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PROOF OF INSURANCE (2012) CLOSEDO�P ID: PR ACORO" CERTIFICATE OF LIABILITY INSURANCE UAT0(MM6/04D/YYYY)� 04/12 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 310- 832 -1131 CONTACT Modern Insurance, Inc. PHONE �n5c ...... Arroyo Insurance Services L — AOOI3S „ .,. ,... 333 W. 5th St., P.O. Box 1031 ��OdRpi�,� ° San Pedro, CA 90733 -1031 Cw,eTQMr"lp#nSANDMA INSURED andmasterinc. Colon y" InSUranCe Corn DBA:SandmasterSandblastin g INSURER B: 18410 San Fernando Mission Bvd Porter Ranch, CA 91326 INSURER c INSURER D INSURER E: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LASTED 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, R �n�...,, .... ,, .. ,,, a ,......_� XObL 30 w ..... _ ----..._ n ...mibUdl E00 , CUdy �.� .,�m.. � .,— .�mm.�__ .. ....... .. _....,.. TYPE OF INSURANCE POLICY NUMBER Y `` MM Y LIMITS GENERAL LIABILITY 1 EACH OCCURRENCE S 1.00010 A X COMMERCIAL GENERAL LIABILITY X X IMP3111091 ICLAIMS -MADE I X II OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS UMBRELLA LIAR OCCUR EXCESS uAs CLAIM DEDUCTIBLE WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? ❑ �NIA (Mandatory in NHI 10130111 � 10130112 :RIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) is Certificate cancelslsupercedes certificate dated 5/15112 "' ifilcate Holder is Additional Insured perform CG2010 7104 and CG2037 attaclTEd including primary and non - contributory Wording, but o111'y as City of El Segundo, Its Officials, and Employe 150 Illinois Street El Segundo, CA 90245 ACORD 25 (2009109) CITEES2 3 COMBINED SINGLE LIMIT 3 (Ea accident) BODILY INJURY (Per person) S BODILY INJURY � II RY (Per accident S PROPERTY DAMAGE (Per acadenl) S EACH OCCURRENCE $ AGGREGATE S HA DE E L. DISEASE . EA EL DISEASE -PO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL GE DELIVERED IN ACCORDANCE W H THE POLICY PROVISIONS. - wa � ©1988 -2009 The ACORD name and logo "a' re registered marks of A TION. All rights reserved. ..s..._......... 5 ........_. Mr�tlAU�isd�rrru��r) ED EXP (Any one person) S PERSONAL & ADV INJURY 3 1,00 � 0 GENERALA AGGREGATE G i..._ S 2,.00 00 PRODUCTS • COMPIOP AGG S 2,DO 3 COMBINED SINGLE LIMIT 3 (Ea accident) BODILY INJURY (Per person) S BODILY INJURY � II RY (Per accident S PROPERTY DAMAGE (Per acadenl) S EACH OCCURRENCE $ AGGREGATE S HA DE E L. DISEASE . EA EL DISEASE -PO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL GE DELIVERED IN ACCORDANCE W H THE POLICY PROVISIONS. - wa � ©1988 -2009 The ACORD name and logo "a' re registered marks of A TION. All rights reserved. COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 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 SCHEDULE Name Of Additional Insured Person(s) Or O anization s : Location And Description Of Completed Opera - tions City of El Segundo, its officials and employees Sandblasting work on Acacia Street City Pool, 150 Illinois Street Acacia Avenue, El Segundo El Segundo, CA 90245 Information required to corn lete this Schedule if not shown will be shown In the Declarations. 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 ". CG 20 37 07 04 0 180 Properties, Inc., 2004 Page 1 of 1 13 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 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) City of El Segundo, its ofircia rq employees 1150 Illinois Street El Segundo, CA 90245 * * *It is further agreed that this insurance shall be primary and non -contributory, but only in the event of a named insured's sole negligence. this Schedule, if not shown 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) desig- nated above. Locations Of Covered Op2rations Sandblasting work on Acacia Street City Pool, Acacia Avenue, El Segundo in the Declarations. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment 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 in- tended use by any person or organization oth- er than another contractor or subcontractor engaged in performing operations for a princi- pal as a part of the same project. CG 2010 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 0 CERTHOLDER COPY SG P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 06 -04 -2012 CITY OF EL SEGUNDO, ITS OFFICIALS SG AND EMPLOYEES 150 ILLINOIS ST EL SEGUNDO CA 90245 -4311 GROUP: POLICY NUMBER: 1635460 -2012 CERTIFICATE ID: 94 CERTIFICATE EXPIRES: 05 -17 -2013 05 -17- 2012/05 -17 -2013 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. Notwithstandin any requirement term or condition of any contract or other document with respect to which Ws 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 terns, exclusions, and conditions, of such policy. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #1600 - OSTOICH, ANTHONY SEC - EXCLUDED. ENDORSEMENT #1000 - ZAMISKA, JOSEPH PRES, TRES - EXCLUDED. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 05-17 -2004 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2012 -06-04 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO, ITS OFFICIALS EMPLOYER SANDMASTER,INC. SG 18410 SAN FERNANDO MISSION BLVD PORTER RANCH CA 91326 [B13,SG] (REV.e -2010) PRINTED : 06 -04 -2012