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PROOF OF INSURANCE (2012) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE (MM' 12/077 /11 /11 YY)
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(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(s).
PRODUCER CONTACT EPIC Lanzillotta
CBIA Insurance Agency, Inc PHONE (818) 926 - 4410 -C Nq (818)459-9037
8001 Canoga Ave Suite A EMAIL e,rtl @cbjamember.com
Canoga Park, CA 91304 INSURERS AFFORDING COVERAGE NAIC #
Phone (877)900 -2242 Fax (866)746 -4801 INSURER A : Atain Ins Co 29033
INSURED
Golden Meters Service
INSURER C
14812 Hunter Lane
I INSURER D:
INSURER E:
Midway City, CA 92655- (714) 450 -5929
INSURER F
COVERAGES CERTIFICATE NUMBER:
REVISION NUMBER:
HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE
BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
DICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
ERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY
LNS
THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
XCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
_ ........................... ...............................
ADD
TYPE OF INSURANCE INSR
UBR
MDa
POLICY NUMBER
POLICY EFF
MMIDD/YYYY
POLICY EXP
MM /DD /YYYY
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$.....1,000,000.00
COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED
PREMISES Ea occurrence
$ 1 OO,000.00
[:1 F-1 CLAIMS -MADE ] OCCUR
CIP132219
MED EXP (Any one person
$ 5,000.00
A
Y
N
11/23/2011
11/23/2012
PERSONAL & ADV INJURY
www
$ 1,000,000.00
GENERAL AGGREGATE
$ 2,000,000.00
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP /OP AGG
$ 2,000,000.00
I"! POLICY ❑ PRO- ❑ LOC�
$
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
F_a accident
❑ ANY AUTO
BODILY INJURY (Per person)
1 $
❑ALL OWNED SCHEDULED
AUTOS Li
BODILY INJURY (Per accident
' .. $
NON -OWNED
❑ HIRED AUTOS F1 AUTOS
PROPERTY "DAMAGE
Per acrrdenf
$
.. ....... .........
❑ ❑
$
❑ UMBRELLA LIAB ❑ OCCUR
EACH OCCURRENCE
$
❑ EXCESS LIAB CLAIMS -MADE
AGGREGATE
$
❑ DED [I RETENTION $
$
..............
W
WORKERS COMPENSATION
I.O.
W C STATU- RH -
❑
AND EMPLOYERS' LIABILITY y / N
TOR LIMIT, ��°
ANY PROPRIETOWPAR "rN�ERrEXECUTIVE. N / A
E,L EACH ACCIDENT
$
OFFICEWMEMSFR EXCLUDED?
(Mandatory in NH) F-1
E,L, DISEASE- EA EMPLOYE
$
If yyYY�w, describe undwa
$
IDIE4SCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
.................. _........_ ...... ............ _._ ..... .
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
City of El Segundo, is named as additional insured on the above indicated General Liability policy per the attached endorsement.
Re: All operations at multiple locations for cert holder clients,
Scope of Duties :
Testing Meters and Meter Repair
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of El Segundo
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
400 Lomita Street
El Segundo 90245
Segundo, °
AUTHORIZED REPRESENTATIVE
C. 31 O a 070
......�_�1
©1988 -2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) QF
The ACORD name and logo are registered marks of ACORD
Aq"' RF3 -- DATE (MMIDDIYYYY)------
CERTIFICATE OF LIABILITY INSURANCE 12/07/11
THIS CERTIFICATE IS ISSUED ASWA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON
RIGHTS 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(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(s).
NTK
PRODUCER NAME: Eric Lanzillotta
CBIA Insurance Agency, Inc PHONE (818) 926 -4410- F OQi„ @18)459-9037
8001 Canoga Ave Suite A MA sus; a�rrc( chuamember.com
Canoga Park, CA 91304 INSURERS AFFORDING COVERAGE NAIC #
Phone (877)900 -2242 Fax (866)746 -4801 INSURER A: Atain Ins Cc 29033
INSURED INSURER B:
..... ............................... .............
Golden Meters Service INSURER C:
14812 Hunter Lane INSURER D ............._.._ _.�._....................._�...
Midway City, CA 92655 (714) 450 5929 INSURER E : ....................... ............. ............... _._- _.-- _.._.._.
INSURER F
COVERAGES CERTIFICATE NUMBER: 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
LTR
..................
TYPE OF INSURANCE
ADDL
SUBR
POLICY NUMBER
m
POLICY EFF
MMIDD/YYYY
.........
POLICY EXP
(MM /DD /YYYY)
.................................... _ ................................................................................................................. ............ .__ ........
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000,00
® COMMERCIAL GENERAL LIABILITY
e .
DAMAGE RGESOI,E_ ence„,, ,....$-..... .....,,_._._..._....�........_.
100,000.00
P �._... RENTED
❑ ❑ CLAIMS -MADE �/❑ OCCUR
CIP132219
MEDEXP(Anyona, person $ 5,000.00
A
p
Y
N
11/23/2011
11/23/2012
PERSONAL & ADV INJURY $ 1 ,000,000.00
GENERAL AGGREGATE
$ 2,000,000.00
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP /OP AGG
$ 2,000,000.00
POLICY ❑ PRO- ❑ LOC
....
$
.._.._�.❑
AUTOMOBILE LIABILITY
...- ..............................................
. ..... .....
_.__.
COMBINED SINGLE LIMIT
Ea AuRdant�,..........- ...........
❑ ANY AUTO
BODILY INJURY (Per person)
$
❑ALL OWNED ❑ SCHEDULED
AUTOS SCHE
BODILY INJURY (Per accident
$
'PROPERTY' DAMAGE
Par acrldant
$
NON -OWNED
❑ HIRED AUTOS ❑ AUTOS
❑ ❑
$
❑ UMBRELLA LIAB ❑ OCCUR
._ .
... ............. .......... ......
„....
EACH OCCURRENCE
$
❑ EXCESS LAB ❑ CLAIMS -MADE
AGGREGATE
$
DED I.❑ RETENTION $
$........
w.__.,.,_ ....
WORKERS COMPENSATION
�
�....
❑ W C yTATU S OTH-
AND EMPLOYERS' LIABILITY YIN
O IdT I
ANY PROrPY RIETOR/PARTNER/EXECUTIVE�
N/A
E.L.. EACH ACCIDENT
OFFICER/MEMBER M d NH EXCLUDED?
E L..
DISEASE - EA EMPLOYE
$
If yes, describe under
DESCRIPTION OF OPERATIONS below
E,L. DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
City of El Segundo, is named as additional insured on the above indicated General
Liability policy per the attached endorsement.
Re: All operations at multiple locations for cert holder clients.
. CERTIFICATE HOLDER ..--...-.... _......_.-- ...- .- - --- -------------_------------- .- ..�.....- .m........._-
..--....--.........._--...----.....----..--......... ...............................
,.......... ....-...m.---- - _. -----
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of El Segundo
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
400 Lomita Street
El Segundo, CA 90245
AUTHORIZED REPRESENTATIVE
Attn: James C. Turner - 310.524.4070
µ ,.
......._
©1988 -2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) OF
The ACORD name and logo are registered marks of ACORD
COMMERCIAL GENERAL LIABILITY
CG 20 33 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - AUTOMATIC STATUS WHEN
REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU
This endorsement modifies insurance provided under the following;
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A. Section II - Who Is An Insured is amended to
include as an additional insured any person or or-
ganization for whom you are performing operations
when you and such person or organization have
agreed in writing in a contract or agreement that
such person or organization be added as an addi-
tional insured on your policy. Such person or or-
ganization is an additional insured 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.
A person's or organization's status as an additional
insured under this endorsement ends when your
operations for that additional insured are com-
peted.
B. With respect to the insurance afforded to these
additional insureds, the following additional exclu-
sions apply:
This insurance does not apply to:
1. "Bodily injury ", "property damage" or "personal
and advertising injury" arising out of the ren-
dering of, or the failure to render, any profes-
sional architectural, engineering or surveying
services, including:
a. The preparing, approving, or failing to pre-
pare or approve, maps, shop drawings,
opinions, reports, surveys, field orders,
change orders or drawings and specifica-
tions; or
b. Supervisory, inspection, architectural or
engineering activities.
2. "Bodily injury" or "property damage" occurring
after:
a. 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
b. 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 subcon-
tractor engaged in performing operations for
a principal as a part of the same project.
CG 20 33 07 04 (0 ISO Properties, Inc., 2004 Page 1 of 1
Mar 28 12 01:08p Golden Meters Service 7148293103 p.2
To: '7148293103AFax.else9undo.or9' From: Timings, LtleieniV' 03/27/12 02:28 IM Fage t %
Reproduetkm of Insurance Services Office, Inc. Form
INSURER.• ISO FORM CG 2010 1185; (MODIFIER)
POLICY NUMBERS COMMERCIAL GENERAL LIABILITY
ENDORSEMENT NUMBER: EXHIBIT 1 -A
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ FT CAREFULLY.
ADDITIONAL INSURED — OWNERS, LESSEES OR
CONTRACTORS (FORM B)
This endorsement modifies insurance provided underthe following:
COMMERCIAL GENERAL LLIkBILITY COVERAGE PART.
SCHEDULE
The City, its ofReers, officials, employees, agents, and volunteers
(if no entry appears above, the information required to complete this endorsement
will be shown in the Declarations as applicable to this endarsentertt.)
WHO IS AN INSURED (Section It) 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.
to ISO famCC 20 10 it $5.
1. The insured scheduled above includes the trtsured's oii'icers, officials, employers weed
volunteers.
2. This insurance shall be primary as rmpects the insured shown in the schedule abovey
or if excess, shall stand in an unbroken chain of coverage excess of the Flamed
Insuteti's scheduled underlyWg primary coverage. In either event, any other insurance
maintained by the Insured scheduled above shall use in excess of this insurance and
shall not be called upon to contribute with it.
3. The insurance afforded by this policy shall not be canceled except after thirty days
prior written notice by certified mail retum receipt requested has been given to the
Entity.
4. Coverage shall not extend to any indemnity coverage for the active negligence of
additional insisted in any case where an agreement to indemnify the di anal im,
would be invalid under Subdivision b eafsection2782 oftttc Civil C
CG 20 10 11 85 Insurance Services Oiflice, Inc. Form {Moditled)
opt -Out: Ilot DeFilted
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