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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