
PRODUCER
310- 659 -4950 NAME Michelle Nla
NIA INSURANCE AGENCY, INC. LIC #0688707 �Q_KQ. ; 310µw6 a 4 Qµ ___ �(AC, :
11041 SANTA MONICA BLVD #719 E MA I L • michelle niainsurancegenq com
LOS ANGELES, CA 90025
INSURER(a,AFFORD,I,NG COy
E,RAGE ........ NAIC # ...
.. _ IIsuaEn _United Specialty cialty InsuraeCom�pa.►?!. _....... .
INSURED INSURER B; ProgreSslve CaSmU�,I,1nymIrISUrgince C ompan
SPEC CONSTRUCTION CO, INC. JNSURER c
1870 S. CARLOS AVE I�.��.��...E RR�...�. ��������� ���__.... _......_ ��.....
ONTARIO, CA 91761 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.
INTR TYPE OF INSURANCE POLICY NUMBER M lYY Y.
...................... ......................._....... . �.._....... ..�,......................... -. y —fi_ .. �,............
D $UBR'.. PO'LtCY EFF P'OLtlCY EXP' LIMITS
COMMERCIAL GENERAL LIABILITY ✓ ✓ EACH OCCURRENCE $ 1 000 ow",
A ........_.
CLAIMS -MADE [J OCCURMI,��
B .� $9,5 CFA — n9_@L_ . mJ.w.�..m
ED EXP (Anyone person) .... ..- _E.5,000. ,........ .�............._
CGD00004043 -01 04/26/2014 04I26/2015 PERSONAL &ADVINJURY $ 1 Q(JIJ,(�QQ
GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $Z00Q,OQQ._,www ..
..... .............
..... POLICY ❑ JECT 71 LOC PRODUCTS - COMP /OP AG
w$ _ QQ_0. OO;, ,,�,
OT'HEIW $
AUTOMOBILE LIABILITY C MBIIJED SINGLE' ..Mh1Nl1 $ 1 000 000
_-.. Spa ".)e ........ ........... ...A..._._.a _...
B ANY AUTO BODILY INJURY (Per person) $
..�.�... ALLOWNED / SCHEDULED ...
AUTOS 'r AUTOS
057559366 05/07/2014 05/07/2015 BODILY INJURY (Per accident) $
�,/�" NON -OWNED PROPERTY DAMAGE ..$ ..
HIRED AUTOS �Y.. AUTOS 4P r {).^rjelflnl� ...
..__........
.. .._.
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
- _ EXCESS LIAB CLAIMS -MADE AGGREGATE $
DED RETENTION $ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS' LIABILITY YIN „S,TATI,JT,Em„ _ E.R
AN'Y PROPREETORIPARTNERJEXECUTVVIE E.L. EACH ACCIDENT $
NIA
OFFICERNEMSER EXCLUDED? , DI.SIT „ w..... ...
(Mand�atcry In NHp E.L., DISEASE w EA EMPLOYEE $
It es, describe under WWWWW _. .........
O SCMPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
Additional Insured Endorsement USIC - CMGIA- 0310 -0412, Waiver of Subrogation USIC -CMGIA 7830, Primary and Non - Contributory
wording USIC -CMGIA including Products & Completed Operations are enclosed. The City, ifs officers, officials, employees and agents
will be covered as additional insured as respects: Liability arising out of activities performed by or on behalf of the Contractor.
Premises owned, occupied or used by Contractors. Primary and Non - Contributory wording is included for its officers, officials,
employees and agents. 30 Days Notice of cancellation for non - payment of premium. Re: City of El Segundo RSI 57 (14 -15).
r crTlPIf'AT` - t4ni nir-P CANCELLATION
City Of El Segundo. RSI Progra 7(14-13) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
333 Main Street Unit A ACCORDANCE WITH THE POLICY PROVISIONS.
El Segundo, CA 90245
AUTHORIZED REPRESENTATI''W
a
488 014 ACO RPORATION. All rights reserved.
,Pf ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACOR
INSURED: SPEC CONSTRUCTION CO, INC.
CARRIER: UNITED SPECIALTY INSURANCE COMPANY
ATTACHED TO AND
FORMING A PART OF
ENDORSEMENT EFFECTIVE DATE
ADDITIONAL INSURED
ENDORSEMENT NO.
POLICY NUMBER
(12;01 A.M. STANDARD TIME)
you and such person or organization have agreed in
a. The preparing, approving, or failing to prepare
writing, and executed such a contract or agreement
or approve, maps, shop drawings, opinions,
City of El Segundo, RSI 57 (14 -13). The City, its officers, offi-
reports, surveys, field orders, change orders
claim, that such person or organization be added as
or drawings and specifications; and
cials, employees and agents. 333 Main St. Unit A
CGD00004043 -01
04/26/2014
El Segundo, CA 90245
USIC- CMGIA -
"personal and advertising injury" caused, in whole or
2. "Bodily injury" or "property damage" occurring
Re: City of El Segundo, RSI 57 (14 -13)
0310
(The above information is required only when this endorsement is issued subsequent to preparation of the policy.)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC
STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A. Section II —Who Is An Insured is amended to in-
of, or the failure to render, any professional
clude as an additional insured any person or organi-
architectural, engineering or surveying services,
zation for whom you are performing operations when
including:
you and such person or organization have agreed in
a. The preparing, approving, or failing to prepare
writing, and executed such a contract or agreement
or approve, maps, shop drawings, opinions,
prior to the time of an occurrence giving rise to a
reports, surveys, field orders, change orders
claim, that such person or organization be added as
or drawings and specifications; and
an additional insured on your policy. Such person or
organization is an additional insured only with respect
b. Supervisory, inspection, architectural or engi-
to liability for "bodily injury," "property damage" or
neering activities.
"personal and advertising injury" caused, in whole or
2. "Bodily injury" or "property damage" occurring
in part, by:
after:
1. Your acts or omissions; or
a. All work, including materials, parts or equip -
2. The acts or omissions of those acting on your
ment furnished in connection with such work,
behalf;
on the project (other than service, mainte-
nance or repairs) to be performed by or on
in the performance of our on oln o eratio for the
p y �-9 P�y
behalf of the additional insured(s) at the site
additional insured.
of the covered operations has been complet-
B. With respect to the insurance afforded to these addi-
ed; or
tional insureds, the following additional exclusions
b. That portion of "your work" out of which the in-
apply:
jury or damage arises has been put to its in-
This insurance does not apply to:
tended use by any person or organization
other than another contractor or subcontrac-
1. "Bodily injury," "property damage" or "personal
for engaged in performing operations for a
and advertising injury" arising out of the rendering
principal as a part of the same project.
NIA INSURANCE AGENCY, INC.
AUTHORIZED REPRESENTATIVE
Includes copyrighted material of ISO Properties, Inc., with its permission.
Copyright, ISO Properties, Inc., 2004
n
09/03/2014
DATE
INSURED: SPEC CONSTRUCTION CO, INC.
CARRIER: UNITED SPECIALTY INSURANCE CO„
ATTACHED TO AND
FORMING A PART OF
ENDORSEMENT EFFECTIVE DATE
ADDITIONAL INSURED
ENDORSEMENT NO.
POLICY NUMBER
(12 :01 A.M. STANDARD TIME)
City of El Segundo, RSI 57 (14 -15). The City, its officials, its
officers, employees, agents .
CGD00004043
04/26/2014
333 Main Street St A
USIC -CMGIA
El Segundo, CA 90245
7830
(The above information is required only when this endorsement is issued subsequent to preparation of the policy.)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
LIMITED WAIVER OF TRANSFER OF RIGHTS OF
RECOVERY AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV—
COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following:
We waive any right of recovery we may have against an additional insured shown on form USIC- CMGIA-
0310 -0412 or USIC -CMGIA -7900 0414 but only with respect to liability for "bodily injury," "property dam-
age" or "personal and advertising injury" caused by:
1. The named insured's acts or omissions; or
2. The acts or omissions of those acting on the named insured's behalf;
in the performance of the named insured's ongoing operations for the additional insured shown on form
USIC -CMGIA -0310 0412, or USIC -CMGIA -7900.
All other Terms and Conditions of this Policy remain unchanged.
NIA INSURANCE AGENCY, INC.
09/03/2014
AUTHORIZED REPRESENTATIVE DATE
Includes copyrighted material of ISO Properties, Inc., with its permission.
Copyright, ISO Properties, Inc., 1992, 2003
I ICIr._rnnrlA 7A4n
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY COMMERCIAL
GENERAL LIABILITY
POLICY NUMBER: CGD00004043 -01
INSURED : SPEC CONSTRUCTION CO, INC.
ADDITIONAL INSURED - PRIMARY AND NON - CONTRIBUTORY - OWNERS, LESSORS OR
CONTRACTORS
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
The City of El Segundo, RSI 57 (14 -15) its officers, officials, employees, agents.
333 Main Street Unit A
El Segundo, CA 90245
Section II -In accordance with the terms, conditions, limitations and provisions of the policy to which
this endorsement is attached, Section II -Who is an Insured is amended to include an Additional
Insured The Person, organization or entity designated in this endorsement but only with respect to
liability for bodily injury or property damage caused, in whole or in part, by your work at the
designated construction project performed for the designated person, organization or entity and
included in the ongoing operations hazard. This endorsement does not create or our part a duty to
defend the designated person, organization or entity or contribute to or reimburse the designated
person, organization or entity. This endorsement is only applicable it the designated person,
organization or entity and the designated project sections are completed.
With respect to the Insurance afforded to these Additional Insured , the following additional
inclusions apply:
This insurance applies to "Bodily Injury" or "Property Damage" occurring after:
1- All work, including materials, parts or equipment furnished in connection with such work, on
the project other than service, maintenance or repairs to by performed by or on behalf of the
Additional Insured.
At the location of the covered operations has been completed ; or
That portion of "Your Work" out of which the injury or damage has been put to its intended
use by any person or organization other than another contractor or subcontractor engaged in
performing operations for the principal as part of the same project.
PRIMARY /NON- CONTRIBUTORY WORDING:
It is agreed that this insurance is primary and non - contributory and that no insurance held or
owned by the designated Additional Insured shall be called upon to cover a loss under
said policy up to the limits of this policy if loss under this policy arises directly from work
performed by Named Insured.
All other terms, conditions and exclusions remain unchanged
(OMINI 7 EFQA12 -11 -5- 1/12/1203051353) Form Edition 05/10/12
Policy Number Named Insured Effective Date
CGD00004043 -01 SPEC Construction Co, Inc. 04/26/2014
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES
OR CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
The City of El Segundo RSI (14 -15), its officials, officers, agents and employees
333 Main St. Unit A
El Segundo, CA 90245
Section II- Who is An insured is amended to include as an additional insured only the person
(s) or organization (s) who have entered into a written contract with "you" prior to "your"
commencement of work for the person(s) or organization (s) with whom "you" have entered into
a written contract and such written contract specifically requires that "you " provide this
coverage, but only with respect to liability for "bodily injury" or "property damage" caused in
whole and exclusively by "you" performing "your work" on completed operations hazard" under
the policy. This amendment does not apply to "your work" on any residential construction
project.
Terms in quotation marks are defined in the policy to which the endorsement is attached.
USIC -CMGIA -7810 Rev.9/25/2013
INSURED: SPEC CONSTRUCTION CO, INC.
CARRIER: PROGRESSIVE CASUALTY INSURANCE COMPANY
ATTACHED TO AND
FORMING A PART OF
ENDORSEMENT EFFECTIVE DATE
(12;01 A.M. STANDARD TIME)
ADDITIONAL INSURED
ENDORSEMENT NO.
POLICY NUMBER
including:
you and such person or organization have agreed in
a. The preparing, approving, or failing to prepare
writing, and executed such a contract or agreement
or approve, maps, shop drawings, opinions,
City of El Segundo, RSI 57 (14 -15). The City, its officers, offi-
reports, surveys, field orders, change orders
claim, that such person or organization be added as
or drawings and specifications; and
cials, employees and agents. 333 Main St. Unit A
organization is an additional insured only with respect
b. Supervisory, inspection, architectural or engi-
El Segundo, CA 90245
USIC- CMGIA-
"personal and advertising injury" caused, in whole or
2. "Bodily injury" or "property damage" occurring
Re: City of El Segundo, RSI 57 (14 -15)
0310
(The above information is required only when this endorsement is issued subsequent to preparation of the policy.)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED — OWNERS, LESSEES OR CONTRACTORS — AUTOMATIC
STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU
This endorsement modifies insurance provided under the following:
COMMERCIAL AUTO LIABILITY COVERAGE PART
A. Section II —Who Is An Insured is amended to in-
of, or the failure to render, any professional
clude as an additional insured any person or organi-
architectural, engineering or surveying services,
zation for whom you are performing operations when
including:
you and such person or organization have agreed in
a. The preparing, approving, or failing to prepare
writing, and executed such a contract or agreement
or approve, maps, shop drawings, opinions,
prior to the time of an occurrence giving rise to a
reports, surveys, field orders, change orders
claim, that such person or organization be added as
or drawings and specifications; and
an additional insured on your policy. Such person or
organization is an additional insured only with respect
b. Supervisory, inspection, architectural or engi-
to liability for "bodily injury," "property damage" or
neering activities.
"personal and advertising injury" caused, in whole or
2. "Bodily injury" or "property damage" occurring
in part, by:
after:
1. Your acts or omissions; or
a. All work, including materials, parts or equip -
2. The acts or omissions of those acting on your
ment furnished in connection with such work,
behalf;
on the project (other than service, mainte-
in the performance of your ongoing operations for the
nance or repairs) to be performed by or on
behalf of the additional insured(s) at the site
additional insured.
of the covered operations has been complet-
B. With respect to the insurance afforded to these addi-
ed; or
tional insureds, the following additional exclusions
b. That portion of "your work" out of which the in-
apply:
jury or damage arises has been put to its in-
This insurance does not apply to:
tended use by any person or organization
other than another contractor or subcontrac-
1. "Bodily injury," "property damage" or "personal
for engaged in performing operations for a
and advertising injury" arising out of the rendering
principal as a part of the same project.
NIA INSURANCE AGENCY, INC.
AUTHORIZED REPRESENTATIVE
Includes copyrighted material of ISO Properties, Inc., with its permission.
Copyright, ISO Properties, Inc., 2004
I ICIr _r nA(;IG_n41n
09/03/2014
DATE
INSURED: SPEC CONSTRUCTION CO, INC.
CARRIER: PROGRESSIVE CASUALTY INSURANCE CO.
ATTACHED TO AND
FORMING A PART OF
ENDORSEMENT EFFECTIVE DATE
ADDITIONAL INSURED
ENDORSEMENT NO.
POLICY NUMBER
(12:01 A.M. STANDARD TIME)
City of El Segundo, RSI 57 (14 -15). The City, its officials, its
officers, employees, agents .
057559366
05/07/2014
333 Main Street St A
USIC -CMGIA
El Segundo, CA 90245
7830
(The above information is required only when this endorsement is issued subsequent to preparation of the policy.)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
LIMITED WAIVER OF TRANSFER OF RIGHTS OF
RECOVERY AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL AUTO LIABILITY COVERAGE PART
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV—
COMMERCIAL AUTO LIABILITY CONDITIONS) is amended by the addition of the following:
We waive any right of recovery we may have against an additional insured shown on form USIC- CMGIA-
0310 -0412 or USIC -CMGIA -7900 0414 but only with respect to liability for "bodily injury," "property dam-
age" or "personal and advertising injury" caused by:
1. The named insured's acts or omissions; or
2. The acts or omissions of those acting on the named insured's behalf;
in the performance of the named insured's ongoing operations for the additional insured shown on form
USIC -CMGIA -0310 0412, or USIC -CMGIA -7900.
All other Terms and Conditions of this Policy remain unchanged.
NIA INSURANCE AGENCY, INC.
09/03/2014
AUTHORIZED REPRESENTATIVE DATE
Includes copyrighted material of ISO Properties, Inc., with its permission.
Copyright, ISO Properties, Inc., 1992, 2003
I ICIr'_('nArIG 7R4n
R° CERTIFICATE OF LIABILITY INSURANCE °A'YY,f„'
°4
09/004/2014/201°
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 Fa chex Insurance Agency Inc
y
NAME
PAYCHEX INSURANCE AGENCY, INC. PHONE FAX
150 SAWGRASS DRIVE 877 266 6850 585 389 -7426
(AdG, „.NO. EXT)* m (AAC Nfa) -
ROCHESTER, NY 14620 E -MAIL a c ex
Certs@paychex.com
Certs @P
ADDRESSa....m.� ........ ... .. ...” - - --
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A: NorGUARD Insurance ....,
INSURED nce Company 31470
_... —
. ............................. .
SPEC CONSTRUCTION CO INC INSURER B:
1870 S. CARLOS AVENUE .,.,.....
ONTARIO, CA 91761 INSURER C:
_ ...............
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. LIM TS A HAVE BEEN REDUCED BY PAID CLAIM S.
".
INSR TYPE OF INSURANCE DDL UBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR INSR D MM /DD /YYYY MM /DDIYYYY
GENERAL LIABILITY
EACH OCCURRENCE
$
COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED
LAAMS-MACLLI i iAgJR
P EI�MG ES(LaaccurmrtIM) - - - --
$ -.-
MED EXP (Any one person)
$
." " ... ...
�I
PERSONAL & ADV INJURY
... -.-
$
_ I'll ------------------------ —
u _111111111111111111 ...... .A
GENERAL AGGREGATE
$
" I�h1 "L AGGREGATE LIMIT APPLIES PER:
POLICY l ] Y^N OJECI LOC
- -..... _ - ----
PRODUCTS COMP /OP AGG
_...... __.. -. - - - --
$
--- ........,.,
.� @...... .0
$
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
$
ANY AUTO
E d
a acci ent)
A O SCHEDULED
BODILY INJURY
(Per pets on)
$
AU TOS AU FOS
N U
HIRED AUTOS AUTOS
INJURY acc P dent)
I
$
PROPE RTY DAMAGE
$
(Per accident)
$
C UMBRELLA LIAO � � OCCUR
EACH OCCURRENCE
$
n EXCESS LAB CLAIMS -MADE
AGGREGATE
...... ...... ............ -
$
................ I .....,
��E.. D. "... , mRETENTION.$. ...............................
$
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
SPWC583326
03/12/2014
03/12/2015
I WC STA "rU- G1"I
X aaRY�Jtnl;r._ - s—
- - - - -- -
E L EACH ACCIDENT
$ 1
ANY PROPRIETOR/PARTNER/EXECUTIVE
,.......— ........ .........
...- _,. -. -m .-- ._._.--- ......
OFFICERIMEMBER EXCLUDED? YIN
-.E EMPLOYEE
(Mandatory In NRI „�
N/A
X
,_ ..
E L, DISEASE - POLICY LIMIT
, „.._
$ 1,000,000.00
Ill describe under
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Waiver of Subrogation granted in favor of the certificate holder
CERTIFICATE HOLDER
City of El Segundo
RSI 57 (14 -13)
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY
333 Main St Unit A
PROVISIONS, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
EI Segundo, CA 90245
LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2010/05) @1988 -2010 ACORD CORPORATION. All rights reserved,
The ACORD name and logo are registered marks of ACORD
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 1.0?__% of the California workers' compensation premium
otherwise due on such remuneration.
Person or Organization
Schedule
Job Description
Blanket Waiver -Any person or organization for whom the All CA Operations
Named Insured has agreed by written contract to furnish ti�is
waiver.
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 Policy No. SPWC583326 Endorsement No,
Insured Insurance Company
Countersigned By
01998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved.