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PROOF OF INSURANCE (2012) CLOSED(MWOOrMV) CERTIFICATE OF LIABILITY INSURANCE DATE 09/2912011 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 IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) 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: (714) 973-1436 Fax: (714) 973-0611 10"TACT DAVID WALSH DAVID WALSH PHONE J #1 t�&pj FAX -0811 -1436 JAC, No (714)973 (714) 973 - ELMCO INSURANCE, INC. DAMAGE TO RENTED EMAIL 1, 000 1905 N. MAIN STREET PRODUCER 5307 SANTA ANA CA 92706-2779 5,000 c1v$yP4ER1or 1,000,000 Agency Lic#: 0509747 INSURERS) AFFORD-ING. COVERAGE INSURED A GOLDEN EAGLE INSURANCE CORPORATION GAFF GROUP INC. INSURER B EVEREST NATIONAL INSURANCE COMPANY 060 S. STATE COLLEGE BLVD. msuRm c � -ed-b—Offs. NATIONAL UNION FkE-06. FULLERTON CA 92831 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 45106 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 ALLTHE TERMS, INM I LTR. I TYPE OF INSURANCE A GENERAL LIABILrry X COMMERCIAL GENERAL LIABILITY CLAIMS-MADE i I X (OCCUR GEN-L AGGREGATE LIMIT APPLIES PER: II PRO LOC X I POLICY I I . JECT D AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS X 1 SCHEDULED AUTOS X HIRED AUTOS X NON -OWNED AUTOS C UMBRELLA LLAB X OCCUR AM, POLICY EFF POLICY EXP roN POLICY NUMBER (ftwpqtyy—"J (MM1DDrnM CBP9576734 03111/11 03111/12 BA6698432 BE067744274 � 08119111 � 06/17/11 LIMITS EACH OCCURRENCE 11000,0010 DAMAGE TO RENTED 1, 000 rj,fl MISES.(Ea ogewonmA MED. EXP (Any one poison) 5,000 PERSONAL & ADV INJURY 1,000,000 GENERAL AGGREGATE PRODUCTS - COMP/OP AGO 081191112 ; COMBINED SINGLE LIMIT (Ea aoc ml BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) 03111/12 EACH OCCURRENCE 2,000,000 1,000,000 s $ $ 1,000,000 1 EXCESS LIAS CLAIMS-MADE AGGREGATE $ 4 An Anft PROD. COMPL AGO, DEDUCTLBLE 1000000 RETENTION $ 01101112 B WORK'ERS COMPENSATION 7600004194111 011011 1,U.T. OTH ER AND EMPLOYERS LIABILITY rpw j E.I., EACH ACCIDENT 1,000,000 ANY PROPRIETOR/PARTMERIEXECUYTVE (OFFICE RIMEMBER EXCLUDED? NIA Mandwary In "11 E.L. DISEASE-EA EMPLOYEE 1 x0,000 E.L. DISEASE - POLICY LIMIT I yes. desalbe Under .1 ESCRIPTION OF RATIONS below s 1,00,0,000 A !BUSINESS PERSONAL PROPERTY CBP9576734 03/11111 03111/12 $204,000 PROP. LIMIT FORM RC, 80% COINSURANCE DEDUCTIBLE: $500,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CARPENTRY CITY OF EL SEGUNDO HAS REQUESTED TO BE NAMED AS ADDITONAL INSURED ON GENERAL LIABILITY PER THE ADDITIONAL INSURED ENDORSMENT CG 2010 (07104). ENDORSEMENT TO FOLLOW. REFERENCE JOB: 25111, CITY OF EL SEGUNDO, CA, CERTIFICATE HOLDER CANCELLATION CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 150 ILLINOIS STREET ACCORDANCE WITH THE POLICY PROVISIONS. EL SEGUNDO, CA 9024 AUTHORIZED REPRESENTATIVE Attention: L c--. I Erin Walsh Forming a part of Policy Number: CBP9576734 Coverage Is Provided In PEERLESS INSURANCE COMPANY - A STOCK COMPANY Named Insured: Agent: GAFF GROUP INC ELMCO INSURANCE Agent Code: 4294058 Agent Phone: (714)- 973 -1436 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) Location(s) Of Covered Operations Or Oraanization(s): THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS AND VOLUNTEERS 150 ILLINOIS ST EL SEGUNDO, CA 90245 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) 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" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. © ISO Properties, Inc., 2004 CG 20 10 07 04 Page 1 of 1 03/1112012 9576734 NEUSXJSG2902 PGDM060D J20225 GC3FPPN 00000065 Page 27 Forming a part of Policy Number: CBP9576734 Coverage Is Provided In PEERLESS INSURANCE COMPANY - A STOCK COMPANY Named Insured: Agent: GAFF GROUP INC ELMCO INSURANCE Agent Code: 4294058 Agent Phone: (714)- 973 -1436 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 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 ". SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIAL EMPLOYEES, AGENTS AND VOLUNTEERS 150 ILLINOIS STREET, EL SEGUNDO, CA 90245 Location And Description Of Completed Operations: DESCR OF WORK: REMOVE AND INSTALL CARPET, DEMO AND INSTALL HAND RAIL NAME OF JOB: MAINTENANCE REPAIRS LOCATION OF WORK: 150 ILLINOIS ST, EL SEGUNDO, CA START DATE: 02/20/2012 COMPLETION DATE: 03/16/2012 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. © ISO Propertles, Inc., 2004 CG 20 37 (07/04) INSURED COPY 03/11/2012 9576734 NEUSXJSG2902 PGDMO60D J20225 GC3FPPN 00000073 Page 35