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PROOF OF INSURANCE (2013) CLOSEDSANDIVI-1 OP ID: SN ATE (MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 17 03/20/13 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 Phone: 310-832-1131 %NAul4k^�' m Modern Insurance, Inc. Fax: - PHONE—­­­­_ ... . . ............. . Arroyo Insurance Services 333 W. 5th St., P.O. Box 1031 E-MAIL San Pedro, CA 90733-1031 DDRESSt -------- Thomas P. Higgins, CIC, CRM ................. . .. ...... —.—_____INSURER(S At ING COVERAGE NAIC # L .. ...... . ............. nyinsurance Company Cq!9ii �INSURED Sandmaster Inc. INSURER B: DBA:SandmasterSandblasting X 6924 Remmet Avenue ........... . . . .... Canoga Park,, CA 91303 JNSYM!! 2: .. . .. ....... ..... . ........... . 50,000 INSURER E . . ...... . ..... . . CLAIMS-MADE OCCUR 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, P OU CY #VF_ POL_1C_YEAV LTR TYPE OF INSURANCE POLICY NUMBER (MMJDDNYYY) [IMM/DD[YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X' COMMERCIAL GENERAL LIABILITY X X MP4031195 10/30112 10/30/13 " DAMAIF TOW- NTEO- R!19�ql,Wp (94,M1 ! ure-q591-- 50,000 CLAIMS-MADE OCCUR MED EXP (Any one person) $ 51000 PERSONAL &_!!Ry_INJURY $ 1,000,000 _ GENERAL AGGREGATE 1 $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: COMP /OP AGG $ 2,000,000 POLICY1 ....... I M F-] LOC $ ....... AUTOMOBILE LIABILITY COMMNED SING. E LIMIT ANY AUTO BODILY INJURY (Per person) $ ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON-OWNED PROPERTY DAMAGE . ...... ... $ S HIRED AUTO AUTOS UMBRELLA LIAB _.EACH OCCURRENCE $ ...HOCCUR EXC E SS LIAB CLAIMS-MADE .... . .. ......... AGGRL EGATE $ OED D RETENTION$ I$ WORKERS COMPENSATION I.T.WCYSITATIU OTH- AND EMPLOYERS' LIABILITY Y f N, �,08, IM TJ__J_E.8_ . . .. ................. . ANY PROPRIETOR/PARTNER/EXECUTIVE [:] OFFICERIMEMBER EXCLUDED? NIA E L EACH ACCIDENT . . ... . .............. $ (Mandatory in NH) DISEASE EA - EA EMPLOYEi $ If yes describe under _E�L. DESCRIPTION RIPTION OF OPERATIONS E,L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Certificate Holder is Additional insured per form CG2010 7/04 and CG2037 7/04 attached, including primary and non-contributory wording, but only as respects to the insureds operations as covered by this policy. CITEES2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTIgE WILL BE DELIVERED IN City of El Segundo ACCORDA 1072 Officials and E JNCt WITH THE POLICY PROVIS 71 Employees 150 Illinois Street "J, El Segundo, CA 90245 �46RJZE V4 t el 0188' !010X,�96ORD CORPORATION. All rights reserved, 4 ACORD 25 (2010/05) The ACORD name rd logo are registered mark '. ACORD COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(*) , - . Or Organization(s): Location And Description Of Completed Opera- tions City of El Segundo, its officials and employees Sandblasting work on Acacia Street City Pool, 150 Illinois Street Acacia Avenue, El Segundo El Segundo, CA 90245 Information required to complete this Schedule if not shown above will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products - completed operations hazard ". O' CG 20 37 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 13 COMMERCIAL GENERAL LIABILITY CG 2010 07 04 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 SCHEDULE Name Of Additional Insured Person(s) Or O anizadon s : Locations Of Covered Op2rations City of El Segundo, its officials and employees Sandblasting work on Acacia Street City 150 Illinois Street Pool, Acacia Avenue, El Segundo El Segundo, CA 90245 . "It is further agreed that this insurance shall be primary and non-contributory, but only in the event of a named insured's sole negligence. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but 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; in the performance of your ongoing operations for the additional insured(s) at the location(s) desig- nated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of 'your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization oth- er than another contractor or subcontractor.,,. engaged in performing operations for a princi- i y pal as a part of the same project. j-1 i 4 J x CO 2010 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 ❑ O CITEES2 City of El 86+ undo N f\ officials srld Employees 160 Illinois Strwt " E! SegMdo, CA 20213 ' mHouLD my of ME ABOM DESCRIBED POLLS 9E ONAMLLED WORE i!E EXPRtATION DATE 7HERBW, MOT10E :PILL BE DELMEMD IN AccoRgimm wam THE PouCy FROhd' MNS. AUTHK dZED Ia9'n6UNTATW Thomm P. Hlgglns, CIC, CRM 01MIS-2010 Ada CORPORATION. AS nIghU reserved. ACDfW 25 (201=51 The ACORD nallls and Ioo4 are mgisftrod marks of ACORD CERTHOLDER COPY SG P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 06 -04 -2012 CITY OF EL SEGUNDO, ITS OFFICIALS SG AND EMPLOYEES 150 ILLINOIS ST EL SEGUNDO CA 90245 -4311 GROUP: POLICY NUMBER: 1635460 -2012 CERTIFICATE ID: 94 CERTIFICATE EXPIRES: 03-17 -2013 05- 17- 2012/05 -17 -2013 This is to certify that we have issued a 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 be 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. Nmo, f Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #1600 - OSTOICH, ANTHONY SEC - EXCLUDED. ENDORSEMENT #1600 - ZAMISKA, JOSEPH PRES, TRES - EXCLUDED. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 05 -17 -2004 ISW' , ATTACHED TO AND FORMS A PART OF THIS POLICY._ „} ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2012 -08 -04 IS. ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME:,iV? CITY OF EL SEGUNDO, ITS OFFICIALS EMPLOYER SANOMASTER,INC. SG 18410 SAN FERNANDO MISSION BLVD PORTER RANCH CA 91326 [B18,SCj PRINTED : 05-04 -2012 (REV.8-2010)