PROOF OF INSURANCE (2012) CLOSEDDATE (MMIDD
ACORD,. 12!15/2011
PRODUCER .410-1148 195) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
,,Ufi`IAE ,S R ZUPKL UUFU'31Dfl°lA04,' 1: " "dd `:,,, III` ^4C ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
N..I ; 1 0721102 HOLDER. THIS CERTIFICATE DOES NOT AMEND„ EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
SAN P1.I.:pH0,f,A 1191111'1 INSURERS AFFORDING COVERAGE �NAIC#
INSURED 1 a I "111D 1 ?11 :k ' INS UR E- RA I k
. ( )NTRA . .
ORS ftS GO 12293
UR a w CI, y N- SURER B: iNF' I'1(
20-2 -60
e.
124 UFO aU...CIPA B a A"III: 1 N' C INSURERC:
L.VA°FtBYH(::9M4F, CA 90250 INSURER D:
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
R gD'dD, O' A..�... _ N _ POLICY NUMBER _ POUCYEFP'UCTIVE P DYEXP$RAVON�. ._ LIMIT
GENERAL LIABILITY' FACHOCC'URRENCE S 1,000,000
�' '' +�. E COMMERCIAL GENERAL LIABILITY 1ilt.k %;,kvDO „11U"I ,1') "aPa -I,:uV O.ud'OO� 011 �!�•.-b'na01D�201 k�L MISAv; G.a;urenT, � S 50,000
PV __ v
CLAIMS MADE x OCCUR MEDEXIItAny one Popson) 5,000
PERSONAL&ADVINJURY S 1,0011,0(.60
GENERALAGGREGATE S 2,000,000
CEN G � PE
REGAIF APPLIES PER: { �` PRODUCTS, COMPIOP.. .. 111 000
POLICY
AUTOMOBILE LIABILITY
X
ANYALITO
ALL OWNED AUTOS
D1.
SCHEDULEDAUTOS
HIREDAUTOS
J NON>OWNEDAUTOS
GARAGE LIABILITY
1 ANY AUTO
- „EXCESS/UMBRELLALIABILITY
i
OCCUR I CLAIMS MADE
V DEDUCTIBLE
S
1 RETENTION ..........._.�.m...._�
WORKERS COMPENSATION AND
EMPLOYE RS' LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE
OFFICERIMEMBER EXCLUDED?
If yes, describe under
SPECIAL PROVISIONS below
�OTHER
rr
1 MHtJ'U`k� II.�'
504610029302001
100,,'5288)
COMBINED SINGLE LIMIT S "N w(11D01U
11 4091201 1 11109Y`2W2 1 (Eaaccdent)
Y: "..1 E A M U AiGCMFNT _I. s_ .. _.
IE_L M 1 ASE: II All ML L0YFII S
E.L DISEASE POLICY LIMIT S
1s13 "11m1,"i wU 7 08/1,512010 $12,500 CUB
DENC:HI "I1 ION OF011:'IERA I110INSI LOGATIIOINSI VEI PNY :0.ESIEX,CLIJSI0INS'ADDED BY ENIDIURSEMIlmIN I I SPECIAL PII:&OftpM11ONS
F" II::I (,'. T°Y OF II "'.U_ 1aEGI..PII'11f O, O FS OFFKAETZS, AGENTS, AND EMPLOYEES ARIE INCLUDED AS All 3D IT6 0 NAIL INSU.➢REr.) Wfl d REGARD TO
9..0AN'11U....ITY AND D h EN E OF SU~ IS A1RIK,)lllrler:"Y 1= RCm)Irw1 ' "ro°"(A.JR 1ROMI"DRK" F'U::R OI°1! ED BY OR ON B 9...iALF OF ..I I°IE Ir°1AW::. -:D IINWR D
N- 1V_GARU.DIL..ES S OF WHET" 1ER 11...11ALB %LffY IS Al I RIBUTABLE FO U N III NAMED IINViLRF°,D OR A f'C:)9Ud%EKA ..L.ION OF TL E NAMED AND IF 9fE
6'kDDIT0NAI... INSURED
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
4,U Y u 1111° I.I. u71 U:11IIA1Po..1C „D DATE THEREOF, THE ISSUING INSURER WILL fiNDSWOR TOMAIL 39 ,,,,,,,,,,,, DAYS WRITTEN
P11, ff3l IC WORKS, D mI="1 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT AIUX �
050 BYa1AIIII"441 II.1P U.: If
11 S�::.GIUP4130, CA 90245
AUTHORIZED REPRESENTATIV
6
ACORD 25 (2001/08) C R,D CORPORATION 1988
ADDITIONAL INSURED- OWNERS, LESSEES OR
CONTRACTORS (FORM
This endorsement modifies insurance provided under the following:
l 1
I -. I I I @ F- L 1
CITY OF 11
PUBLIC WORKS DEPT.
.1 STREET
EL SEGUNDO, CA 90245
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.
PRIMARY WORDING CLAUSE
1) The City of El Segundo, its officers, agents and employees are included as additional
insured with regard to liability and defense of suits arising from "your work" performed
by or on behalf of the named insured regardless of whether liability is attributable to the
named insured or a combination of the named and the additional insured.
2) Any other insurance maintained by the City of El Segundo is excess of the insurance and
will not contribute to it.
3.) This insurance applies separately to each insured against whom claim is made or suit is
brought except with respect to the company's limits of liability. The inclusion of any
person or organization as an insured does not affect any right with such person or
organization ld have as a claimant if not so included.
CG2010 (1 1 /85) Copyright, Insurance Services Office, Inc., 1984
POLICYHOLDER COPY
SC
P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 01 -08 -2012
CITY OF EL SEGUNDO SC
DEPT OF BUILDING & SAFETY
350 MAIN ST
EL SEGUNDO CA 90245 -3813
GROUP: 000319
POLICY NUMBER: 0000267 -2010
CERTIFICATE ID: 7
CERTIFICATE EXPIRES: 04 -01 -2012
04 -01- 2011/04 -01 -2012
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.
A Representative President and CEO
UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING:
THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER;
EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING
CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS'
COMPENSATION LAW.
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE,
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01 -06 -2012 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
-�- uj,;iw o� 9ubro��
EMPLOYER
CHAVARIN, RUBEN C. DBA: A R C PLUMBING
3124 W ROSECRANS AVE STE C
HAWTHORNE CA 90250
SC
[LAC,CNj
PRINTED : 01 -08 -2012
(REV.8-2010)