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PROOF OF INSURANCE (2015) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 4/30/2014 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 rA�rtlficate holder in lieu of such endorsement(s). PRODUCER NAIM ... 626-844-3070 1 _ Deale , Renton & Associates PHONE � _ — S Los Robles # 540 EAJM Nr�,.£ mswYaney @insdra.com I04X- 199 i Pasadena, c 9A 91 101 E fdATL INSURER s AFI;7itr I, ArkD1%65$; -- i_l IJG CoVErd/k,CAs Surplus Lines Insurance .. _ tNSr�RERA Westchester..._.. — INSURED _.._....... ,,.,.. __ .. .... INSWRR. B ........_ .... .......... ... ._— ,..,.,.... ,,..._...__.....— ........,..- Gale /Jordan Associates, Inc. INSURERr — 3358 Carson Street, Suite 200 INSUriER .. . Torrance, CA 00503 -5613 _. 310 - 316 -4377 INSUREB INSUR F: CCT ERAt ES CE TIFICAT "E NUMBER: 1502961407 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. _— At'ITYC'S1„r'13!I'� ..... _ POIJI4�4"�F "P�CiLIC"CEXP .. Aso LTR TYPE OF INSURANCE I POLICY NUMBER YY l 1MWQQ1yYYYl LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y 24391656002 U2812014 V28Q01'.5 EACH OCCURRENCE $3 „,000 O��O,.,..._ �. - "gAt�9AGB °rrra RrN Ii: .. . CLAIMS -MADE � x .PF;EMI (r tFaige rylurlfm,Pal $50,00 EXP [Any irererscn) S5 „'000 ��IIUtIfIOL?al)a PERSONAL &AD%1IN Jul RY 52,,009100._ GENERAL A, GEN'L AGGREGATE LIMIT APPLIES PER: AGGREGATE $4,000 9104'1 - JEGT ^V — - COMP /OP AGG S4 „000 000 POLICY o- _......, PRO- LOC 0 ..-- -� .PRODUCT..,. ... ,....... .... S OTHER: Contr Pol. Liab $2,000,000 UMIT A, AUTOMOBILE LIABILITY 624391656002 I1�211I2014 12W2015 artlderul), I $2,D00 „000 ANY AUTO INJURY (Per person) $ BODILY.....•..--- --.... ...,- .. ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS X HIRED j( NON -OWNED P'R{kPr'b$ti DAMAGE' $ AUTOS ..iPeran k. .. ... ,... - -- X NO OwnedAuto $ UMBRELLA LIAB ]OCCUR CCU $- EACH OCCURRENCE, EXCESS LIAB CLAIMS -MADE AGGREGATE $ WORDED .._.__ ,..,.. $ WORKERS COMPENSATION PER l- DEMPLOYERS' LIABILITY N I A E .. .. ,. ..- AN YIN TAT�t..rE ANY PROP RIETORIf ARTNEWEXEC'UT'IVE L EACH ACCIDENT $ .,.,' CIh'E'ICERIMEIABER EXCLUDED? - . _ (Mandatory I NN) .,,E L DISEASE EA EMPLOYEE $ ...,, -- II y'es, domfibe undea B L.. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS beNewr A Professional Liability C324391656002 02812014 028/2015 $2 „000,000 Per Claim Claims made Form $2 000 000 Annual Aggr DESCRIPTION LN OF "I OPERATIONS e Remarks Schedule, may be attached If more space Is required) e DESCWPTION OF OPERATIONS 8 LOCATIONS I VEHICLES (ACORD 101, Additional policy excludes claims arising out of the performance of professional services. Contractors Polulion & Professional Liability Endorsements Pungi, Mold, or Microbial Matter Coverage limit $1x000,000 each claim /$1,000,000 Fungi Aggregate Unit (included in th General Liability Aggregate) deductible $10,000 each claim, retro date; 04/2612006. General Liability: XCU included. Auto Limit is Included in GL Limit. RE: All operations -- City of El Segundo, its officers, agents and employees are named as additional insured as respects general liability for Claims arising from the operations of the named insured as required per contract or agreement. CERTIFICATE HOLDER CANCELLATION 30 Day NOC 110 Day for NonPay of Prem SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE �' *- • •. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED v 1N City of El Segundo, PUbIiC Works Dept, w� ACCO NCE WITH THE POLICY PROVISIONS. °. 350 Main Street A I A TH D REPRESENTATIVE El Segundo CA 90245 w �^' C� 1988 -2014 ACORD GORPt31�TION. All rights reserved, ACORD 25 (201401) The ACORD name and logo are registered marks of ACORD Named Insured Endorsement Number Gale /Jordan Associates Inc G2439 � Period ._ 04/28/2014 Poliey Symbol P ollcy Nu 1656002 04/28/2014 to 04/28/2015 Effective Bate of End onement ECP Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company Insert the policy number, The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy„ g THIS ENDORSEMENT CHANGES THE POLICY. PI -EASE RE=AD IT CAREFULLY. �� ADDITIONAL INSURED ENDORSEMENT - OWNERS, LESSEES OR CON'T'RACTORS (PRIMARY AND NON - CONTRIBUTORY) �y "., This endorsement modifies insurance provided under the following: X, JI COMMERCIAL GENERAL LIABILITY COVERAGE CONTRACTOR'S POLLUTION LIABILITY COVERAGE Aw i SCHEDULE: Name of Person or Organization: Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. no entry appears above, information required to complete this endorsement Willi be shown in the Declarations as applicable to this endorsement.) SECTION II - WHO IS AN INSURED is amended to include: A. SECTION II - WHO IS AN INSURED is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply 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 be performed by or on behalf of the additional insureds) at the site 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. C. The coverage provided hereunder shall be primary and not contributing with any other insurance available to those designated above under any other third party liability policy. ENV -3101 (08 -04) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page i of 1 Insert the policy number. The remainder of the Information is to be completed only when thla endorsement Is issued subsequent to the preparation of the policy, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART SCHEDULE Name of Person or Ofganization: Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (It no entry appears above, intormatlon required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or your work done under a contract with that person or organization and included in the products- completed operations hazard. This waiver applies only to the person or organization shown in the Schedule above. All other terms and conditions remain the same, ENV -3143 (03 -05) Includes copyrighted material of Insurance Services Office, Inc. with its permisslon Page 1 of 1 4 w IV POLICYHOLDER COPY STATE P.O. BOX 8192, PLEASANTON, CA 94588 FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 02 -03 -2014 GROUP: + i .Y�� - POLICY NUMBER: 1118442 -2014a CERTIFICATE ID: 220 CERTIFICATE EXPIRES: 02-01 -2018 rc w 02 -01- 2014/02 -01 -2015 THIS CERTIFICATE SUPERSEDES AND CORRECTS CERTIFICATE # 317 DATED 02-01 -1014 CITY OF EL SEGUNDO. PUBLIC WORKS DEPT. $C 350 MAIN ST EL SEGUNDO CA 90245 -3813 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. £� Authorised Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #1000 - CHRISTOPHER K. GALE, PRESIDENT - EXCLUDED. ENDORSEMENT #1800 - THOMAS A. JORDAN, SECRETARY TREASURER - EXCLUDED. ENDORSEMENT #2088 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 02- 01-2000 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2670 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2014-02-03 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO. PUBLIC WORKS DEPT. EMPLOYER GALE /JORDAN ASSOCIATES, INCORPORATED 3859 W CARSON ST STE 200 TORRANCE CA 90503 SC IP1 Z,SC1 IREV.1.2012i PRINTED : 02-03 -2014 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION 1118442 -14 RENEWAL SC 2- 70 -70 -25 PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE FEBRUARY 3, 2014 AT 12.01 A.M. o �w ALL EFFECTIVE DATES ARE AND EXPIRING FEBRUARY 1, M� - 2015 AT 12.01 A.M. r AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME GALE /JORDAN ASSOCIATES, INC, 3858 W CARSON ST STE 200 TORRANCE, CA 90503 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, PUBLIC WORKS DEPT. WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, GALE/JORDAN ASSOCIATES, 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: FEBRUARY 5, 2014 2570 AUTHORIZED REPRESENTA IVE PRESIDENT AND CEO SCIF FORM 10217 (REV.1-2012) OLD DP 217 Hegvold, Julie From: Garcia, Angelina Sent: Monday, November 03, 2014 1:09 PM To: Hegvold, Julie Cc: Shilling, Mona; Rivera, Floriza; Bola, Arianne Subject: RE: Gale Jordan - Water Dept Testing Looks good0 Angelina Garcia From: Hegvold, Julie Sent: Monday, November 03, 2014 12:20 PM To: Garcia, Angelina Cc: Shilling, Mona; Rivera, Floriza; Bola, Arianne Subject: Gale Jordan - Water Dept Testing Hi Angie, Here is a new agreement with Gale Jordan for Haz Mat Testing at the Water Division. Insurance should be current as Gale Jordan has had a few agreements this year with the CH Roof Project. Please let me know if acceptable and I'll bring the hard copies by your office for initialing. Thanks! 350 Main Street, El Segundo, CA 90245