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PROOF OF INSURANCE (2013) CLOSED��DATE (MM /DDNYYY) "°'" CERTIFICATE OF LIABILITY INSURANCE 08/21/2012 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 endorsements . PRODUCER 1 -800 -247 -7756 CONTACT HolmesMurphy & Assoc - WDM PHON: E ............... ��................................................................................. .........................�.�.�I FIAX.......- ......... PO Box 9207 Des Moines, IA 50306 -9207 INSURED Musco Sports Lighting, LLC Attn: Carrie Ferguson P 0 Box 808 Oskaloosa, IA 52577 COVERAGES CERTIFICATE NUMBER: 28760590 INSURERS AFFORDING COVERAGE NAIC # EMPLOYERS .....� .................. .......................... - -- --- MUT.. CSC........ ............. P CO mA- XII 21415 .....TA....�YLR.S . & LI O A X c/o RT S ecialt,38318 REVISION Nt1MRER- 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 L U POLICY EFF POLICY EXP TYPE OF INSURANCE LIMITS LTR POLICY NUMBER. MMIDDIYYYY MMIDDIYYYX. • GENERAL LIABILITY 2DS362513 07/01/12 07/01/13 EACHOCCURRENCE $ 1,000,000 X ...., .t"I'.YMMiERCIAN. GENERAL LIABILITY 6AAhA,1`Ytu ra ft PREMIS fa 9c urrwme) $ 0 CLAIMS -MADE X _ OCCUR -Ea MED EXP (Any ono person i0"0",­0­0 $ 15,000 X Contractual Liability _......_ . ......................................................................................... ............................... PERSONAL &ADV INJURY ................ $ 1,- 000,000 . .. ................. ...+"" GENERAL AGGREGATE $ 2,000,000 ...$...2,000,�000����..� sEN' V..... +�('�i� %�I�I�GAT... LIMIT APPLIES PER: PRODUCTS- COMP /OPAGG POI ICY • AUTOMOBILE .. -.... LIABILITY 2E5362513 COMBINED SINGLE LIMIT ..,(Ea,,. ar�g9tW)� 1 000 000 . �....1 X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) .......... ...................... .. $ .�. X NON -OWNED lx P OPER fY DAMAGE $ HIRED AUTOS AUTOS B UMBRELLA LIAB X OCCUR �.........�.. SISCSEL015252112 07/01/12 07/01/13 EACH OCCURRENCE ... ----..... ........ EXCESS LIAB I CLAIMS -MADE AGGREGATE $ 1,000,000 DED RETENTION $ • WORKERS COMPENSATION 2P5362513 (Florida) 07/01/1 07/01/13 X WLSI'Atl�U OTH I R ECUTIVE Ded States ES EAEMPLOYEE OFFICERIMEMBBEE CLUDD N/A .............. 00 A H 2M5362513NewJersey) 07/01/1 07 /01 /13,E.DAE LS 500 • DESCRIPTION OF OPERATIONS below ,2ZS362513(All Other States)07 /01 /1 07/01/13, E,L. DISEASE - POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Project: SVC- 323388 - Richmond Street Elementary School City of E1 Segundo, its officers, officials, employees and agents are included as Additional Insureds on the Commercial General Liability policy for work performed for them by the Named Insured when required by written contract or agreement. Waiver of Subrogation applies to the Additional Insureds on the WC policy when required by written contract for work performed by the Named Insured. Workers Compansation and Employers, Liability is underlying on the Excess Liability policy. LtK I It- IUA It HULUtK GANGtLLA I FUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street AUTHORIZED REPRESENTATIVE E1 Segundo, CA 90245 I USA © 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ssteinbachwdsm 28760590 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - CONSTRUCTION CONTRACTS INCLUDING COMPLETED OP IONS This endorsement modifies the insurance provided under the f+oliowin COMMERCIAL. GENERAL LIABILITY COVERAGE PART 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 to your policy and where a Certificate of Insurance showing that person or organization as an additional insured has been Issued. 3. The insurance provided to the additional insured does not apply to "bodily injury," "property damage" and "personal and advertising injury" arising out of an architect's, engineer's, or surveyor's rendering of or failure to render any professional services including: The written contract or agreement must be: (a) Currently in effect or becoming effective during the term of this policy; and (b) Executed prior to the "bodily injury' or "property damage." 4. The insurance provided to the additional insured is limited as follows: 1. That person or organization is only an additional insured with respect to liability arising out of "your work" performed for that additional insured by or for you. 2. The limits of insurance applicable to the additional insured are those specified in the Declarations for this policy or in the written contract or agreement, whichever is lower. These limits of insurance are inclusive of and not in addition to the limits of insurance shown in the Declarations. a. The preparing, approving, or failing to prepare or approve maps, drawings, opinions, reports, surveys, field orders, change orders or design and specifications; and b. Supervisory, inspection, architectural or engineering activities_ Any coverage provided hereunder shall be excess over any other valid and collectible insurance available to the additional insured whether primary, excess, contingent or any other basis, unless a contract specifically requires that this insurance be primary, or you request that it apply on a primary basis. When coverage is provided on a primary basis we will not seek contribution from any other insurance available to that additional insured if a contract requires that this insurance be noncontributory, or you request that it apply on a noncontributory basis, 5. All other terms and conditions of this policy remain unchanged. CG7174,1M(10 -01) Includes copyrighted material of ISO Properties, Inc. with its permission. Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 4 -84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an i n)ury covered by this policy. We will not en- force 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.) This agreement sP610pt operate directly or indirectly to benefit any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION 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 Policy No. Endorsement No. Insured Premium $ Insurance Company Countersigned By WC 00 03 13 (Ed. 4 -84) Copyright 1983 National Council on Compensation Insurance. Ramos, Vina From: Garcia, Angelina Sent: Tuesday, August 21, 2012 4:43 PM To: Ramos, Vina Cc: Shilling, Mona Subject: RE: Insurance Cert and W9 / Project -- SVC- 323388 Please route for signatures. Insurance accepted. Angelina Garcia - - - -- Original Message---- - From: Ramos, Vina Sent: Tuesday, August 21, 2012 12:32 PM To: Garcia, Angelina Cc: Shilling, Mona Subject: FW: Insurance Cert and W9 / Project -- SVC- 323388 Hi Angie, Please see below's email from Troy for the Richmond lighting repair project regarding Worker's Comp. Thanks Vina - - - -- Original Message---- - From: Troy.Shilling @musco.com [ mailto:Troy.Shilling @musco.com] Sent: Tuesday, August 21, 2012 12:30 PM To: Ramos, Vina Subject: Re: Insurance Cert and W9 / Project -- SVC- 323388 Vina, Please see the attached document and the email below from our insurance company. Thanks Troy 8/21 We did provide WC Waiver and the endorsement? I have reissued the certificate to show that the WC is underlying to the Excess policy. Let me know if it gets kicked back again, thanks! Stacy Troy Shilling Lighting Service Sales Rep Musco Lighting LLC Phone 800 825 -6020 1