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PROOF OF INSURANCE (2015) CLOSED (2)
CERTIFICATE OF LIABILITY INSURANCE IAA I C lWviyOfkouo'I k A 1,1 09/04/2014 THIS CERTIF'CATE 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 end'orsement('s). PRODUCER PATRICK MCRAE INSURANCE SERVICES 1290 N. HANCOCK ST., SUITE 210 ANAHEIM HILLS, CA 92807 'ENSURED _.._... BIG WEST CONSTRUCTION 15331 NORMANDIE Irvine COVERAGES CA 92604 CERTIFICATE NUMBER: PHONE 1 a_CA); (714) 779 -6999 FAX• Ntb): (714) 779 - 6903 ADDRESS. F.rincrae (osbc9lobal,net INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: MT. HAWLEY INSURANCE COMPANY 37974 ,INSURER : GOLDEN EAGLE INSURANCE CORPORATION 10836 INSURER C: INSURER D: REVISION IIIl11 InC rVLIVICJ Vr IIVJVRMIVIiC LIJICU DCLIJVV r1MVC DCCIV IJJUCU I Ir1t INJUKtU NAMtU At3UVt FUK IHE 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, 4SR TYPE OF INSURA A X COMMERCIAL GENERAL LIABILITY AX L� MGL 1180690NUMBER 04/30/2014 04/3012015 LIMITS EACHOCCURR'�r�E 1,000,000 r CLAIMS -MADE X� OCCUR , [ PREMISESlrslloccalrrrr9aca) $ 50,000 r l _ N'L AGGREGATE LIMIT APPLIES PER f X_I PRO- POLICY LOC AUTOMOBILE LIABILITY X 1 ANY AUTO PERSONAL & ADV INJURY a' ALL OWNED i SCHEDULED X AUTOS HIRED AUTO S l AUTOS I X I NON -OWNED AUTOS 1 I UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRk'A" CR /PAR 1 NV'. =TV OCCUR CLAIMS -MADE i below YIN NIA MED EXP (Any one person) � $ EXCLUDED PERSONAL & ADV INJURY a' 1,000,000 GENERAL AGOREGATE $ 2,000,000 PRODUCTS - COMP /OP AGG $ 2,000,000 1 Is 07/ 1172 1497/11/2015 C MMBINE) INGLEiLIMIi $ 1,000,000 I QU;ri a3C;C1�1PrlG)_ _.. BODILY INJURY (Per person) ( $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE. (Pee ac�ldtrrrt) $ _ $ EACH OCCURRENCE I $ AGGREGATE $ $ rV. STATUTE ER V ` El EA014 ACCIDENT EL DISEASE EA CMPLOYET, $ - E. L DISEASE POLICY LIMIT $ I I I I DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if mores ace is required) THE CITY OF EL SEGUNDO, ALONG WITH THEIR OFFICERS, OFFICIALS, AGENTS, EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSURED WITH RESPECTS TO THE ABOVE MENTIONED POLICIES PER ATTACHED ENDORSEMENT(S). COVERAGE IS PRIMARY & NON - CONTRIBUTORY AS REQUIRED BY VVRITTEN CONTRACT, PER ATTACHED ENDORSEMENT FORMS WAIVER OF SUBROGATION APPLIES, IF REQUIRED BY WRITTEN CONTRACT, 'SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, A 30 DAY WRITTEN NOTICE WILL BE ISSUED. SHOULD ANY OF THE ABOVE POLICIES BE CANCELLED FOR NON - PAYMENT, A 10 DAY WRITTEN NOTICE WILL BE ISSUED. RE GROUP 55 PROJECT CERTIFICATE 1X81 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE CITY OF EL SEGUNDO THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 MAIN ST. ACCORDANCE WITH THE POLICY PROVISIONS. EL SEGUNDO, CA 90245 w "" AUTHORIZED REPRESENTATIVE ACORD 25 (2013/04) ©1988 -2013 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Policy Number: MGLO178121 Mt. Hawley Insurance Company 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 include as an additional insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability for "bodily injury," "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; 1. "Bodily injury," "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engi- neering activities. 2. "Bodily injury" or "property damage" occurring after: in the performance of your ongoing operations for the additional insured. a. All work, including materials, parts or equipment furnished in connection with such A person's or organization's status as an additional work, on the project (other than service, insured under this endorsement ends when your maintenance or repairs) to be performed by or operations for that additional insured are completed. on behalf of the additional insured(s) at the location of the covered operations has been B. With respect to the insurance afforded to these completed; or additional insureds, the following additional exclusions apply: b. That portion of "your work" out of which the This insurance does not apply to: injury or damage arises has been put to its m.`. 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. CG 20 33 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 Insured Policy Number: MGLO180690 Mt. Hawley Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS (FORM C) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART (If no entry appears below, information required to complete this endorsement will be shown in the Declarations as appli- cable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Sched- ule, but only with respect to liability arising out of "your work" for that insured by or for you. To the extent required under contract, this policy will apply as primary insurance to additional insureds scheduled below and other insurance which may be available to such additional insureds will be non - contributory. Section IV., Condition 4., of this policy is amended accordingly. SCHEDULE Name of Person or Organization: All persons or organizations where required by written coat t.' ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. CGL 216 (04/98) Page 1 of 1 Insured Policy Number: MGLO180690 Mt. Hawley Insurance Company 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 SCHEDULE Name Of Person Or Organization: All persons or organizations where required by written contract. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as appli- cable to this endorsement.) 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 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. CG 24 04 10 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 Insured BIGWE -1 OP ICS: C DATE (MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 09105/2014 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 certificate holder in lieu of such endorsementis). PRODUCER INVENSURE Insurance Brokers 17991 Cowan Irvine, CA 92614 -6025 Richard M. Sherman, CIC INSURED Big West Construction Corp. 15331 Normandie Ave Irvine, CA 92604 Phone: 949 - 756 -4100 Fax: 949-756-4199 INSURER B, INSURER C: E„ State Comp. Insurance Fund 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. I R „_,,, M . ............. ADbL s`Ur3a __ . -... ...., R TYPE OF INSURANCE POLICYNUMBER e...._ ... , , I OFF POLICY EJTP " "'° POLICY LIMITS GE_ ERAL LIABILITY EACH OCCURRENCE $ CO COMMERCIAL AL LIABILITY DAMAGF`T0 B DITED PREIWMSS (E u�turpnce) $ CLAIMS-MADE OCCUR � h 1. MED EXP (Anyone person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ POL6C:Y 9 °IC• LOC $ AUTOMOBILE LIABILITY COM INEO SING -r_ LIMIT . $,. ...., .., ... ANY AUTO i BODILY JURY (Per person) $ ALL OWNED SCHEDULED AUTOS S AUTOS ,....- BODILY IN Per accident ( ) $ ' NON -OWNED HIRED AUTOS AUTOS �. PROPER7`!'DANiIA05 (Per accidarj) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DELI RETENTION $ k $ WORKERS COMPENSATION WC STATU X AND EMPLOYERS' LIABILITY YIN „ TORY IMITS _ A ANY PROPRIETOR/PARTNER /EXECUTIVE X 9102636 -14 06/01I2014 06/01/2016 NT $ 1,000,00 E.L. EACH ACCIDENT OFFICER/MEMBER EXCLUDED? NIA L�� m (Mandatory In NH)� E.L. DISEASE - EA EMPLOYEE $ 1,000,00 If es, describe under D SCRIPTION OF OPERATIONS below 1 E.L DISEASE - POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Waiver of Subrogation applies per attached endorsement. CERTIFICATE HOLDER CANCELLATION City of El Segundo ELSEG -1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. i AUTHORIZED REPRESENTATIVE A ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD GIRYVnor-lY1C1Y 1 MVIlCC1Y1G1m1 WAIVER OF SUBROGATION 9102636 -14 NEW SP PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE SEPTEMBER 4, 2014 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING JUNE 1, 2015 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME BIG WEST CONSTRUCTION CORP 15331 NORMANDIE AVE IRVINE, CA 92604 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 WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, BIG WEST CONSTRUCTION CORP 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: SEPTEMBER 8, 2014 2570 .. AUTHORIZED REPRESENT IVE PRESIDENT AND CEO