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PROOF OF INSURANCE (2012) CLOSEDClient#: 66735 18BUXTOCOM DATE (MM /DD/YYYY) ACORD,. CERTIFICATE OF LIABILITY INSURANCE 11/11/2011 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(les) must be endorsed. If 8U 13ROGATION IIS 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 NAME: Wortham Insurance & Risk Mgt a N O" - ._ .. . . ........................... ... ... TAB 1r c:. .o1,..._8.1..7... 336 -8.2.5 �.EX ............mm .. 1600 West Seventh Street E-MAIL ADDRESS: Fort Worth, TX 76102 -2505 RE INSURS) AFFOR D ING C 817 336-3030 ._, .,. _..m FO .m.N COVERAGE �NAIC a........ INSURERA. Valley Forge Insurance Company 20508 INSURED Buxton Company 2651 S. Polaris Drive Fort Worth, TX 76137 COVERAGES CERTIFICATE NUMBER! INSURER B: Continental Casualty Company 20443 INSURER Scottsdale Insurance Company 41297 . INCIIRFQ A National Fire Insurance Co of H 20478 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 CONTRACTOR 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 _�. ADDL'SUB IN$R WM,(, POLdCY NUMBER POLICY EPF POLICY EXP.. JNVMP41�?Y'Y'NY(Y) , LIMITS ,,,, ... -. ...,. A GENERAL LIABILITY X X P2093358583 7/13/2011 07/13/20121,EACH99 CURRENCE $1 000,000 X COMMERCIAL GENERAL LIABILITY P' EFAtRS Ea =Arr n e $3000OO CLAIMS -MADE OCCUR MED EXP (An one person) $5 000 PERSONAL & ADV INJURY ', $ 7U000�O00 _ AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2 OOO,OOO .GENT .I, POLICY �ff7,.,....... LOC $ .. D AUTOMOBILE LIABILITY X X P1079708301 7/13/2011 07/13/201 G t CYMBINEO SIN LE LIMIT iLAMMLCEnl ............................ 1,000,000 ......................... X., ANY AUTO BODILY INJURY (Per person) $ ....... ALL OWNED WWW SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) WPROPERTY $ X X NON -OWNED DAMAGE $ HIRED AUTOS AUTOS ;(,Per atod;ertt B UMBRELLA LIAB OCCUR P2093460191 7/13/2011 07113/201 EACH OCCURRENCE ITmmmmmmmmmITm $5,000, l�OQmmmmmmmmm�mm AGGREGATE $5,000,000 EXCESS LIAB CLAIMS -MADE $ RETENTION $10,000 WORKERS COMPENSATION A X WC2093007771 5/0312011 05/03/207 WC STATU- OTH- X pRY LIMITS 9,R AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $1,0001000 N OFFICER/MEMBER EXCLUDED? NI (Mandatory in NH) N I A E.L. DISEASE - EA EMPLOYEE $1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,000,000 _ C Errors & Omission EKS3051479 11/11/2011 11/11/201 3,000,000 _. ..._._. DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Blanket additional insured coverage for holder is subject to a written contract between the Named Insured and City of El Segundo, its officials and employees that requires such status. Waiver of Subrogation endorsement has been issued and will apply only to the extent provided by law per any contractual provision. This coverage is primary and non - contributory. 17 O, City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE y g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main St. ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ©1908.2010 ACORD CORPORATION. All rights reserved, ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S266690/M266689 180AS POLICY NUMBER: P2093358583 COMMERCIAL GENERAL LIABILITY CG 02 05 12 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. TEXAS CHANGES - AMENDMENT OF CANCELLATION PROVISIONS OR COVERAGE CHANGE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCT WITHDRAWAL COVERAGE PART PRODUCTSICOMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART In the event of cancellation or material change that reduces or restricts the insurance afforded by this Coverage Part, we agree to mail prior written notice of cancellation or material change to: SCHEDULE 1. Narne: City of El egtsnd' 2_ Address: 350 Main St. El Segundo,CA 90245 3. 1 Number of days advance notice:030 Intormation required to completeethis Schedule it not shown above, will be shown In the Declarations, 4� r a CG 02 05'12 04 Copyright, ISO Properties, Inc., 2003 Page 1 of 1 POLICY NUMBER: P1079708301 COMMERCIAL AUTO CA 02 44 06 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. TEXAS CANCELLATION PROVISION OR COVERAGE CHANGE ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective: Countersigned By: Named Insured: Authorized Representative) SCH E. Number of Days' Notice; Name Of Person Or Organization: City of El Segundo 19? 350 Main St. Address El Segundo,CA 90245 If this policy is canceled or materially changed to reduce or restrict coverage, we will mail notice of cancellation or change to the person or organization named in the Schedule. We will give the number of days' notice indicated in the Schedule. w CA 02 44 06 04 Copyright, ISO Properties, Inc.,2003 Page 1 of 1 4 V POLICY NUMBER INSURED NAbM AND ADDRESS P 2093358583 BUXTON COMPANY 2651 S. POLARIS DRrVE FOR.,r WOR,ni, TX '76137 POLICY CHANGES BLANKET CG MO (G-300693-A) This Change Endorsement changes the Policy. Please read it carefully. This Change Endorsement is a part of your Policy and takes effect on the effective date of your Policy, unless another effective date is shown. POLICY NUMBER:2093358583 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 7-11S ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSU=- - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCzIEDULE Name Of Additional Insured Person(s) Or organization(s) See Below Any person or organization you have agreed in a written contract or written agreement to add as an additional insured on this Coverage Part, provided the written contract or written agreement was executed prior to; a. The "bodily injury" or "property damage"; or b. The offense that caused the "personal and advertising injury for which the additional insured seeks coverage under this Coverage Part. The written contract or written agreement must pertain to your ongoing operations for the additional insured, and must specifically require additional insured status according to the provisions of CC 20 1-0. But notwithstanding the above, no person or organization is an additional insured for professional architectural or engineering services provided at or for the Location(s) of Covered Operations. Page 1 of 2 ***City of El Segundo Chairman of the BoardetpY G-56015-B (ED. 11/91) ........... POLICY NUM BE R ID18 D1 - Akb ADDRESS P 2093358583 BUXTON COMPANY 2651 S. POLARIS DRIVE ............ FORT WORTH, TX 76137 ............. POLICY CHANGES BLANKET CG 10 (G-300693-A) PAGE 2 This Change Endorsement changes the Policy. Please read it carefully. This Change Endorsement is a part of your Policy and takes effect on the effective date of your Policy, unless another effective date is shown. Location(s) Of Covered Operations 350 Main St., El Segundo, CA 90245 As per the written contract or written agreement, provided the location is within the "coverage territory" of this Coverage 'Part. 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) designated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment 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" our of which the injury or damage arises has been put to its intended use by any person or organization ocher than another contractor or subcontractor engaged in per-forming operations for a principal as a part of the same project. Page 2 of 2 IM 4JL4-- S.alaq ChaIrman of the Board G-56015-B (ED. 11/91) POLICY M.MER INSURED NAME AND ADDRESS P 2093358583 BUXTON COMPANY 2651 S. POLARIS DRIVE FORT WORTH, 'TX 76137 .......... POLICY CHANGES SCHEDULE CG 2404-1093 This Change Endorsement changer. the Policy. Please read it carefully. This Change Endorsement is a part of your Policy and takes effect on the effective date of your Policy, unless another effective date is shown. ANY PERSON OR ORGANIZATION THAT YOU HAVE AGREED IN WRITING IN A CONTRACT OR AGREEMENT TO WAIVE ANY RIGHT OF RECOVERY AGANIST SUCH PERSON OR ORGANIZATION, BUT ONLY IF r.-M CONTRACT OR AGREEMENT; 1.IS IN EFFECT OR BECOMES EFFECTIVE DURING THE TERM OF THIS POLICY: AND 2. WAS EXECUTED PRIOR TO LOSS. 4—j" Chairman of the Board Sevetary G-56015-B (ED. 11/91) Al l POLICY NUMBER: P1079708301 COMMERCIAL AUTO CA 04 03 06 04 THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY„ TEXAS ADDITIONAL INSURED This endorsement viodifies Insurance provided under the trullowing: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect lo coverage provided by this endorsement, Jie provisions of the Coverage Form apply unles,,-, rneclihed by the endorsement. This endorsernent changes the policy effective on the inception date of the policy unless anolher date is indicated below, Endorsement Effective: ICountersigned By: iNAmmized R2Erp-,r,,ntative SCHEDULE Name and Address of Additional Insured:w1T'A WHOM YOU HAVE A WPT.'T.'TE?q CONTRACT (if no entry appears above, information required to complete this endorsement will be shover in the Declarations as applicable to this endorsement.) A, Who Is An Insured(Section 11)is amended to include C. You are authorized to act for the additional insurec as an "insured" the person(s) or organization(s) named in the Schedule or Declarations in all rnatters shown in the Schedule, but only with respect to their pertaining lo this insurance. legal liability for acts or omissions of a person for D,. We will mail the additional insured named in the whom Liability Coverage is afforded under this Schedule or Declarations notice of any cancellation policy- of this policy, if we cancel, we will give 10 days B. The additional insured named in the Schedule or notice to the additional insured. Declarations is not required to pay for any premiums E. The additional insured named in the Schedule or stated in the policy or earned from the policy- Any Declarations will retain any right of recovery as 2 return premium and any dividend, if applicable, claimant under this policy. declared by us shall be paid to you. CA 04 03 06 04 Copyright, ISO Properties, Inc,,2003 Page 1 of 1