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PROOF OF INSURANCE (2015) CLOSEDCertificate of Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON YOU THE CERTIFICATE HOLDER, THIS CERTIFICATE IS NOT AN INSURANCE POLICY AND DOES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED BELOW, POLICY LIMITS ARE NO LESS THAN THOSE This is to Certify that WEST COAST AHSCISTS, INC 2200 EAST VIA BURTON NAME AND ANAHEIM CA 92806 a Mutual,,, � OF INSURED -- L I N S U R A N (" is, at the issue date of this certificate, insured by the Company under the policy(ies) listed below, The insurance afforded by the listed policy(ies) is subject to all their terms, exclusions and Conditions and is not altered by any requirement, term or condition of any contract or other document with respect to which this certificate may be issued. If the certificate expiration date is continuous or extended terra you will be notified if coverage is terminated or reduced before the certificate expiration date NOTICE OF CANCELLATION: (NOT APPLICABLE UNLESS A NUMBER OF DAYS IS ENTERED BELOW.) BEFORE THE STATED EXPIRATION DATE THE COMPANY WILL NOT CANCEL OR REDUCE THE INSURANCE AFFORDED UNDER THE ABOVE POLICIES UNTIL AT LEAST 30 DAYS NOTICE OF SUCH CANCELLATION HAS BEEN MAILED TO: Liberty Mutual Insurance Group FCity of El Segundo 350 Main Street E`XP DATE Elaine Ulan m d El Segundo CA 90245 ❑ CONTINUOUS Los Angeles / 0603 AUTHORIZED REPRESENTATIVE TYPE OF POLICY ❑ EXTENDED POLICY NUMBER LIMIT OF LIABILITY ❑ POLICY TERM Los Angeles CA 90017 213 - 624 -1171 11/13/2014 WORKERS 7/1/2015 WA7 -66D- 039499 -074 COVERAGE AFFORDED UNDER WC LAW OF THE FOLLOWING STATES: EMPLOYERS LIABILITY COMPENSATION CA,NV,AZ Bod'illr ]rr "grmy b} Accitlerdt STATUTORY CERT NO.: 22360235 CLIENT CODE: LM 2919 Kathy Creisher 11/13/2014 3:35:26 PM (CST) Page 1 of 2 1 000 OOL;, , ant Bodily Injury By Disease $1,000,000 Bodily Injury By Disease $1,000,000 COMMERCIAL 7/1/2015 T132- 661 - 039499 -014 'General Aggregate GENERAL LIABILITY $2,000,000 m OCCURRENCE Products / Completed Operations Aggregate $2 000 000 ❑ CLAIMS MADE Each Occurrence $1,000,000 RETRO DATE Personal & Advertising Injury $1,000,000 Per Person/ Organization Other Iher FIRE DAMAGES $100,000 MEDICAL PAYMENTS $5,000 AUTOMOBILE 7/1 /2015 AS7- 661 - 039499 -034 I ach Accident Single Limit $2,000,000 B I. And P.D. Combined LIABILITY Each Person OWNED NON -OWNED Each Accident or Occurrence �m LI HIRED Each Accident or Occurrence OTHER 7/l/2014-7/l/2015 TH7 -661- 039499- 044I�f %F� % /�j/ Umbrella Excess Liability i - ADDITIONAL COMMENTS See Addendum. If the certificate expiration date is continuous or extended terra you will be notified if coverage is terminated or reduced before the certificate expiration date NOTICE OF CANCELLATION: (NOT APPLICABLE UNLESS A NUMBER OF DAYS IS ENTERED BELOW.) BEFORE THE STATED EXPIRATION DATE THE COMPANY WILL NOT CANCEL OR REDUCE THE INSURANCE AFFORDED UNDER THE ABOVE POLICIES UNTIL AT LEAST 30 DAYS NOTICE OF SUCH CANCELLATION HAS BEEN MAILED TO: Liberty Mutual Insurance Group FCity of El Segundo 350 Main Street Elaine Ulan m d El Segundo CA 90245 Los Angeles / 0603 AUTHORIZED REPRESENTATIVE r x 818 W 7th Street, Suite 850 0564408 Los Angeles CA 90017 213 - 624 -1171 11/13/2014 OFFICE PHONE DATE ISSUED This certificate is executed by LIBERTY MUTUAL INSURANCE GROUP as respects such insurance as is afforded by those Companies NM 772 07 -10 CERT NO.: 22360235 CLIENT CODE: LM 2919 Kathy Creisher 11/13/2014 3:35:26 PM (CST) Page 1 of 2 LDI COI 268896 02 11 AGENCY CUSTOMER ID: LM 2819 LOC #: AC40R" AnnITHIMAI REMARKS Sr.Wl= ll ll F AGENCY Mutual Insurance Co. National Insurance West POLICY NUMBER CARRIER I!... NAIC CODE MI !!A THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: NM FORM TITLE: Certificate of Casualty Insurance CERTIFICATE HOLDER. City of El Segundo ADDRESS: 350 Main Street El Segundo CA 90245 NAMEDINSURED WEST COAST ARBORISTS„ INC 2200 EAST VIA BURTON ANAHEIM CA 92806 EFFECTIVE DATE: Paae of Per forms CG 2010 and CG2037 for General Liability and CA 2048 for Automobile Liability The City of E1 Segundo, its officials, and employees are included as Additional Insured, but only if required by written contract with the Named Insured prior to an occurrence and as per attached endorsements. Per form LN 2001 this insurance shall be excess over any other coverage available to the additional insured, unless a written agreement obligates the named insured to provide insurance to the additional insured on another basis. In that event, this policy will apply on the basis required by written contract. Waiver of subrogation in favor of the City of E1 Segundo, its officials, and employees included on WC where allowed by statute and applies only to the specific jobs of the insured performed under written contract. ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ADDENDUM CERT NO.: 22360235 CLIENT CODE: LM ,2819 Kathy Creisher 11/13/2014 3:35:26 PM (CST) Page 2 of 2 POLICY NUMBER: TB2 -661 -039499 -014 CONWRCIAL GENERAL LIABILITY CG 2010 0413 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 A. Section II — Who Is An Insured is amended to 1. All work, including materials, parts or include as an additional insured the person(s) or equipment furnished in connection with such organization(s) shown in the Schedule, but only with work, on the project ('other than service, respect to liability for "bodily injury ". "property maintenance or repairs) to be performed by or damage" or "personal and advertising injury" on behalf of the addiitional insureds) at the caused, in whole or in part, by: location of the covered operations has been 1. Your acts or omissions; or completed: or 2. The acts or omissions of those acting on your be half; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However. 1. The insurance afforded to such additional insured only applies to the extent permitted by law: and 2. if coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. 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. 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. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance. If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of Insurance: 1. Required by the contract or agreement; or 2.. Available under the applicable Limits of insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. SCHEDULE Name Of Additional Insured Person(s) Location(s) Of Covered Operations Or Organizadon(s); Any owner, lessee, or contractor for whom you have Any location listed in such agreement agreed in writing prior to a loss to provide liability insurance Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 2010 0413 Q Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: TB2- 661039499 -014 COMMERCIAL GENERAL LIABILITY CG 26.37 0413 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 PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART A Section ll — 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'. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. Name Of Additional Insured Person(s) Or Organization(s): B. With respect to the insurance afforded to these additional insureds, the following is added to Section [[I — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance_ SCHEDULE Any owner, lessee, or contractor for whom you have agreed in writing prior to a loss to provide liability insurance 1. Required by the contractor agreement; or 2. Available .under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations, Location And Description Of Completed Operations Any located listed in such agreement Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 20 37 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 1 Policy Number TB2- 661 -039499 -074 Issued by Liberty Mutual Fire Insurance Co. THIS ENDORSENENT CHANGES THE POLICY. PLEASE READ ITCAREFULLY. BLANKET ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SECTION 11- WHO IS AN INSURED is amended to include as an insured any person or organization for whom you have agreed in writing to provide liability insurance. But; The insurance provided by this amendment: 1. Applies only to "bodily injury" or "property damage" arising out of (a) "your work" or (b) premises or other property owned by or rented to you; 2. Applies only to coverage and minimum limits of insurance required by the written agreement, but in na event exceeds either the scope of-coverage or the limits of insurance provided by this policy; and 3. [does not apply to any person or organization for whom you have procured separate liability insurance white such insurance is in effect, regardless of whether the scope of coverage or limits of insurance of this policy exceed those of such other Insurance or whether such other Insurance is valid and collectible. The following provisions also apply: 1. Where the applicable written agreement requires the insured to provide liability insurance on a primary, excess, contingent, or any other basis, this policy will apply solely on the basis required by such written agreement and Item 4. Other Insurance of SECTION IV of this policy will not apply. 2. Where the applicable written agreement does not specify on what basis the liability insurance will apply, the provisions of Item 4. Other Insurance of SECTION lV of this polity will govem. 3 This endorsement shall not apply to any person or organization for any 'bodily injury" or "property damage" if any other additional Insured endorsement on this policy applies to that person or organization with regard to the "bodily injury' or "property damage".. 4. If any other additional insured endorsement applies to any person or organization and you are obligated under a written agreement to provide liability insurance on a primary, excess, contingent, or any other basis for that additional insured, this policy will ,apply solely on the basis required by such mitten agreement and Item 4. Other Insurance of SECTION 1V of this policy will not apply, regardless of whether the person or organization has available other valid and collectible insurance. If the applicable written agreement does not specify on what basis the liability insurance will apply, the provisions of Item 4. Other Insurance of SECTION IV of this policy will govern. LN 20 0106 05 POLICY NUMBER:AS7- 661 - 039499 -034 COMMERCIAL AUTO CA 20 48 110 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. SCHEDULE Name Of Person(s) Or Any person or organization whom you have agreed in writing to add as an additional insured, but only to coverage and minimum limits of insurance required by the written agreement, and in no event to exceed either the scope of coverage or the limits of insurance provided in this policy. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.I. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 10 13 0 Insurance Services Office, Inc., 2011 Page 1 of 1 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA 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. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Cr anizatiop Job Description Where required by contract or written agreement prior to loss and allowed by law. Subject to a minimum premium of $250 per policy. Issued by Liberty Insurance Corporation 21814 For attachment to Policy No. WA7 -66D- 039499 -074 Effective Date Premium $ Issued to West Coast Arborists, Inc. WC 04 03 06 Page 1 of 2 ED: 04/1984