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PROOF OF INSURANCE (2013) CLOSEDD / Y) ACORD n CERTIFICATE OF LIABILITY INSURANCE E 08124/2012 PRODUCER 310 - 548 -1989 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION JAMES R: UII:�' ll:: OP'�I�;I.Y�'>�a11� CE �, CS, VNC ONLY Ahl0 CONFERS NO RIGHTS UPON THE CERTIFICATE LVC 0721102 ALTER THIS CERTIFICATE DOES NOT AMEND„ EXTEND OR ALTENR THE COVERAGE AFFORDED BY THE POLICIES BELOW_ fILRTH 77 #P2A SAN PFDRO, CA 90731 � INSURERS AFFORDING COVERAGE _ I NAIC # wsuReD...,,,,,, C /0C RCCVII-[N C HA1VAAF%R4 � IN¢yVRERB .1NN1 UI%TY 10 gpLJRAVN�,l0�o�0b111r11-ANY �� 20260.... 3124 ROS I~.:U�f-4hSS AVE S I IE B INSURER(` SURER D, U... IAA- IR-NI�9C11rJI�,� ",FaI9L) "�LuO �.� �..... _ ..... w SURFR F: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREI] NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WYTII RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN'IrS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I'SRAOD "L POLICY NUMBER _ POI'.NGY &FFAeETi�W'E POLICY EXPIRATION LIMITS E # LIRANCE —ATE T.EIMMffl2DM L GENERAL LIABILITY EACHOCCURRENCE I $ 1,()00,000 A'�n A'I � ...i- OC?0018:3�6 -��.° K.98A0LUA,:/I"./1 :r? 1 03/0911.."0'11 � DAMAGE TO RENTED ) ... I �._.... a OP�E.Y X COMMERCIAL GENERAL LIABILITY PREPALS S Eaaerrxwlwrmrwa $ CI..A I INI S OI AII111 IIq^1;1p.PR MED EXP (Any one Person) I $ ......, � �.... " PERSONAL&ADV INJURY ,,... $ 1o01i90000 qrE ERALAGGREGATE $ 2,001..... _ ...... ),1)1)0, 1,000,000 ' 0a I r I L C _•__....a I 1 AUTOMOBILE LIABILITY .. COMBINED SINGLE LIMIT $ 1,0G,)ID.1➢ &961 B X ANY AUTO '� 2," 2 f E ccldent) „.,�040'11/0i29 ":)02000 11,A09A. 0111 11/C,)A20'0� ! (ae ALL OWNED AUTOS BODILY INJURY _.... (Per person) I, i SCHEDULEDAUTOS HIREDAUTOS BODILYINJURY $ NON>OWNEDAUTOS (Per accident) L PROPERTY DAMAGE S I (Peraccident) GARAGE LIABILITY 4 AUTO ONLY) EA ACCIDENT $ ANY AUTO N /A OTHERTHAN EAACC $ ...... AUTO ONLY: AGG $ _.� LLA �� EACH OCGUi.RE°NCP E %CESSlUMBRE LIABILITY $ OCCUR CLAIMS MADE I AGGREGATE S S DEDUCTIBLE j .... _.... .... RETENTION $ $ ' WORKERS COMPENSATION AND ' _. .. ORYLIM.dT� 1 ER , �. EMPLOYERS' LIABILITY N/A E. L, EACH ACCIDENT ANY PROPRIETOR/PARTNER/EXECUTIVE ' OFFICERIMEMSER EXCLUDED? F11 IIN If A E k ILA ILIIRPI OYII Y S IF yes, describe under - - -- -- -• ,_. SPECIAL. PROVISIONS below E L. DISEASE +POLICY LIMIT $ OTHER �y C �IoN 11..) 10082888 08/1;,°512011 08/1512012 � 1'2., a�00 CLB I ...... .,.,_...._. .. ....__..... .....,.,. . ..... D ...-- ,...._ ._.. - ESCRIPTION OF OPERATIONS / LOCATIONS! VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL. PROVISIONS' THE UICY OF EL ":9EG U @'NCO, n 1 C OFFICERS, RS F1GIEN rS AEI` D LEJODLOYE Er ARE I�IGL.UI11E1::9 AS AIf1DITi &OVAL kNSUREO 'WII LH REGARD TO ll....IABIL._V'p"'Y AN I) D EE:::E �GSE G')u= SCI f S AR IS Fi:E(DM "'YOU V�AL:)RK" IfPCI~II °��h "M E*D BY OR ON Fir- UId�U..F fi9I='�>rHE I�Vd'iMED CINS;UJYrdJI::C::7 _ 11ti1 REGARDLESS OF IP /HIETI IER LIABIlk...1 "hY IS A_1...I..IF OU2TABLE TO OINK.= NIA"` NIE D INSURED OR A4 COM BRNJL.L.1ON OF TI iE NAMIE[) AIL' D 11E fill:: Al[)DILIIONA....INSU IR[ U.:9 CERTIFICATE HOLDER CANCELLATION SHIIJULO AANY or THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE' THEREOF, . THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN �;I..I.Y C9I- I"I �I��E /s�I10�9 I I.' UB111C.'AOJ0RKS DEPT T NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL 3;'40 MAIN STREET IIiMPIOSE. NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR EL B,ECIJIVDO, 9E� 24 RBPRESENT TIVFS ..,, ACORD 25 (2001108) 1`'" ' ACORD CORPORATION 1988 COMMERCIAL GENERAL LIABILITY POLICY NUMBER: GLF 000013356 -02 EFFECTIVE DATE: 03/09/2012 INSURED: ARC PLUMBING BY: UNITED CONTRACTORS INSURANCE CO. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSIL:E OWNERS, LESSEES OR CONTRACTORS (FORM B) `l "leis ctidorseinetit niod'il"ies iiistiraticc provided Wider the fdllo ittg: COMMERCIAL GENERAL LIABILITY COVERAGE PART,. Name ofPet^.+r►u or Organization CITY OF EIS S :!GUN )'O PUBLIC WORKS DEPT. 3y�s0 ;MAIN STREET EL S1r.t; UNDO, CA 90245 WHO IS AN INSURED (Section II) is aanaended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" for Ilrrrt`,insnred by or for you. P141MA'ItY wOR.I'.l'IN(; CI.A(:iS'E 1) The City of El Segundo, its officers, agents and employees are included as additional insured with regard to liability and defense of suits arising from "your work" performed by or on behalf of the named insured regardless less of whether liability is attributable to the named insured or a combination of the named and the additional insured. 2) Any other insurance maintained by the City of El Segundo is excess of the insurance and will not contribute to it. 3.) This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the company's limits of liability. The inclusion of any person or organization as an insured does not affect any right with such person or organization would have as a claimant if not so included. CG2010 (11185) Copyright, tnrauraroce Services Office, Inc., 1984 CERTHOLDER COPY SC P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 08 -27 -2012 GROUP: 000319 POLICY NUMBER: 0000287 -2011 CERTIFICATE ID: 9 CERTIFICATE EXPIRES: 04 -01 -2013 04 -01- 2012/04 -01 -2013 CITY OF EL SEGUNDO SC 350 MAIN ST EL SEGUNDO CA 90245 -381 This is to certify that we have issued 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 he 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. ✓� —�4mu, c4 Authorized Representative President and CEO UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' COMPENSATION LAW. EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE„ ENDORSEMENT #2085 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04 -01 -2012 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2012 -08 -27 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO EMPLOYER CHAVARIN, RUBEN C. DBA: A R C PLUMBING SC 3124 W ROSECRANS AVE STE C HAWTHORNE CA 90250 [JAN,CNI (REV.1 -2012) PRINTED : 08 -27 -2012 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION 319 -11 000267 RENEWAL SC PAGE HOME OFFICE SAN FRANCISCO EFFECTIVE AUGUST 27, 2012 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING APRIL 1, 2013 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME A R C PLUMBING 3124 W ROSECRANS AVE S'I''., °:....��` r� HAWTHORNE, CA 90250 J 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, A R C PLUMBING 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: AUGUST 29, AUTHORIZED REPRESENTA WE SCIF FORM 10217 (REV.1 -2012) 1 2012 2570 I� PRESIDENT AND CEO OLD DP 217 JUNE 25, 2012 CITY OF EL SEGUNDO DEPT OF BUILDING & SAFETY 350 MAIN ST EL SEGUNDO CA 90245-3813 IN REPLY REFER T0: CERTIFICATE OF WORKERS' COMPENSATION INSURANCE CANCELLATION WITHDRAWAL NOTICE RE: CERTIFICATE DATED APRIL 1, 2012 THE CANCELLATION HAS BEEN WITHDRAWN FOR THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW. THIS LETTER SUPERSEDES THE NOTICE OF CANCELLATION SENT TO YOU ON MAY 21, 2012. THIS EMPLOYER'S WORKERS' COMPENSATION INSURANCE COVERAGE CONTINUED UNINTERRUPTED. EMPLOYER: A R C PLUMBING 3124 W ROSECRANS AVE STE C HAWTHORNE, CA 90250 POLICY 319 - 0000267 -11 CUSTOMER SERVICE REPRESENTATIVE CUSTOMER SERVICE CENTER (877) 405 -4545 5860 Owens Dr Pleasanton, CA 94588 -3900 Mailing Address: P.O. Box 8192 • Pleasanton, CA 94588 -9682 SCIF 19102