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PROOF OF INSURANCE (2013) CLOSEDJE�?p� CERTIFICATE OF LIABILITY INSURANCE 911; o12 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. It SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endomonnenl. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsemengsl_ PRODUCER Cossio Insurance Agency PO Box 188 Simpsonville, SC 29681 (864) 668-0121 INSURED SPORTS AND RECREAT40N PROVIDERS ASSOCIATION (PURCHASING GROUP) AND ITS PARTICIPATING MEMBERS: J & Windows & Doors, Inc dba Fiesta N Jump Fiesta N Jump 3750 W Ell Segundo Blvd. Hawthorne, CA 90250 Contact Name: Aracell Salvallerra Phone 3102631848 Fax 3106755881 (A/C, No. Ext): (PVC, Noy. E -Mail: jawlndowsndoors@aol.com INSURER(S) AFFORDING COVERAGE INSURER A: Riverport Insurance Company (MINNEAPOLIS, MN) INSURER B: Berkley Life & Health Insurance Comparry INSURER C: INSURER D: INSURER E: NAIC III 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 TYPE OF POLICY ADDL SUER POLICY HUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MMIDD1YY) (MMMDIYY) V GENERAL LIABILITY X, COMMERCIAL GENERAL LIABILRY CLAIMS MADE X OCCUR X FLDG180311 3/1712012 3/1712013 GEWL AGGREGATE LIMIT APPLIES PER 'X POLICY PROJECT LOC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIREDAUTOS NON-OWNED AUTOS UMBRELLA LIAB OCCUR EXCESS LIAR CLAIMS MADE DED RETENTION; WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPPJETORIPARTNERrEXECUTIVE YR`I OFFICERNAEMBER EXCLUDED? NIA (Mandatory in NH) If yes, desaae under DESCRIPTION OF OPERATIONS below 13 Accident Medical Each Occurrence General Aggregate Products Completed Operations Personal & Advertising Injury Medical Expenses Fire Damage Deductible $1,000,000 $2,000,000 $2,000,000 $1,000,000 $5,000 $300,000 None COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY $ (Per Person) BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) WC STATU- OTH TORY LIMITS CR Maximum Medical Benefit per Claim $10,000 Accidental Death/Dismemberment B $10,000 PAI L00233479 -001 3!1712012 3/1712013 Deductible NOW DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Party Equipment Rentals Operations located at 3750 W. El Segundo Blvd, Hawthorne. CA 90250, Certificate Holder As Add @tonal Insured Amusement devices on file with the company for special event(s) dated 10/31/12 to 10/31112 located at 350 Main Street, El Segundo, CA 90245. It's Ofticers, Official, Employees, Agents an# Vokin toots listed additional insured. CERTIFICATE HOLDER: The City of El Segundo City 350 Main Street, Room 5 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 ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD ®1988 -2010 ACORD CORPORATION. All rights reserved. COMMERCIAL GENERAL LIABILITY CG 20 10 03 97 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Policyholder: J & Windows & Doors, Inc dba Fiesta N Jump Policy Number: FLDG180311 SCHEDULE (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Who Is An Insured (Section 11) 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. To the extent that any of the additional insureds named herein are liable for occurrences arising out of the named insured's negligent acts or omissions, the insurance afforded to the additional insureds under this endorsement is primary insurance over any other valid or collectible insurance which the additional insureds may have with respect to loss under any of the listed policies. Other insurance of any additional insured applicable to loss is non - contributory and excess over the coverage provided by this endorsement, and the amount of the company's liability under this policy shall not be reduced by the existence of such other insurance. CG 2010 03 97 Copyright, Insurance Services Office, Inc., 1996 Page 1 of 1 El '''?mz °" CERTIFICATE OF LIABILITY INSURANCE 1 °" `""'°°'""�'' 1'I2 THIS CERTIFICATE IS ISSUED AS A WITTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE OM NOT AFFIRMATIVIIY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOY CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT., It tha c—wRcsts holder Is an ADDITIONAL INSURED, ft pol"Iss) must be endorsed. if SUBROGATION t$ WAIVED, vub]ect to the teems and eondltlon s of the poky, eirteln policies may require an endowment. A statement on Oft aertlfloate does not eanfvr rights to the PROOMM AAA club Sorvicee, LLC I.O. Box Santa Ant, CA 922790 House A000unt 2 "13.74 Corn ip"RED J & A Windows & Doors Im. INEIIROI Jose 8ahraderm 2750 W. El Segundo Blvd lam Hawthome, C.A 90250 M'° -URg GENERAL VARILM AL O'R RAL I.MM11YY CLAW-KAng 0 OCCUR "LAOGREOATELIMITAPP PER AUTOMOnE UAIMUTY A AY AVTQ x COFICR13607366 10!09/12 IOMS113 ELYINI AL OWEQ SE0ULED IR:Y Y {Pr (Par EDALMS A pg" UMBRELLA LWB ill � k OCCUR EXCESS LNIV LMAUM ANY PROMIE�AA Y' �MIAJ I E_LDMIGAEi-EA AND EMPL I^.- -I I O.__W..._...., 1XCLU13ELl [j- mcM"QN OF OPEM ON9 I LOCATION I MIMS (Aetah AGORA 101, AdaM R01 RamMM Scbwuu, R MR GPeee Y MgairaG) Proof of Insurance Only" ACORD 2512010/05) PROMF SHOULD ANY OF THE ABOVE DE.SORMEU PauCltrn pE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE wITN THE POLICY PROVISIONS. AF PREPREBaNTA S HAccount ._ 01" -20 ACORDCORPOR 7IiN. All rights reserved. The ACORD name and logo are regleteeed marks o CORO .4� u D,r, CERTIFICATE OF LIABILITY INSURANCE RD22 09 -20 -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 SUBROGATIONIS 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'or! miAnttnl. PRODUCER CONT INSUREZONE. COM OF TEXAS INC PRO '. .: eS S7 505009 P:(866)467 -9663 F:(817)885 -7985 -9,663 y I (8717)885 -7985 1612 SUMMIT AVE SUITE 100 DRESS: 1 FORT WORTH TX 76102 INSURERISI AFFORDING COVERAGE NAIC T INSURER A: Sentinel Ins Co LTD lIMS1ARED INSURER B J & A WINDOWS AND DOORS INC. INSURER c 3750 W EL SEGUNDO BLVD INSURER D HAWTHORNE CA 90250 INSURER E INSURER F 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 .TYPE BEEN REDUCED BY PAID CLAIMS. Lr OF AYS1ArfWCE UCY htwwR / r nrvrYr Lmrs GEARFAAL LMMUrY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY —� PREMISES 'MIL__ E�� CLAIMS -MADE � OCCUR ❑ ❑ MED EXP I AnYpnwgsereawwl i PERSONAL & AOV INJURY e GENERAL. AGGREGATE s L AGGR OMIT S PER: PRODUCTS - COMPIOP AGG d POLtC'Y PR LOC AUFOMOOME ZIABMffV COMBINED SINGLE LIMIT $ (Ea accidentl ANY AUTO BODILY INJURY (Per p,.) $ ALL OWNED SCHEDULED ❑ AUTOS BODILY INJURY 41 er accident) $ AUTOS HLRED AUTOS NON-OWNED PROPERTY DAMAGE 0 AUTOS IPer accident) ....... $ UNORELLL 1/AA OCCUR EACH OCCURRENCE $ EXCESS4A CLAIMS-MADE ❑ ❑ AGGREGATE $ DE RETENTION e e IiYORXER$ GO'd6tffdIYSAtl MraP AAV C STAT X EMP$OVERS' 1MftffY r H ANY PROPRIETOIU'PARTNERlEXECI.IW"0V A OFFLCERPMEMBEREXCLUDEOk N/A ❑ 46 WEC 253516 11/01/2011 11/01/2012 IL, EACH ACCIDENT • 001 ()00 iMlarrdwrdrlr rd ApP 4 deed -E L. DISEASE EA CMKOYEE 5 1,000,000 ' CRLPTION OPERATIONS IlRpcl' E,L. DISEASE POLICY LIMIT 6 1,000,000 ❑ ❑ WSCWTXWV Of OM#Ar,MV& /C004 770 / VEMLES (4(1w h A+COAD 10 t. Addkk4W R rs, p' Those usual to the Insured's Operations. waiver of Subrogation applies in favor of the Certificate Holder per Waiver of our Right to Recover from Others Endorsement WC 04 03 06 attached to this policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE The City of El Segundo �� DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS„ 350 MAIN ST RM 5 > AUTHORIZED REPRESENrAnVE EL S EGUNDO , CA 90245 " 1888 -2010 ACORD CORPORATION. All rights reserved, ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD y w THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number: 46 WEC ZS3516 Endorsement Number: 02 Effective Date: 09/17/12 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: J AND A WINDOWS AND 'DO0,RB•,, INC 3750 W. EL SEGUNDO HAWTHORNE, CA 90250u We have the right to recover our payments from anyone liable can 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 premium otherwise due on such remuneration. Person or Organization HAR-BRO INC., HAR -BRO CONSTRUCTION & CONSULTING, INC., HAR -BRO OF NORTHERN CALIFORNIA, INC., HAR -BRO OF WASHINGTON, INC. AND HAR -BRO WEST, INC. 2750 SIGNAL PARKWAY LON BEACH, CA 90755 THE CITY OF EL SEGUNDO 350 MAIN ST RM 5 EL SEGIMO, CA 9245 SCHEDULE 2 % of the California workers' compensation .lob Description WINDOW INSTALLATION DELIVERY OF EQUIPMENT ✓ Countersigned by Authorized Representative Form WC 04 03 06 (1) Printed in U.S.A. Process Date: 09/18/12 Policy Expiration Date: 11/01/12 REGIONAL OFFICE INSTRUCTION SHEET POLICY NUMBER: 46 WEC ZS3516 CHANGE NUMBER: 002 ROUTING INSTRUCTIONS SEND TO RECORDS. TRANSFER CORR IF APPLICABLE. 16 POLICY FACE SHEET 35 ZS WEC SENTINEL INSURANCE COMPANY, LTD ENDT NO: 02 ENDT EFF DATE: 09 -17 -12 RECORDS RETENTION - PERMANENT POLICY NO: 46 WEC ZS3516 01 RENEWAL HOUSING CODE: SC 1. NAMED INSURED AND J AND A WINDOWS AND DOORS INC MAILING ADDRESS: 3750 W. EL SEGUNDO HAWTHORNE, CA 90250 THE NAMED INSURED IS: CORPORATION 2. POLICY PERIOD: 11 -01 -11 TO 11 -01 -12 PRODUCER'S CODE: 505009 PRODUCER'S NAME: INSUREZONE.COM OF TEXAS INC BUSINESS OF NAMED INSURED: WINDOW STORES AUDIT PERIOD: ANNUAL 3. STATES COVERED: CA ACCOUNT NUMBER: 13130885 PAYOR: INSURED FREQUENCY: MONTHLY /3 MO DOWN BASIC BROAD FORM GENERATED BEST IND = 06 AUDIT (4) MARKET SEG ID #: 570 POLICY SIC CODE: 5251 INFORMATION MESSAGE: FULLY SUPPORTED TRANS TYPE: ENDT CNTL #:005 POLICY FACE SHEET TERMINAL ID: R022VFCA 09 -18 -12 46 WEC ZS3516 (11- 01 -12) Vi THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.. CHANGE IN INFORMATION PAGE INSURER: SENTINEL INSURANCE COMPANY, LIMITED NCCI Company Number: 13161 AUDIT PERIOD: ANNUAL POLICY EFFECTIVE DATE: 11 /01 /11 POLICY EXPIRATION DATE: 11/01/12 Pollcy Number: 46 WEC ZS3516 Endorsement Number: 02 HOUSING CODE: SC Effective Date: 09/17/12 Effective hour is the same as stated in the Information Page of the policy. Named Insured and Address: J AND A WINDOWS AND DOORS INC 3750 W. EL SEGUNDO HAWTHORNE, CA 90250 FEIN Number: 262721164 PRO RATA FACTOR: .123 PRODUCER NAME: INSUREZONE.COM OF TEXAS INC PRODUCER CODE: 505009 It is agreed that the policy Is amended as follows: ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING STATEMENT. IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BANK ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A BILL. IN CONSIDERATION OF AN ADDITIONAL PREMIUM OF $6 IT IS AGREED THAT: (A) POLICY IS AMENDED TO CHANGE PAYROLL ON CLASS 8028 FOR INSD 01 ST 04 LOC 01 (B) POLICY IS AMENDED TO ADD LOCATION 03 FOR INSD 01 ST 04 LOC READS: 350 MAIN ST. RM 5 (WOS) EL SEGUNDO, CA 90245 FORM NUMBERS OF ENDORSEMENTS DELETED FROM THIS POLICY AT ENDORSEMENT ISSUE: FORM NUMBERS OF ENDORSEMENTS REVISED AT ENDORSEMENT ISSUE: WC040306 Countersigned by Form WC 99 00 06 A (1) Printed in U.S.A. Process Date: 09/18/12 Authorized Representative Pagel (CONTINUED ON NEXT PAGE) Policy Expiration Date: 11/01/12 CHANGE IN INFORMATION PAGE (Continued) Policy Number: 46 WEC ZS3516 SCHEDULE IT IS AGREED THAT THE POLICY IS AMENDED AS FOLLOWS: CLASS CODE NUMBER AND DESCRIPTION ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER 100 OF ANNUAL REMUNERATION REMUNERATION PREMIUMS (A) 8028 5,400 10.62 573 EQUIPMENT OR MACHINERY RENTAL YARDS NOT DEALERS IN NEW OR USED EQUIPMENT ALL EMPLOYEES - INCLUDING COUNTERPERSONS (B) 8028 400 10.62 42 EQUIPMENT OR MACHINERY RENTAL YARDS NOT DEALERS IN NEW OR USED EQUIPMENT ALL EMPLOYEES - INCLUDING COUNTERPERSONS WAIVER OF SUBROGATION (0930) 2.00 PERCENT OF PREMIUM 50 ALL OTHER STATE CLASS PREMIUM 1,312 CA TERRITORIAL DIFFERENTIAL PREM 9682 (1.020) 38 TOTAL CLASS PREMIUM 2,015 CA SURCHARGE - 2.559 PERCENT 56 USER FUNDING ASSESSMENT 1.4721 PERCENT 32 FRAUD ASSESSMENT 0.4348 PERCENT 9 CA UNINSD EMPL BENEFIT TRUST FUND 0.4101 PERCENT 9 CA SUBSEQ INJ BENEFITS TRUST FUND 0.1776 PERCENT 4 CA OCCUP SAFETY AND HEALTH FUND 0.2467 PERCENT 5 CA LABOR ENFORCE AND COMPL FUND 0.2315 PERCENT 5 EXPENSE CONSTANT (0900) 150 TERRORISM (9740) 43,000 .030 13 TOTAL ESTIMATED ANNUAL PREMIUM - CA 2,298 CA TERRITORIAL DIFFERENTIAL PREM 9682 (1.020) 38 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 2,015 EXPENSE CONSTANT 0900 150 TOTAL ESTIMATED STATE SURCHARGE 120 TERRORISM (9740) 13 TOTAL ESTIMATED ANNUAL PREMIUM 2,298 ESTIMATED ANNUAL ADDITIONAL ENDORSEMENT PREMIUM 52 Form WC 99 00 06 A (1) Printed in U.S.A. Page 2 Process Date: 09/18/12 Policy Expiration Date: 11/01/12