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PROOF OF INSURANCE (2012) CLOSEDClient #:85887 BUCKAS01
INSURANCE pAT /26 /2DIY
ACORD,. CERTIFICATE OF LIABILITY _ a3zs/2o12
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 INS REDire an oldorses) mu t se endorsed. uIf SUBROGATION IS WAIVED, subject to
the terms and conditions o policy, t on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
Willis
In _ Art INS, Karen
949 885 1200 949 -885 1225
Wllis Insurance Services of P�d��.�_..._� �"
California Inc License #0371719
ADJR�„� N�a)en blaker�wlNlls.cam _..
18101 Von Karman Ave Suite 600 RAGE NAIC#
,� I.fdS:C)RrR(S)AFFORDINGCOVE mITT
Irvine CA 92612
y 4
_.._.�...___.�
INSURER A
INSURED INSURERS Rtinental GasUalty COmt7df9y 20443
Sucknam Infrastructure Group, Inc.
INSURER C
3548 Seagate Way, Suite 230
INSURER D
Oceanside, CA 92056
INSURER E:
INSURER F:
_.
COVERAGES CERTIFICATE NUMBER: 485436 REVISION NUMBER: 1
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED
NAMED ABOVE FOR THE POUCYPERIOD
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.
_ ..,p ... m....... Y NUMBER (M,MIDDIYYYYj (MMI. .._•.T.,. LIMITS ,.._,_...._...... ,......_...
LT,�TYPE OF fNSURANCE "c' V R POLICmm POLICY EPP PC7LICY EXP
r
iyDD/YYYY1 ..._� ...... .........._.,_..,.e.,.,..,... ...,_ _.... ..........�,........._.,....
A _..E.......... L LIABILITY
GENERA � Y 6806A55628A _........_�__— � ' 9!1612091 09116/2012 EACH OCCURRENCE $1,000000
X COMMERCIAL GENERAL p AABiLI' ht� C " C9 )aENTrU
TY ALh�1�� iF�u a :crier, ence $1 0E10 000
. CLAIMS -MADE [:X] OCCUR MFD EXP (Any one person) $1 0 000 m „mmmITmm
PERSONAL & ADV INJURY $11000,000 s,
GENERAL AGGREGATE. $2,000,0 0 .,0
GENT. AGGREGATE LIMIT APPLIES PER:
PR PLOPAGG 62,000 000mm
POLICY ODUCTS COM mm
PRO' _ C OM�BINEDS INGtX � L011' $INCL iPJ GL
AUTOMOBILE ELIABILI Y �. �.__.... ... � .... 6806A55628A � ........_... . 9/16/2011 09/1 .�.__., .,..
L-11-01C _
A 161201 t -� ,Adam
BODILY
ANY AUTO INJURY (Per person) $
ALL OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS AUTOS rFtOiTli'rY DAdRA'' _ mm
NON•OWNED $
Per acoi enC
w
X HIRED AUTOS !� , AUTOS I fi - -•
a.$ ........._
... OCCUR
UMBRELLA LIAR EACH OCCURRENCE $
ftEGA E $ _�
EXCESS LIAS CLAIMS-MADE AGG7
$
DELI _ RETENTfON S m .,... _ _... -_
XJUB3790T99 9/16/2 96I 21 X ”. W C STATU A WORKERS COMPENSATION O.'T..H
AND EMPLOYERS LIABILITY Y! N 011 0/I - T4fY - -. ER.
ANY PROPM15TOWPARTNER /EXECUTIVE E L EACH ACCIDENT "
$1.' 1000,000
OPFICERfMEMBEREXCLUDED? L W I N / A
(Mandatory In N)) L. DISASE
......_....
- EA EMPLOYEE l 000 000
If yes, describe under _ t
E L DISEASE •POLICY LIMIT $1 000,000
_'.DE6CRIP'FIOfJ.QF OPERATIONS „below ...._...... ......m..Am a.�,.,. _..._...._..._,,,�... , M.. �... �.... .._._...�....._._.._,_.w...�... _ — ._.__. ___.....
B
Professional MGH288359767 0911612011 09116/201 $1,000,000 Per Claim
Liabilit $1 000,000 Aggregate
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required)
City of El Segundo, its officials and employees are named Additional Insured with respects to General
Liability and Insurance is PRIMARY Non Contributory per attached.
CERTIFICATE 1401-DER CANCELLATION
City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Y g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Attn: Ms. Maryam Jonas ACCORDANCE ITT THE POLICY PROVISIONS,
350 Main Street
'
El Segundo, CA 90245 UTH 'RIZ WSNTATIV
I'll qt'
fl ACORD CORPORATION, All rights reserved.
ACORD 25 (2010105) 1 of 1 The ACORD name and logo are registered mark
#S485608/M485340 MPEAK
COMMERCIAL GENERAL LIABILITY
POLICY NO 6806A55628A
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ
BLANKET ADDITIONAL INSURED
(ARCHITECTS, ENGINEERS AND SURVEYO
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A. The following is added to WHO IS AN
INSURED (Section II):
Any person or organization that you agree in a
"contract or agreement requiring insurance" to
include as an additional insured on this
Coverage Part, but only with respect to liability
for "bodily injury", "property damage" or
"personal injury" caused, in whole or in part, by
your acts or omissions or the acts or omissions
of those acting on your behalf:
a. In the performance of your ongoing
operations;
b. In connection with premises owned by or
rented to you; or
c. In connection with "your work" and
included within the "products- completed
operations hazard ".
Such person or organization does not qualify
as an additional insured for "bodily injury",
"property damage" or "personal injury" for
which that person or organization has
assumed liability in a contract or agreement.
The insurance provided to such additional
insured is limited as follows:
d. This insurance does not apply on any
basis to any person or organization for
which coverage as an additional insured
specifically is added by another
endorsement to this Coverage Part.
e. This insurance does not apply to the
rendering of or failure to render any
"professional services ".
f. The limits of insurance afforded to the
additional insured shall be the limits which
you agreed in that "contract or agreement
requiring insurance" to provide for that
additional insured, or the limits shown in
the Declarations for this Coverage Part,
whichever are less. This endorsement
does not increase the limits of insurance
stated in the LIMITS OF INSURANCE
(Section III) for this Coverage Part.
Y.
B., The following is added to Paragraph a. of 4.
Other Insurance in COMMERCIAL
GENERAL LIABILITY CONDITIONS (Section
IV):
However, if you specifically agree in a "contract
or agreement requiring insurance" that the
insurance provided to an additional insured
under this Coverage Part must apply on a
primary basis, or a primary and non-
contributory basis, this insurance is primary to
other insurance that is available to such
additional insured which covers such additional
insured as a named insured, and we will not
share with the other insurance, provided that:
(1) The "bodily injury" or "property damage"
for which coverage is sought occurs; and
(2) The "personal injury" for which coverage
is sought arises out of an offense
committed;
after you have entered into that "contract or
agreement requiring insurance ", But this
insurance still is excess over valid and
collectible other insurance, whether primary,
excess, contingent or on any other basis, that
is available to the insured when the insured is
an additional insured under any other
insurance.
C. The following is added to Paragraph 8.
Transfer Of Rights Of Recovery Against
Others To Us in COMMERCIAL GENERAL
LIABILITY CONDITIONS (Section IV):
We waive any rights of recovery we may have
against any person or organization because of
payments we make for "bodily injury",
"property damage" or "personal injury" arising
out of "your work" performed by you, or on your
behalf, under a "contract or agreement
requiring insurance" with that person or
organization. We waive these rights only
where you have agreed to do so as part of the
"contract or agreement requiring insurance"
with such person or organization entered into
by you before, and in effect when, the "bodily
CG D3 81 09 07 © 2007 The Travelers Companies, Inc. Page 1 of 2
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
J3
injury" or "property damage" occurs, or the
"personal injury" offense is committed.
The following definition is added to
DEFINITIONS (section V):
"Contract or agreement requiring insurance"
means that part of any contract or agreement
under which you are required to include a
person or organization as an additional insured
on this Coverage Part, provided that the "bodily
injury" and "property. damage" occurs, and the
COMMERCIAL GENERAL LIABILITY
"personal injury" is caused by an offense
committed:
a. After you have entered into that contract or
agreement;
b. While that part of the contract or
agreement is in effect; and
c. Before the end of the policy period.
CG D3 81 09 07 © 2007 The Travelers Companies, Inc. Page 2 of 2
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
TRAVELERS Jft
ONE TOWER SQUARE
HARTFORD, CT 06183
CHANGE EFFECTIVE DATE: 07 -09 -12
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
CHANGE DOCUMENT WC 99 99 98 (00)
POLICY NUMBER: (XJUB- 3790T99 -A -11)
NCCI CO CODE: 13579
INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMER A
INSURED'S NAME: BUCKNAM INFRASTRUCTURE GROUP,
INC.
This change is issued by that member of The Travelers Insurance Companies which issued the policy and forms
a part of the policy. It is agreed that the policy is amended as follows:
An absence of an entry in the premium spaces below means that the premium adjustment, if any, will be made at
time of audit.
ADDITIONAL PREMIUM $
ADDITIONAL NON - PREMIUM $
RETURN PREMIUM $
RETURN NON - PREMIUM $
The following endorsement charge is added to the schedule:
STATE OF CA
LOCATION 001 01
WAIVER OF SUBROGATION
SEE ENDT WC 99 03 76 ( A) -001
CLASSIFICATION CODE PREM. BASIS RATE
WAIVER OF SUBROGATION 0930 0.0300
The following endorsements are added:
WC 99 03 76 ( A) -001
WC 89 06 14 (00) -001
The following endorsement is deleted:
ESTIMATED
PRO RATA
PREMIUM
47MP
DATE OF ISSUE: 07 -16 -12 JM CHANGE NO: 001 PAGE 001 OF LAST
POL. EFF. DATE: 09 -16 -11 POL. EXP. DATE: 09 -16 -12
OFFICE: SPECIALIST A &E 21X
PRODUCER: WILLIS INS SVCS OF CA CGW81
COUNTERSIGNED AGENT
TRAVELERS J� WORKERS COMPENSATION
ONE HAR TFORD, CT 06183 TOPER SQUARE AND
EMPLOYERS LIABILITY POLICY
HARTFORD,
ENDORSEMENT WC 89 06 14 (00) — 001
POLICY NUMBER: (XJUB- 3790T99 -A -11)
POLICY INFORMATION PAGE
ENDORSEMENT
Item 3.D. Endorsement numbers is changed to read:
"See Change Document or Information Page Schedule"
ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED,
DATE OF ISSUE: 07 -16 -12 ST ASSIGN:
TRAVELERS /� WORKERS COMPENSATION
AND
ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY
HARTFORD, CT 06183
ENDORSEMENT WC 99 03 76 ( A) — 001
POLICY NUMBER: (XLUB- 3790T99 -A -11)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS
ENDORSEMENT - CALIFORNIA
(BLANKET WAIVER)
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not
enforce our right against the person or organization named in the Schedule.
The additional premium for this endorsement shall be 03. % of the California workers' compensation pre-
mium.
Schedule
Person or Organization
CITY OF EL SEGUNDO
350 MAIN STR
EL SEGUNDO CA 90245
Job Description
PAVEMENT MANAGEMENT
PROGRAM UPDATE 2012
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise
stated.
(The information below is required only when this endorsement is issued subsequent to preparation of
the policy.)
Endorsement Effective Policy No. Endorsement No.
Insured Premium
Insurance Company Countersigned by
DATE OF ISSUE: 07 -16 -12 ST ASSIGN: Page 1 of 1