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PROOF OF INSURANCE (2015) CLOSEDOP ID: MD CERTIFICATE OF LIABILITY INSURANCE °1205/2014Y' 12/0512014 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 CONTAC ACEC /MARSH NAME. PHONE FAX 701 Market St., Ste. 1100 l�Cti _Q_ExtJ� .. �.. h! . ? L.... . ...... . ........ St Louis, MO 63101 r MAtL Jeff B. Connelly t c— _ .. _.. ....A,. ........................ A ORES w, r„ r „. PHOEN -2 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. ................ .. _...... _....._ „_ �.w.. 9NSR TYPE OF INSURANCE POLICY NUMBERMM/DO(YYYX MVDD/11YYY LIMITS GENERAL UABIUTY EACH OCCURRENCE $ 2,000,00 COMMERCIAL GENERAL LIABILITY X 84SBWPB1209 0512012014 05120/2015 CWW PRE ISE"S. EEa oocnacronro $ 2,000,00( CLA LL CLAIMS-MADE MED EXP (Any one person) ..... 10,00( PERSONAL & ADV INJURY $ 2,000,00 PRORLIABILITY EXCLUDED GENE......._. ..............REGAT.�.......... 0,00( RAL AGGR_ $ 4,000,00 E'N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 4,000,00 POLICY. X Pk�O. LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 2,000,00 (Ea accident) ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ _...... SCHEDULED AUTOS PROPERTY DA GE ......................... r....$........-------- ...--- __.................... A X HIREDAUTOS 84SBWPB1209 05/20/2014 05/20/2015 (PERACCIDENT ............................_. XNON -OWNED AUTOS W........................................$. . ..... . _--- _.------- ....-- ........a�..... UMBRELLA LIAR I OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X WCSTATU- OTH - -- AND EMPLOYERS' LIABILITY Y / N T.QRY..L.IMITS _ Ef _ B OFFICER/MEMBER MEMBB EXCLUDED? ECUTIVE ❑ N / A 84WEGBK9922 05/2012014 05/2012015 E L EACH ACCIDENT $ 1,000,00 HR) .L. DISEASE - EA EMPLOYEE $ 1,000,00 If yes, describe under DESCRIPTION OF OPERATIONS below E,L, DISEASE - POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Re: Park Vista Senior Housing Roof Repair Project. When required by written The City E1 Segundo, its contract: of officials, and employees are named as additional insureds for General Liability on a primary and non - contributory basis. Waiver of Subrogation is included in favor of additional insured. CE'RTIFIC'ATE HOLDER CANCELLATION yJ)bTYO E SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of El Segundo *,( ,v�� ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street *” '" El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE '� � � � n © 1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD ---o"N OP ID: MD '4`°R°° CERTIFICATE OF LIABILITY INSURANCE °ATE(MM/20, "' 12/0512014 i 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 endorsement(s). PRODUCER CONTACT _ACEC/MARSH PHON E t a 701 Market St,Ste.1100 I (N 9,No,:......... St Louis,MO 63101 Jeff B.Connelly rRODU CUSTOMER ID#.PHOEN-2 m..... . INSURERS AFFORDING CQVERAGE NAIC# Ventura .C. INSURERB: _. .. INSURED Phoenix Civil Engineering Inc _ � 4 4532 Telephone Rd.,Ste 113 INSUr�Ra:Travelers Casual a � 9 ... nd Sure 311 A 93003 INSURER c: � INSURER D .....,-, ....... ______________,.,. ._._ ,.,.,.._ INSURER E: INSURER F: COVERAGE'S 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 INSURANCE ^^^^-----POLICY NUMBER ^^^ ........'... MM DD/YYVY MtlMM1 DY Y LIMITS GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR MAD"�'L""7" "II'wk "I"L .... ---- -- COMMERCIAL GENERAL LIABILITY �j{Eq, �c�{,I�a C�cn�rGeracs] $ ED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'LAC"aGREGAT'E:LIMIT APPLIES PE: - ��-�--�-- � R: PRODUCTS-COMP/OPAGG $ FRO- POLGC"Y X LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ............................................ ....... BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ W SCHEDULED H RED AUTOS AUTOS PROPERTY DAMAGE $ PER ACCIDENT) NON-OWNEDAUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ .......... .-.............. ........m.,,........,...,,,,,,_,,,,,,,........,,.,,...-„................................. EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN- T�?�?�X..I.J .I.T m.....,.� R -...�. ............................ O ANY ICdEER MEMBB HR)EXCLUDED?PROPRIETOR/PARTNER/EXECUTIVE t._�l N/A E L DISEASE.... If yes,describe under ....._-................................ .. ... ................ . ......... DESCRIPTION OF OPERATIONS below E .DISEASE-POLICY LIMIT $ A Professional 105775627 05/20/2014 05/20/2015 Claim 1,000,00 Liability DEDUCTIBLE$2,000 1 Aggregate 2,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) Re: Park Vista Senior Housing Roof Repair Project. CERTIFICATE HOLDER V CANCELLATION �4TYOF,6 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo V A wry, ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street " AUTHORIZED REPRESENTATIVE El Segundo,CA 90245 n ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD ­,� 0 CERTIFICATE OF LIABILITY INSURANCE M/DD/YYYY) 12//17/217/2014 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 endorsement(s). PRODUCER CONTACT NAtlTt Sponsored Programs PHONE _........... Marsh S p 4 800 338-1391 a service of Seabury & Smith, Inc„ 4AL I°................... _.. m LN N(s),888 „-_621 3173 _.." E MAIL 701 Market Street, Ste. 1100 ADDRESS:acecclientrequest @marsh.com ......... ......... . St. Louis MO 63101 INSURERJS)AFFORDINGCOVERAGE NAIC# INSURER A .Phoenix CivilEngineering �.R�... . .. ......................____� m....... _.. ._..., INSURED INSURER B:Sentinel Ins Co 11000 INSURER C'. 4532 Telephone Rd., Ste 113 INSURER D., Ventura, CA 93003 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 BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE----�.,--_--,�.�; 6�L B'BIY POLICY NUMBER Md47LICY E PA lffexp.. .. .. .... -------- ---- -- -----------------..----.... LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS-MADE p OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ POLL Y' .... PLOT- LOC l $ AUTOMOBILE LIABILITY !Fw =son)ANY AUTO BODILY IN $ __......,m............ .......... .. . ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS ... ... NON-OWNED 7~aElt ' HIRED AUTOS AUTOS Per aoc'eq $ ... UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE. AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION Y 84WEGBK9922 '.05/20/20141 05/20/201.5 WCSTATU- "OTH- AND EMPLOYERS'LIABILITY Y/N X.. T,0Ry.L.1M1TS,.. ER_- ANYPROPRIETOR/PARTNER/EXECUTIVE E.L,EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N/A — -------- — If andatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E,LDISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Re: Park Vista Senior Housing Roof Repair Project Waiver of Subrogation is included when required by written contract. SS 04 38 09 09 CERTIFICATE HOLDER 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. City of El Segundo 350 Main Street AUTHORIZED_REPRESENTATIVE El Segundo, CA 90245 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ACS CERTIFICATE OF LIABILITY INSURANCE M°°°,YY ` 12//22/222/2014 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 endorsement(s). PRODUCER CONTAtT NAME„ Marsh Sponsored Programs CA PHONE AN ,Ext) e000C1 egzt e91m arsYl,c M C.Nol:�888 621-3173 701 Market Street, Ste. 1100 ADORI=SS, quest @m om P g a service of Seabur & Smith, Inc. St. Louis MO 63101 NSURERS)AFFORDINGCOVERAGE NAIC# INSURED................,_ _,__...--- INSURER A:Hartford Fire Ins.Co. 19682 INSURER B Phoenix Civil Engineering Inc INSURER C: 4532 Telephone Rd., Ste 113 INSURE.R..D...i............................................................................-..... ......... .......... -..-.............. �. Ventura, CA 93003 INSURER E: INSURER F: COVERAGES CE'RTIFICAT'E 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. ILN.TR' TYPE OF INSURANCE............. AlbbL"6k# Y...... _.mm..,�.� .. . .....pald�y.. �,-.. .-F_Cf �. __._.,�,..,�.. ................... ....�.- _ POLICY NUMBER MWDDIYYYY) IMMIDDfYYYYI LIMITS A GENERAL LIABILITY Y Y 84SBWPB1209 05/20/2094 05/20/2015 EACHOCCURRENCE $2,000,000 CLAIMS-MADE PROF.LIABILITY EXCLUDED 2 . L MFPG91Sf (e rcmurraailpe) $ ,0 0 0 000 , X...COMMERCIAL GENERAL �I OCCUR .,.... -- - ...- .. ED EXP(Any one person) $10 000 ......... ....... --- _, ....__...............�,._,.. _ PERSONAL&ADV INJURY $2,000,000 ._,.. ... .� GENERAL ......................... _.........,,�. AGGREGATE $4,000,000 .................... GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG...$4 000,000 POLICY X]Ma. 7,LOC $ AUTOMOBILE LIABILITY COMBINIEnt,6i I LIMIT — 1 . __.. ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per $ AUTOS AUTOS mm www HIRED AUTOS NON-OWNED PpdORMWTy A_MA.4'E $ AUTOS der ps, dxa k)..........._ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DE RETENTION$ $ WORKERS COMPENSATION WCSTATU- OTH- AND EMPLOYERS'LIABILITY Y/N .....-L.CBY..LI�M,l74 _...... ........ ANY PROPRIETOR/PARTNER/EXECUTIVE E..L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA - ......El ..-..--. ...., ...,............ .....--. (Mandatory in NH) E,L..DISEASE-EA EMPLOYEE $ If yes,describe under ... ..._.................................... DESCRIPTION OF OPERATIONS below E .DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Re: Park Vista Senior Housing Roof Repair Project - The City, its officials, and employees are i_nlcuded as addit-i.onal insured when required by written contract. Waiver of subrogation is included for additional. insured when required by written contract. 30 day notice of cancellation for certificate holder per policy endorsement. SSO4380909, GLAI, SS41700611 CERTIFICATE(HOLDER 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. City of El Segundo 350 Main Street AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 C ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 84SBWPB1209 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION /1 NV/ This endorsement modifies insurance provided under the following: 'V BUSINESS LIABILITY COVERAGE FORM l txl ` SCHEDULE r5V Name Of Additional Insured Person(s) Or Organization(s): Location(s)Of Covered Operations City of El Segundo, its officials, and employees. Park Vista Senior housing Roof Repair Project Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section C.—Who Is An Insured is amended to B.With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for"bodily injury", "property damage"or"personal and advertising injury" This insurance does not apply to"bodily injury"or caused, in whole or in part, by: "property damage"occurring after: 1. Your acts or omissions; or 1.All work, including materials, parts or 2. The acts or omissions of those acting on your equipment furnished in connection with such behalf; work, on the project(other than service, maintenance or repairs)to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. 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. Form SS 41 70 06 11 Page 1 of 1 Process Date: 12/22/2014 Policy Expiration Date: 05/20/2015 02011, The Hartford (Includes copyrighted material of Insurance Services Office, Inc., with its permission) it THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. HIRED AUTO AND NON-OWNED AUTO This endorsement modifies insurance provided under the following: BUSINESS LIABILITY COVERAGE FORM This coverage is subject to all provisions in the moved from the place where they are BUSINESS LIABILITY COVERAGE FORM not accepted by the "insured"for movement into expressly modified herein: or onto the covered "auto"; or c. After the "pollutants" or any property in A. Amended Coverage: which the "pollutants" are contained are Coverage is extended to "bodily injury" and moved from the covered "auto" to the place where they are finally delivered, disposed of "property damage" arising out of the use of a "hired or abandoned finally the"insured". auto"and "non-owned auto". B. Paragraph B. EXCLUSIONS is amended as Paragraph a. above does not apply to fuels, lubricants, fluids, exhaust gases or other follows: similar "pollutants" that are needed for or 1. Exclusion g. Aircraft, Auto or Watercraft does result from the normal electrical, hydraulic not apply to a "hired auto" or a "non-owned or mechanical functioning of the covered auto". "auto"or its parts, if: 2. Exclusion e. Employers Liability does not (1) The "pollutants" escape, seep, migrate, apply to "bodily injury" to domestic "employees" or are discharged or released directly not entitled to workers' compensation benefits from an "auto" part designed by its or to liability assumed by the "insured" under an manufacturer to hold, store, receive, or "insured contract". dispose of such "pollutants"; and 3. Exclusion f. Pollution is replaced by the (2) The "bodily injury" and "property following: damage" does not arise out of the "Bodily injury" or "property damage" arising out operation of any equipment listed in of the actual, alleged or threatened discharge, paragraphs 15.b. and 15.c. of the dispersal, seepage, migration, release or definition of"mobile equipment". escape of"pollutants": Paragraphs b. and c. above do not apply to a. That are, or that are contained in any "accidents" that occur away from premises property that is: owned by or rented to an "insured" with (1) Being transported or towed by, handled, respect to "pollutants" not in or upon a or handled for movement into, onto or covered "auto" if: from, the covered "auto"; (1) The "pollutants" or any property in (2) Otherwise in the course of transit by or which the "pollutants" are contained are on behalf of the"insured'; or upset, overturned or damaged as a result of the maintenance or use of a (3) Being stored, disposed of, treated or covered "auto'; and processed in or upon the covered "auto". b. Before the "pollutants" or any property in which the "pollutants" are contained are Form SS 04 38 09 09 Page 1 of 3 C 2009, The Hartford (Includes copyrighted material of ISO Properties, Inc.,with its permission) (2) The discharge, dispersal, seepage, company)for an "auto"owned by him or her migration, release or escape of the or a member of his or her household. "pollutants" is caused directly by such d. Anyone liable for the conduct of an "insured" upset, overturn or damage as a result of described above but only to the extent of that the maintenance or use of a covered liability.y� D. With respect to the operation of a "hired auto" and 4. With respect to this coverage, the following "non-owned auto", the following additional additional exclusions apply: conditions apply: a. Fellow employee 1. OTHER INSURANCE Coverage does not apply to "bodily injury"to a. Except for any liability assumed under an any fellow "employee" of the "insured" "insured contract"the insurance provided by arising out of the operation of an "auto" this Coverage Form is excess over any owned by the "insured" in the course of the other collectible insurance. fellow"employee's"employment. b. Care, custody or control However, if your business is the selling, servicing, repairing, parking or storage of Coverage does not apply to "property "autos", the insurance provided by this damage" involving property owned or endorsement is primary when covered transported by the "insured" or in the "bodily injury" or "property damage" arises "insured's"care, custody or control. out of the operation of a customer's "auto" C. With respect to "hired auto" and "non-owned auto" by you or your"employee". coverage, Paragraph C. WHO IS AN INSURED is b. When this Coverage Form and any other deleted and replaced by the following: Coverage Form or policy covers on the The following are"insureds": same basis, either excess or primary, we will pay only our share. Our share is the a. You. proportion that the Limit of Insurance of our b. Your "employee" while using with your Coverage Form bears to the total of the permission: limits of all the Coverage Forms and policies (1) An "auto"you hire or borrow; or covering on the same basis. (2) An "auto" you don't own, hire or borrow in 2. TWO OR MORE COVERAGE FORMS OR your business or personal affairs; or POLICIES ISSUED BY US (3) An "auto" hired or rented by your If the Coverage Form and any other Coverage "employee" on your behalf and at your Form or policy issued to you by us or any direction. company affiliated with us apply to the same c. Anyone else while using a "hired auto" or "non- "accident", the aggregate maximum Limit of owned auto"with your permission except: Insurance under all the Coverage Forms or policies shall not exceed the highest applicable (1) The owner or anyone else from whom you Limit of Insurance under any one Coverage hire or borrow an "auto". Form or policy. This condition does not apply to (2) Someone using an auto while he or she is any Coverage Form or policy issued by us or an working in a business of selling, servicing, affiliated company specifically to apply as repairing, parking or storing "autos" unless excess insurance over this Coverage Form. that business is yours. E. The following definitions are added: (3) Anyone other than your "employees", G. LIABILITY AND MEDICAL EXPENSES partners (if you are a partnership), members DEFINITIONS: (if you are a limited liability company), or a 1. "Hired auto" means any "auto" you lease, lessee or borrower or any of their "employees", while moving property to or hire, rent or borrow. This does not include from an"auto". from any of your""employees", r borrow , yourpartne s (4) A partner (if you are a partnership), or a (if you are a partnership), members (if you member (if you are a limited liability are a limited liability company), Page 2 of 3 Form SS 04 38 09 09 or your "executive officers" or members of their households. This does not include a long-term leased "auto" that you insure as an owned "auto" under any other auto liability insurance policy or a temporary substitute for an "auto" you own that is out of service because of its breakdown, repair, servicing or destruction. 2. "Non-owned auto " means any "auto" you do not own, lease, hire, rent or borrow which is used in connection with your business. This includes: a. "Autos" owned by your "employees" your partners (if you are a partnership), members (if you are a limited liability company), or your "executive officers", or members of their households, but only while used in your business or your personal affairs. b. Customer's "auto" that is in your care, custody or control for service. Form SS 04 38 09 09 Page 3 of 3 411�� THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ✓rr WORKERS' COMPENSATION BROAD FORM ENDORSEMENT EXTENDED OPTIONS ' N Policy Number: 84 WEG BK9922 Endorsement Number: L' Effective Date: 05/20/14 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PHOENIX CIVIL ENGINEERING, INC 4532 TELEPHONE ROAD STE, 113 VENTURA, CA 93003 Section I of this endorsement expands coverage provided under WC 00 00 00. Section II of this endorsement provides additional coverage usually only provided by endorsement. Section III of this endorsement is a Schedule of Covered States. You may use the index to locate these coverage features quickly: INDEX, SUBJECT PAGE SUBJECT PAGE SECTION 1 2 B. Part One Does Not Apply 3 PARTS ONE and TWO 2 C. Application of Coverage 3 01 We Will Also Pay 2 D. Additional Exclusions 3 PART-THREE 2 E. West Virginia 3 02 How This Insurance Works 2 EXTENDED OPTIONS 4 PART-SIX 2 01 Employers' Liability Insurance 4 03 Transfer of Your Rights and Duties 2 02 Unintentional Failure to Disclose 4 04 Liberalization 2 Hazards SECTION II 2 03 Waiver of Our Right to Recover from 4 VOLUNTARY COMPENSATION INSURANCE 2 Others 05 Voluntary Compensation Insurance 04 Foreign Voluntary Compensation 4 A. How This Insurance Applies 2 A. How This Reimbursement Applies 4 B. We Will Pay 2 B. We Will Reimburse 4 C. Exclusions 3 C. Exclusions 4 D. Before We Pay 3 D. Before We Pay 5 E. Recovery From Others 3 E. Recovery From Others 5 F. Employers' Liability Insurance 3 F. Reimbursement For Actual Loss 5 EMPLOYERS'LIABILITY STOP GAP 3 Sustained ENDORSEMENT 3 G. Repatriation 5 06 Employers' Liability Stop Gap H. Endemic Disease 5 Coverage 3 05 Longshore and Harbor Workers' 5 A. Stop Gap Coverage Limited to Compensation Act Coverage Montana, North Dakota, Ohio, 3 Endorsement Washington, West Virginia and SECTION III 6 Wyoming 01 Schedule of Covered States 6 Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 1 of 6 Process Date: 02/15/14 Policy Expiration Date: 05/20/15 ©2000, The Hartford SECTION I PARTS ONE and TWO PART THREE 1. WE WILL ALSO PAY 2. How This Insurance Applies D. We Will Also Pay of Part One (WORKERS' Paragraph 4. of A. How This Insurance Applies COMPENSATION INSURANCE); and of Part 3 (Other States Insurance) is replaced by E. We Will Also Pay of Part Two (EMPLOYERS' the following: LIABILITY INSURANCE) is replaced by the 4. If you have work on the effective date of this following: policy in any state not listed in Item 3.A. of the We Will Also Pay Information Page, coverage will not be afforded for that state unless we are notified We will also pay these costs, in addition to within sixty days. other amounts payable under this insurance, as part of any claim, proceeding, or suit we PART SIX defend: 1. reasonable expenses incurred at our 3. Transfer Of Your Rights and Duties request, INCLUDING loss of earnings; C. Transfer Of Your Rights and Duties of Part 6 2. premiums for bonds to release (Conditions) is replaced by the following: attachments and for appeal bonds in bond Your rights or duties under this policy may not amounts up to the limit of our liability be transferred without our written consent. under this insurance; If you die and we receive notice within sixty 3. litigation costs taxed against you; days after your death, we will cover your legal 4. interest on a judgment as required by law representative as insured. until we offer the amount due under this 4. Liberalization law; and If we adopt a change in this form that would 5. expenses we incur. broaden the coverage of this form without extra charge, the broader coverage will apply to this policy. It will apply when the change becomes effective in your state. SECTION II VOLUNTARY COMPENSATION AND EMPLOYERS' 3. The bodily injury must occur in the United LIABILITY COVERAGE States of America, its territories or 5. Voluntary Compensation Insurance possessions, or Canada, and may occur elsewhere if the employee is a United A. How This Insurance Applies States or Canadian citizen, or otherwise This insurance applies to bodily injury by legal resident, and legally employed, in the accident or bodily injury by disease. Bodily United States or Canada and temporarily injury includes resulting death. away from those places. 1. The bodily injury must be sustained by any 4. Bodily injury by accident must occur officer or employee not subject to the during the policy period. workers' compensation law of any state 5. Bodily injury by disease must be caused shown in Item 3.A. of the Information or aggravated by the conditions of the Page. 2. The bodily injury must arise out of and in the course of employment or incidental to work in a state shown in Item 3.A. of the Information Page. Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 2 of 6 officer's or employee's employment. The If the persons entitled to the benefits of this officer's or employee's last day of last insurance make a recovery from others, they exposure to the conditions causing or must reimburse us for the benefits we paid aggravating such bodily injury by disease them. must occur during the policy period. F. Employers' Liability Insurance B. We Will Pay Part Two (Employers' Liability Insurance) We will pay an amount equal to the benefits applies to bodily injury covered by this that would be required of you as if you and endorsement as though the State of your employees were subject to the workers' Employment was shown in Item 3.A. of the compensation law of any state shown in Item Information Page. 3.A. of the Information Page. We will pay This provision 5. does not apply in New Jersey or those amounts to the persons who would be Wisconsin. entitled to them under the law. C. Exclusion EMPLOYERS'LIABILITY STOP GAP COVERAGE This insurance does not cover: 6. Employers'Liability Stop Gap Coverage A. This coverage only applies in Montana, North 1. any obligation imposed by workers' Dakota, Ohio, Washington, West Virginia and compensation or occupational disease law Wyoming. or any similar law. B. Part One (Workers' Compensation Insurance) 2. bodily injury intentionally caused or does not apply to work in states shown in aggravated by you. Paragraph A above. 3. officers or employees who have elected C. Part Two (Employers' Liability Insurance) not to be subject to the state workers' applies in the states, shown in Paragraph A., compensation law. as though they were shown in Item 3.A. of the 4. partners or sole proprietors not covered Information Page. under the Standard Sole Proprietors, D. Part Two, Section C. Exclusions is changed Partners, Officers and Others Coverage by adding these exclusions. Endorsement. D. Before We Pay This insurance does not cover; 5. bodily injury intentionally caused or Before pay benefits to the persons entitled aggravated by you or in Ohio bodily injury to them,, they must: resulting from an act which is determined 1. Release you and us, in writing, of all by an Ohio court of law to have been responsibility for the injury or death. committed by you with the belief than an 2. Transfer to us their right to recover from injury is substantially certain to occur. others who may be responsible for the However, the cost of defending such injury or death. claims or suits in Ohio is covered. 3. Cooperate with us and do everything 13. bodily injury sustained by any member of necessary to enable us to enforce the right the flying crew of any aircraft. to recover from others. 14. any claim for bodily injury with respect to If the persons entitled to the benefits of this which you are deprived of any defense or insurance fail to do those things, our duty to defenses or are otherwise subject to pay ends at once. If they claim damages from penalty because of default in premium you or from us for the injury or death, our duty under the provisions of the workers' to pay ends at once. compensation law or laws of a state E. Recovery From Others shown in Paragraph A. E. This insurance applies to damages for which If we make a recovery from others, we will you are liable under West Virginia Code Annot. keep an amount equal to our expenses of S23-4-2. recovery and the benefits we paid. We will pay the balance to the persons entitled to it. Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 3 of 6 EXTENDED OPTIONS 1. Employers' Liability Insurance 4. Foreign Voluntary Compensation and Item 3.13. of the Information Page is replaced by Employers'Liability Reimbursement the following: A. How This Reimbursement Applies B. Employers'Liability Insurance: This reimbursement provision applies to bodily 1. Part Two of the policy applies to work in injury by accident or bodily injury by disease. each state listed in Item 3.A. Bodily injury includes resulting death. 1. The bodily injury must be sustained by an The Limits of Liability under Part Two are officer or employee. the higher of: 2. The bodily injury must occur in the course of employment necessary or incidental to Bodily Injury work in a country not listed in Exclusion by Accident $500,000 Each Accident C.1. of this provision. 3. Bodily injury by accident must occur Bodily Injury during the policy period. by Disease $500,000 Policy Limit 4. Bodily injury by disease must be caused or aggravated by the conditions of your Bodily Injury employment. The officer or employee's by Disease $500,000 Each Employee last exposure to those conditions of your employment must occur during the policy OR period. B. We Will Reimburse 2. The amount shown in the Information We will reimburse you for all amounts paid by Page. you whether such amounts are: This provision 1 of EXTENDED OPTIONS does not 1. voluntary payments for the benefits that apply in New York because the Limits Of Our would be required of you if you and your Liability are unlimited. officers or employees were subject to any In this provision the limits are changed from workers' compensation law of the state of $500,000 to $1,000,000 in California. hire of the individual employee. 2. Unintentional Failure to Disclose Hazards 2. sums to which Part Two (Employers' If you unintentionally should fail to disclose all Liability Insurance) would apply if the existing hazards at the inception date of your Country of Employment were shown in Item 3.A. of the Information Page. policy, we shall not deny coverage under this policy because of such failure. C. Exclusions 3. Waiver of Our Right To Recover From Others This insurance does not cover: A. We have the right to recover our payments 1. any occurrences in the United States, from anyone liable for an injury covered by this Canada, and any country or jurisdiction policy. We will not enforce our right against which is the subject of trade or economic any person or organization for whom you sanctions imposed by the laws or perform work under a written contract that regulations of the United States of requires you to obtain this agreement from us. America in effect as of the inception date This agreement shall not operate directly or of this policy. indirectly to benefit anyone not named in the 2. any obligation imposed by a workers' agreement. compensation or occupational disease B. This provision 3. does not apply in the states law, or similar law. of Pennsylvania and Utah. 1 bodily injury intentionally caused or aggravated by you. Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 4 of 6 4. liability for any consequence, whether of America necessarily incurred as a direct direct or indirect, of war, invasion, act of result of bodily injury. Foreign enemy, hostilities (whether war be Our reimbursement shall be limited as follows: declared or not), civil war, rebellion, revolution, insurrection or military or 1, to the amount by which such expenses usurped power. No endorsement now or exceed the normal cost of returning the subsequently attached to this policy shall officer or employee if in good health, or be construed as overriding or waiving this 2. in the event of death, to the amount by limitation unless specific reference is which such expenses exceed the normal made thereto. cost of returning the officer or employee if D. Before We Pay alive and in good health. Before we reimburse you for the benefits to the In no event shall our reimbursement exceed persons entitled to them, you must have them: the bodily injury by accident limit shown in 1. release you and us, in writing, of all Item 3.B. of the Information Page as respects any one such officer or employee whether responsibility for the injury or death, dead or alive. 2. transfer to us their right to recover from H. Endemic Disease others who may be responsible for their injury or death, The word "disease" includes any endemic diseases. 3. cooperate with us and do everything necessary to enable us to enforce the right The coverage applies as if endemic diseases to recover from others. were included in the provisions of the workers' If the persons entitled to the benefits compensation law. p paid fail to do these things, our duty to reimburse ends 5. Longshore and Harbor Workers' Compensation at once. If they claim damages from us for the Act Coverage injury or death, our duty to reimburse ends at General Section C. Workers' Compensation once. Law is replaced by the following: E. Recovery From Others C. Workers'Compensation Law If we make a recovery from others, we will Workers' Compensation Law means the keep an amount equal to our expenses of workers or workers' compensation law and recovery and the benefits we reimbursed. We occupational disease law of each state or will pay the balance to the persons entitled to territory named in Item 3.A. of the Information it. If persons entitled to the benefits make a Page and the Longshore and Harbor Workers' recovery from others, they must repay us for Compensation Act (33 USC Sections 901- the amounts that we have reimbursed you. 950). It includes any amendments to those F. Reimbursement for Actual Loss Sustained laws that are in effect during the policy period. It does not include any other federal workers This endorsement provides only for or workers' compensation law, other federal reimbursement for the loss you actually occupational disease law or the provisions of sustain. In order for you to recover loss or any law that provide nonoccupational disability expenses under this reimbursement you must: benefits. 1. actually sustain and pay the loss or Part Two (Employers' Liability Insurance), C. expense in money after trial, or Exclusions, exclusion 8, does not apply to 2. secure our consent for the payment of the work subject to the Longshore and Harbor loss or expense. Workers' Compensation Act. G. Repatriation This coverage does not apply to work subject Our reimbursement includes the additional to the Defense Base Act, the Outer expenses of repatriation to the United States Continental Shelf Lands Act, or the Nonappropriated Fund Instrumentalities Act. Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 5 of 6 SECTION III 1. SCHEDULE OF COVERED STATES B. If a state, shown in Item 3.A. of the Information A. This endorsement only applies in the states Page, approves this endorsement after the listed in this Schedule of Covered States. effective date of this policy, this endorsement will apply to this policy. The coverage will apply in the new state on the effective date of the state approval. C. Schedule of Covered States: CA Countersigned by Authorized Representative Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 6 of 6 Shilling, Mona From: Hegvold, Julie Sent: Monday, December 29, 2014 4:18 PM To: Shilling, Mona Cc: Katsouleas, Stephanie; Garcia, Angelina Subject: Phoenix Engineering - Park Vista Senior Housing Project Attachments: Phoenix Engng - Park Vista. CM.pdf; PHOENIX CIVIL-Forms and Endorsements.pdf; Phoenix. Declaration Page Corp Officers signing authority.pdf; Phoenix Ins cert COI.pdf; Phoenix Ins cert.pdf Hi Mona, Attached for finalization is a design contract and applicable insurance certs with Phoenix Civil Engineering for the Park Vista Senior Housing Project. Consultant contact: Phoenix Civil Engineering Jon Turner iturner @phoenixcivil.com I will drop off the hard copies to your office today. Please let me know if you need anything additionally, Thank you, Julie Hegvold,Management Analyst CITY OF EL SEGUNDO I Public Works Dept. 350 Main Street,Fl Segundo,CA 90245 Tel.(3M)524-2365 1 jhe vold@elsegundo.org CITY'1 A,.I..@I.,IS CLOSED ON.F'.RID.AYS ........................... _. From: Garcia, Angelina Sent: Monday, December 29, 2014 3:39 PM To: Katsouleas, Stephanie Subject: RE: Park Vista Senior Housing Project Yes. Angelina Garcia From: Katsouleas, Stephanie Sent: Monday, December 29, 2014 3:39 PM To: Garcia, Angelina Subject: RE: Park Vista Senior Housing Project No problem. So insurance is accepted? 1