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PROOF OF INSURANCE (2015) CLOSEDAC R - CERTIFICATE OF LIABILITY INSURANCE DATE NMI L '1010712014 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(I'es) 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 CONTACT Gabriel Stubin Western Republic Ins. Services PHONE J888) 467 -1718 wAa 714' 536 -0599 PO Box 268 E -MAIL , info wrinsurance.com, Huntington Beach CA 92648 IN R AFF RDING COVERAGE _ _ 1C INSURED Manuel Alba Moreno dba Golden Meters Service 14812 Hunter Lane Midway City CA 92655 -1331 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. INSR ADOL SUBR POLICY EFF POLJCY EXP LIMITS TYPE OF INSURANCE POLICY N BE GENERAL LIABILITY EACH OCCURRENCE $ 1 .0-9-010 0 0 RENTED DAMAGE TO R ..POSES.. °. 1100 000 .W.w.W_... '..A COMMERCIALGENEEIABILIITY cLAUMS -MADE X OCCUR Y Y XN104293202 0910912014 09/0912015 MED Ex�A �'n one erson 5,000 PERSONAL & ADV INJURY s 1 000 000 GENERALAGGREGATE s2.000.000 "iEWLAGGRCGATE, LIMIT APPLIES PER: PRODUCTS- COMPIOPAGG 151,000,000 ^ S X POLICY PRO- LOC.. AUTOMOBILE LIABILITY CEO- MBINEOSINGLELIMIT 1000000__ B ANY AUTO BODILY INJURY (Per person) S ALL OWNED X SCHEDULED Y BA040000002873 11102/2013 1110212014 BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED --- PROPERTY DAMAGE S HIRED AUTOS AUTOS $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE s2,000,000 C EXCESS LIAB CLAIMS -MADE EBU061800520 09/09/2014 09/09/2015 AGGREGATE s 2 000 000 DIED R TE TION WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS' LIABILITY YIN 176000110061 ANY PROPRIETORIPARTNER/EXECUTIV E.L. EACH ACCIDENT $1,000,000 v N / A 4 03/0712014 D 1 0310712015 oFFICER/MEMBER EXCLUDED. IMandatory In NH) E.L. DISEASE -F&EMELOXEg $1,000,000 If yes, describe under 0 P I A I w E.L. DISEASE - POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, U more space Is required) Those usual to the insured's operations. A blanket additional insured endorsment is included with the general liability policy. Additional insured status is automatically granted where required by written contract. The certificate holder is named as additional insured where required are by written contract. -- __ .... ........ __ ........ — City of El Segundo 350 Main St. El Segundo, CA 90245 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD r M POLICY NUMBER: XN104293202 COMMERCIAL GENERAL LIABILITY NX GL 189 05 11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSUREDS - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Policy Number: XN104293202 Endorsement Effective: 9/9/2014 12:01 a.m. Named Insured: Counter Signed By: MANUEL ALBA MORENO , D', : GOLDE METERS SERVICE SCHEDULE Name of Person or Organization: Any person or organization that the named insured is obligated by virtue of a written contract or agreement to provide insurance such as is afforded by this policy. Location: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section II — Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization shown in the Schedule is held liable for your acts or omissions 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 services, maintenance or repairs) to be performed by or on behalf of the additional insured(s) 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 words "you" and "your' refer to the Named Insured shown in the Declarations. NX GL 189 05 11 Page 1 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission POLICY NUMBER: COMMERCIAL GENERAL LIABILITY NX GL 189 05 11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. D. The following are added to SECTION V — DEFINITIONS: "Your work" means work or operations performed by you or on your behalf; and materials, parts or equipment furnished in connection with such work or operations. E. The following additional provisions apply to any entity that is an insured by the terms of this endorsement: Primary Wording With respect to the Third Party shown above, this insurance is primary and non - contributing. Any and all other valid and collectable insurance available to such Third Party in respect of work performed by you under written contractual agreements with said Third Party for loss covered by this policy, shall in no instance be considered as primary, co- insurance, or contributing insurance. Rather, any such other insurance shall be considered excess over and above the insurance provided by this policy. 2. Waiver of Subrogation If required by written contract or agreement: We waive any right of recovery we may have against an entity that is an additional insured per the terms of this endorsement because of payments we make for injury or damage arising out of "you work" done under a contract with that person or organization. NX GL 189 05 11 Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 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 5 % of the California workers' compensation premium otherwise due on such remuneration. PERSON OR ORGANIZATION CITY OF EL SEGUNDO 350 MAIN STREET EL SEGUNDO, CA 9024 SCHEDULE JOB DESCRIPTION WATER METER TESTING. VARIOUS LOCATIONS FOR CITY OF EL SEGUNDO 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 06 -26 -14 Policy No. 7600011006141 Endorsement No. 001 Insured MORENO, MANUEL (AN INDIVIDUAL) Premium $ INCL . Insurance Company EVEREST NATIONAL INSURANCE COMPANY Countersigned By -1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual -1999.