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PROOF OF INSURANCE (2014) CLOSEDDATE (MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 04/18/2013 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 policll(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($). PRODUCER CONTACT NAME: _ PATRICK INSURANCE SERVICES 14) 779 -6903 2 0 N. HA COCK ST SUITE 210 E-M APL p incree sbC bel.ne t ADDRESS: _ ANAHEIM HILLS, CA 92807 INSURER(S)AFFORDINGCOVERAGE NAIC# INSURERA: MT. HAWLEY INSURANCE COMPANY 37974 INSURED INSURER B: GOLDEN EAGLE INSURANCE CORPORATIO 10836 BIG WEST CONSTRUCTION 15331 NORMANDIE Irvine COVERAGES CA 92604 CERTIFICATE NUMBER: INSURER C: INSURER D r. 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. POLICY EFF POLICY EXP,,,,,, LTR TYPE OF INSURANCE INSR V4VD POLICY NUMBER. MM /DD/XYYY MMIDDNYYYI LIMITS A GENERAL LIABILITY X MGLO178121 04/30/2013 04/30/2014 EACH OCCURRENCE $ 1,000,000 < X COMMERCIAL GENERAL LIABILITY DAMAGE...Y(� I��N"`eiJ ,,,,, PREMISES (Ea cscC�ggrq¢tce� $ ,,,,, ,,, m.� CLAIMS -MADE X ] OCCUR MED EXP (Any one�erson) mm $ EXCLUDED PERSONAL&ADVINJURY ,,,, •�.. $ 1,000,000- .,.. ... GENERAL AGGREGATE $ 2,000,000 — „ GENT AGGREGATE LIMIT APPLIES PER PRODUCTS COMP /OP AGG $ 2,000,000 POLICY X P"Coi LOC $ B AUTOMOBILE LIABILITY X 102 -CE- 226519 -1 - 07/11/201207/11 /2013 COMBINED SI LELIMIT 1,000,000 ccidenll $ X ANY AUTO BODILY INJURY (Per person) . �, $ ALL OWNED SCHEDULED : AUTOS .� � AUTOS BODILY INJURY Per accident ( ) ......... ....... $ X NON -OWNED HIRED AUTOS X AUTOS PROPERTY DAMAP (Per acc,denq $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N T,Q.SY L1mT3,,., „w ER, °.''..,.° ANY PROPRIETOR /PARTNER /EXECUTIVE E L EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA T - (Mandatory in NH) E L DISEASE -EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E L DISEASE -POLICY LIMIT $ E, DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required THE CITY OF EL SEGUNDO, ALONG WITH THEIR OFFICERS, OFFICIALS, AGENTS, EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSURED WITH RESPECTS TO THE ABOVE MENTIONED POLICIES PER ATTACHED ENDORSEMENT(S). COVERAGE IS PRIMARY & NON - CONTRIBUTORY AS REQUIRED BY WRITTEN CONTRACT, PER ATTACHED ENDORSEMENT FORMS. WAIVER OF SUBROGATION APPLIES, IF REQUIRED BY WRITTEN CONTRACT. . SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, A 30 DAY WRITTEN NOTICE WILL BE ISSUED. SHOULD ANY OF THE ABOVE POLICIES BE CANCELLED FOR NON - PAYMENT, A 10 DAY WRITTEN NOTICE WILL BE ISSUED, . RE: ALL OPERATIONS tout 111 -H.cA It HUL,latK, CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN r THE CITY OF EL SEGUN ACCORDANCE WITH THE POLICY PROVISIONS. � � 350 MAIN ST. AUTHORIZED REPRESENTATIVE EL SEGUNDO, CA 90245 - ©1988 -2010 ACORD All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: MT. HAWLESURANCE COMPANY MGL017812 4/30/2013 TO 04/30/2014 COMMERCIAL GENERAL LIABILITY CG 20 10 11 85 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: THE CITY OF EL SEGUNDO, ALONG WITH THEIR OFFICER VOLUNTEERS ARE NAMED AS ADDITIONAL INSURED. RE: ALL OPERATIONS 1 (If no entry appears above, information required to complete thi as applicable to this endorsement.) N�' °IIJI'1S, AGENTS, EMPLOYEES AND I will be shown in the Declarations WHO IS AN INSURED (Section II) 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 work" for that insured by or for you. CG 20 10 11 85 © ISO Properties, Inc., 2000 Page 1 of 1 ❑ BIGWEST -03 SEAN ACOROtt DATE (MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 4/25/2013 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Automatic Data Processing Insurance Agency, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1 ADP Boulevard HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Roseland, NJ 07068 INSURERS AFFORDING COVERAGE NAIC # ,. .. .,.,- _ W INSURED Big West Construction Corporation INSURERA: Liberty Mutual Insurance Co. .. _ 15331 Normandie Ave INSURER B: Irvine, CA 92604 C ,... INSURER C: INSURER D: j r:r)VFRAr;FS THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUREMENT, 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS.. ,- ,�,�,.,,- „�, „,,,, . -- . �., m ,. E- 'IVE PO EXPRRATNON R D "LS POLICY NUMBER PALIC'YMJDD T" Y LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 0AMAG12 YO RENiEC) „ COMMERCIAL GENERAL LIABILITY PREMISES $,,,., "(Ea„opcurence),n" ",, CLAIMS MADE OCCUR MED, EXP (Any,one person) $ PERSONAL & ADV INJURY $ �GEN'L GENERAL AGGREGATE $ R IT APPLIES PER: AGGEGATE LIMIT PRODUCTS_- COMP/OP AGG $ '..... POLICY PRA" LOCI AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ '.. ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ '.. SCHEDULED AUTOS (Per person) L. HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) __ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ . -. ANY AUTO EA ACC OTHER THAN $ ...,� .,,,....a,,,,,,,,, AUTO ONLY: AGG '.. $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $.. $ WORKERS COMPENSATION X W C STATU- OTH- AND EMPLOYERS' LIABILITY Y / N I ANY PROPRIETOR/PARTNER/EXECUTIVE WC2 -Z91- 459335 -012 6/1/2012 6/1/2013 E L. EACH ACCIDENT $ 1,000,UU OFFICER/MEMBER EXCLUDED? Y ' � ' 1 ' (Mandatory in NH) E.L DISEASE - EA EMPLOYE $ ,000,00 If yE describe under ” 1,000,000 SPECIAL PROVISIONS below E L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Project Location: 350 Main St El Segundo, CA 90245 Installation of Windows & Doors l favor holder. This certificate includes a Waiver of Subrogation in of the certificate * Should the policy be cancelled for non payment a 10 day written notice will be issued* CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN City of El Segundo NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL 350 Main St IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR El Segundo, CA 90245-3813 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2009/01) ©1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD BIGWEST -03 SEAN IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2009/01) CERTHOLDER COPY P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 06 -01 -2012 CITY OF EL SEGUNDO SG DEPT OF BUILDING & SAFETY 350 MAIN ST EL SEGUNDO CA 90245 -3813 GROUP: 000238 POLICY NUMBER: 0015095 -2012 CERTIFICATE ID: 3 CERTIFICATE EXPIRES: 06 -01 -2013 06 -01- 2012/06 -01 -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. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE, ENDORSEMENT #1600 - CARR, THOMAS, SECRETARY TREASURER - EXCLUDED, ENDORSEMENT #1600 - CARR, MARGARET, PRESIDENT - EXCLUDED. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 05 -03 -2012 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2012 -06 -01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO EMPLOYER BIG WEST CONSTRUCTION CORPORATION SG 15331 NORMANDIE AVE IRVINE CA 92604 M0408 (REV.8 -2010) PRINTED : 05 -17 -2012 SG