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PROOF OF INSURANCE (2015) CLOSEDACOOR" CERTIFICATE OF LIABILITY INSURANCE OATE(MMYYY) �. 01/31/201/2014 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 pollcy(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 1 -909- 243 -8200 CONTACt' Hays of California Insurance Services - Ontario pHoNB 909- 243 -8200 _ FAx dNC.Ne,Extt: IpJasry �^Mr.909- 243 -8201 Empire Towers IV �" MFUL 3800 Contours, Suite 3400 PRODUCER " Ontario CA 91764 GUSTOMERIDII NAIC .IYWStl.VRERA.;NSP INSURED TRANSPORTATION INS CO , 20494 � Clinical Laboratories of San Bernardino, Inc. „. -.. -,. .,. INSURER B : HARTFORD FIRE^ IN CO 119682 ._ _, - _._.. -, P.O. Box 329 INSURERC: CONTINENTAL CAS CO 20443 San Bernardino, CA 92402 INSURER D: ._ ,. ,., .... .." .. ....._ . a,. 11 . _ „INSURER E'_ INSURER F: COVERAGES CERTIFICATE NUMBER: 38345817 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW FIAVE 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. _m IN.xR ....._._. CE..,. .. .gAbu SOON ... ----- PONfCY N'u..MOER. .. t L'I "R TYPE OF INSURAN 41oL,ICX EF'�� -- °- IPgL¢rr'Y O%ti �.. ,�...u.0 . , ....._µ.. P =rYYYY. mmm Dr YY LIMITS A LIABILITY C C 4034939429 02 O1 1 02/01/15 / / EACH OCCURRENCE $ 1 000 000 [GENERAL X CO MMERCIAL GENERAL LIABILITY � t"�F ltlhl' GTAtUA' �O � $ 100,000 PRM .__.. 4 X ] IFtu oCe�Unsdnce d _ CLAIMS -MADE OCCUR 1 » J MED EELS _.,_.. -.... XP An one arsrny � S 10 0 .., ....._.... T PERSONAL 8 ADV INJURY 4 S 1 0 00 000 4 m _: 000 IGE ERAL AGGREGATE t5 000 ... GENLAGG 'REGATS, LIMIT APPLIS;SPER: G PRODUCTS COMPIOPAGGqS 2 000 000 PRO X POLNC'ti I � LOC S A ' AUTOMOBILE LIABILITY ° C 4034939463 � 02/01/1 02 01 /15 COMBINED SINGLE LIMIT S 1,000 000 X (Ea accident) ANY AUTO t .,_ .. .,. ,.. h (Per 1-9 BODIL Y NJU IRY person) ALL OWNED AUTOS �.- !Y -�...` BODILY INJURY accident) N S ...,._ .. SCHEDULED AUTOS .. .(Per .,..., .,,.....,...- .. .....,._ ,. ROP ERTY DAMAGE " HIRED AUTOS ` I X S Per accident ) P NON -OWNED AUTOS _ .,., .. t $ —..., A �UMBRELLALIAB X OCCUR 02/01/1$ 02/01/15 p EACH OCCURREN CE GS 5 000,000 ICUP4034939477 [X EXCESS LWB a 1 k CLAIMS MADE AGGREGATE _... $ _ X RETENTIONE S 0 I S .._ 41WEC BA0213 WORKERS COMPENSATION B �� B AND EMPLOYERS NIA LIABILITY �. b VC STATU OTH 02/01/1 02/01/15 X I T.0Y I IM/ITS..), FR Y / N ANY PR ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER PAR LUDEDV NIA A ❑', . EL EACH ACCIDENT 5 1 000 000 " ,....w_� .�_ .............. . . e in NH) r E.L. DISEASE EA EMPLOYE S 1,000,000 U es, describe under ti DESCRIPTION OF OPERATIONS below .,(Mandatory ,,.., .....___..._ . „..a.. w ...,,.... "... ...... E.L. DISEASE POLICY � 1, 000, 000 LIMIT S C ro ees bna Liability I'EEH 7 1 023 - ClaimeMae '01/15 3 ,..._. ,. a _,... 000 DESCRIPTION OF OPERATIONS 9 LOCATIONS M VEHNCN.ES (Attach AGORI3' t.Ut, Art1dRUearlad RarnarNra. Schedule lC more spare Is rotluirad) The City of E1 Segundo, its officials and employees are named Additional Insured as respects work performed by the named insured only. Insurance is primary and non - contributory CERTIFICATE HOLDER ,'' CANCELLATION City of El Segundo t�k� 1� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN James Turner ACCORDANCE WITH THE POLICY PROVISIONS. 4000 Lomita St.. AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 USA ..^.,:..� ACampos ©1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD 38345817 i; 4 s � G- 17957 -G99 /yal (Ed.10101) CONTRACTOR'S SCH ENDORSEMENT WITH LIMITED PRODUCTS - COMPLETED OPERATIONN COVERAGE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Name of Person or Organkation: Designated Project: (Coverage under this endorsement is not aftcted by an antsy or lack of entry In the Schedule above.) A. WHO IS AN INSURED (Section 11) is amended to Include as an insured any person or organization, including any person or organization shown In the schedule above, (called additional insured) whom you are required to add as an additional insured on this 3. policy under a written contract or written agreement; but the written contract or written agreement must be: t. Currently in effect or becoming effective during the term of this policy; and 2. Executed prior to the "bodily injury," "property damage," or "personal and advertising Injury." E. The insurance provided to the additional insured is limited as follows: I . That person or organization is an additional Insured solely for liability due to your negligence and specifically resulting from 'your work" for the additional insured which is the subject of the written contract or written agreement. No coverage applies to liability resulting from the sole negligence of the additional insured. 2. The Limits of Insurance applicable to the additional insured are those specified in the written contract or written agreement or in the G- 17957 -G99 (Ed. 10 /01) Declarations of this policy, whichever is less. These Limits of Insurance are inclusive of, and not in addition to, the Limits of Insurance shown in the Declarations. The coverage provided to the additional insured by this endorsement and paragraph f. of the definition of "insured contract" under DEFINITIONS (Section V) do not apply to "bodily injury" or 'property damage" arising out of the "products - completed operations hazard" unless required by the written contract or written agreement. When coverage does apply to "bodily injury" or "property damage" arising out of the "products- completed operations hazard' such coverage will not apply beyond: a. The period of time required by the written contract or written agreement; or b. 5 years from the completion of "your work" on the project which is the subject of the written contract or written agreement, whichever is less. 4. The insurance provided to the additional insured does not apply to "bodily injury," "property Page 1 of 2 G- 17957 -G99 (Ed. 10 101) damage," or "personal and advertising injury" 4. Other Insurance arising out of an architect's, engineer's, or surveyor's rendering of or failure to render any b. Excess Insurance professional services including: This insurance is excess over any other a. The preparing, approving, or failing to prepare insurance naming the additional insured or approve maps, shop drawings, opinions, as an insured whether primary, excess, reports, surveys, field orders, change orders contingent or on any other basis unless a or drawings and specifications; and written contract or written agreement specifically requires that this insurance be b. Supervisory, or Inspection activities performed either primary or primary and as part of any related architectural or noncontributing to the additional insured's engineering activities. own coverage. This insurance is excess C. As respects the coverage provided under this over any other insurance to which the endorsement, SECTION Iii — COMMERCIAL additional insured has been added as an GENERAL LIABILITY CONDITIONS are amended as additional insured by endorsement. follows: When this insurance is excess, we will 1. The following is added to the Duties In The Event have no duty under Coverages A or 6 to of Occurrence, Offense, Claim or Suit Condition: defend the additional insured against any suit" If any other Insurer has a duty to e. An additional insured under this endorsement defend the additional insured against that will as soon as practicable: "suit." If no other Insurer defends„ we wilt (1) Give written notice of an occurrence or an undertake to do so, but we will be entitled offense to us which may result in a claim to the additional insured's rights against or "suit" under this insurance; all those other insurers. (2) Tender the defense and indemnity of any When this insurance is excess over other claim "suit" to us for loss we Dover insurance, we will pay only our share of th under this Coverage Para; ; the amount of the loss, if any, that exceeds the sum of: (3) Tender the defense and indemnity of any claim or "suit" to any other insurer which (1) The total amount that all such other also has insurance for a loss we cover insurance would pay for the loss In under this Coverage Part; and the absence of this Insurance; and (2) The total of all deductible and self- insurance which the additional insured insured amounts under all that other has for a loss we cover under this Insurance, Coverage Part. We will share the remaining loss, if any, f. We have no duty to defend or indemnify an with any other Insurance that is not described in this Excess Insurance additional insured under this endorsement until we receive written notice of a claim or provision and was not bought specifically "suit" from the additional insured. to apply In excess of the Limits of Insurance shown in the Declarations of 2. Paragraph 4.b. of the Other Insurance Condition is this Coverage Part, deleted and replaced with the following: G- 17957 -G99 Page 2 of 2 (Ed. 10/01) I n.. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM . OTHERS ENDORSEMENT - CALIFORNIA Policy Number: 41 WEC BK0213 Endorsement Number: Efhotivs Dab: 02/01/14 Effective hour Is the same as stated on the Information Page of the policy. Named Insured and Address: CLINICAL LABORTORIES OF SAN BERNARDINO, INC. PO BOX 329 SAN BERNARDINO, CA 92402 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 premium otherwise due on such remuneration. SCHEDULE Person or Organization ANY PERSON OR ORGANIZATION ANY FROM WHOM YOU ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT TO OBTAIN THIS WAIVER OF RIGHTS FROM-US. 3 % of the California workers' compensation Job Description Countersigned by horized Representative Form WC 04 03 06 (1) Printed in U.S.A. Policy Expiration Date: 02/01/15