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PROOF OF INSURANCE (2013) CLOSED (2)ACOR CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 08/24/2012 PRODUCER 310-548-1959 THIS, CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ,JAMES R ZUPKE. �NSURANCE SVCS, INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR L IC # 0721102 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. BE RTI 1 77 #P2A SAN l::lE[)R(), CA 9073 1 INSURERS AFFORDING COVERAGE NAIC # E . . . ..... ....... . . ........... - INSURED AR.0 lnV UMBING ......... INSL ERA: NATIOII,�JAI. CONFRACIORS TNS.CO, 12293 C/Oi RUBII IN CHAVARIN ............................ . .. ..... . . — INSURERB, iNFINFrY IN[SUl-",ANCE CONIPANY %d) 63 3124 ROSECRANS AN/E S IFE B INSURERG- 11 IAW I 11 iOR NE, CA 90250 INSURER 0; INSURER E: COVERAGES 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 1a SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, OLICYETF 'CTY POLICY EXPIRATION LTR INSRO POLICY NUMBER_ mm' M,DQNYl LIMITS GENERAL LIABILITY EACH OCCURRENCE 000,000 A GlI F 0000 13356-02 wih),0/20�2 0310qr2.013 -DAMAMTCY RENTED 1)( X COMMERCIAL GENERAL LIABILITY CLAIMSMADE OCCUR M 0 EXP Anyonep4nsonj $ 5,000 PERSCNAL&ADViNJURY 5 l,coo,000 .. . .. . . . .............. — GENERALAGGREGATE 2000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS, COMP OP AGG i S 1 1000 000 PRO, X POLICY JEQT I AUTOMOBILE LIABILITY B COMBINED SINGLE LIMIT $ 1,000�000 (Eaaccident) X ANYAUTO 5046fl)029302001 J T M1)120 11 11/0912012 ------------------- - ALL OWNED AUTOS BODILY INJURY X ;SCHEDULED AUTOS HIRED AUTOS BODILYINJURY NOWOWNED AUTOS '': .............. PROPERTY DAMAGE (Paraccident) GARAGE LIABILITY TOONLY,F j_AU -AACC)DENT $ ANY AUTO NIA jOTHERTHAN EAACC AUTOONLY: AGG S EXCESSIUMBRELLA LIABILITY I EACH OCCURRENCE s OCCUR CLAIMS MADE TE DEDUCTIBLE RETENTION s WORKERS COMPENSATION AND WC 8TATU dill ER EMPLOYERS' LIABILITY N/A JOY , I LIM El.EACHACCIDENT ANYPRO PRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? E-L DISEASE r EAEMPLqYEE I II xts,,, descrbe u nder ,, AL PRQyqgN%.below S .r - � EL DISEAStIFoul, LIMIT, s -- OTHER C BOND '10052883 08115T201 1 08115/2012 $12,500 cl-B DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS AD DED BY F= NUURbLMLN I 'fl IE CITY OF EL SEGUNDO, ITS lf,-.)f�= FICERS, AGENTS AND EMPLOYEES ARE INCL UIDED AS ADI )ITIOP1,41,L INSURED WITH REGARD '10 LIA13II I 1Y AND ICDI I ENSE OF S[ H 171,3 ARISING I,R()M "YOUR WORK" PERF'ORMED BY O1I:Z ON BE IAA b:: OF T] IF NANTED INSURED REGARDLESS OF tiAh IE CI iER I IA1131ITY IS A-1 9 R6d .J-IABLE TO THE NAMLD INSURED OR A COMI[.3INA G IOlq OF I R 8I NAMED AND T HE ADDI I 0NAL INSURED .......... CERTIFICATE HOLDER CANCELLATION CITY OF I"'[ SEGUNDO P111.)BI 6.0 16101[�ZIKS I)Ep-r 350 MAflN STRl[.:::ET r- - 1 S 11 GUNI..)O, CA < 02,1 kc-0-1,16 25 (2001!08) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 -- DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR ZZ099 'ACORD CORPORATION 1988 COMMERCIAL GENERAL LIABILITY POLICY NUMBER: GLF 000013356 -02 EFFECTIVE DATE: 03/09/2012 INSURED: ARC PLUMBING BY: UNITED CONTRACTORS INSURANCE CO. 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: CITY OF EL SEGUNDO PUBLIC WORKS DEPT. 350 MAIN STREET EL SEGUNDO, CA 90245 WHO IS AN INSURED (Section 11) is amended to include as au 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 would have as a claimant if not so included. CG2010 (11185) Copyright, Insurance Services Office, Inc., 1984 CERTHOLDER COPY SC P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 08 -27 -2012 GROUP: 000319 POLICY NUMBER: 0000287-2011 CERTIFICATE ID: 9 CERTIFICATE EXPIRES: 04 -01 -2013 04 -01- 2012/04 -01 -2013 CITY OF EL SEGUNDO SC 350 MAIN ST EL SEGUNDO CA 90245 -381 This is to certify that we have issued 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. t;��e-rI4 Nhul f4w- Authorized 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 04 -01 -2012 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2012 -08 -27 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO EMPLOYER CHAVARIN, RUBEN C. DBA: A R C PLUMBING SC 3124 W ROSECRANS AVE STE C HAWTHORNE CA 90250 [JAN,CN] (REV. 1-2012) PRINTED : 08 -27 -2012 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION 319 -11 000267 RENEWAL SC PAGE HOME OFFICE SAN FRANCISCO EFFECTIVE AUGUST 27, 2012 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING APRIL 1, 2013 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME A R C PLUMBING 3124 W ROSECRANS AVE STE,,,/ HAWTHORNE, CA 90250 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING: IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST. CITY OF EL SEGUNDO WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY. A R C PLUMBING IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03%. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUGUST 29, AUTHORIZED REPRESENTA kVE SCIF FORM 10217 (REV.1 -2012) 1 2012 2570 Iu PRESIDENT AND CEO OLD DP 217