Loading...
PROOF OF INSURANCE (2015) CLOSEDCERTIFICATE Off" LIABILITY I SURAI CE Pa e 1 of 2 04/13/20 I 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). Willis of Pennsylvania, Inc. PHONE F, 877 945 7378 e r nn 88$ 467 2378 c/o 26 Century Blvd. _ , 0, fir a . --MAIL P. O. Sox 305191 hDDR P SS _940.1.r l. ll hem Nashville, TN 37230 -5191 INSU RER(S)AFFORDINGOOVERAGE N_AIC ... # w. _ .. INSURERA Liberty Mutual Fir e Insurance Compa zy 23035-001 ...... .......- ..� .1-- m...�,„�.., ____ ......_ INSURERB:Westchester Fire Insurance Company 10030 001 VCI Utility Services, Inc. dba Vantage Utility Services INSURERC:Liberty Insurance Corporation ._ —� w . ....... .. ....u,,. �. ... 42404-001 _. -- - 1369 West Ninth Street - Upland, CA 91786 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 23090437 REVISION NUMBER :See Remarks 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 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. .INSR., ...,__..,... DDL SUB POL ................_,._.. ° °-- -- TR TYPE OF INSURANCE uen wv 1 CYNUMBER ...�..... .... .... ,_ ..... „_____ _ ..... POLICYEFF POLICY EXP ,.... ............... n.wnn,vwv� LIMITS r A X COMMERCIAL GENERAL LIABILITY Y Y TB2631004260014 7/31/2014 7/31/2015,,'9 CHOCCURRENCE $ S.000.00041, 000 000 _. �. CLAIMS -MADE OCCUR PANNUM-�aTS5,6e4 $„ 1 000 000 .— ... ..................... ....... ..._........_ ..� MED EXP & one r:raod .. $ ........ .. ,.......,, PERSONAL& ADV INJURY $ 5.000.000 GEN'LAGGREGATELIMITAPPLIESPER: LIMIT G,,,,,,,,,� $ 5 000. 000 lLIESP PRO- POLICY LOC „m,,�,--- _�._.�_ PRNERALAGGREGATE ODUCTS- COMP /OPAGG ..., S 5a 000. 000 0'R HER: $ _ A AUTOMOBILE LIABILITY Y Y AS2631004260024 7/31/2014 ...7/31/2015.7MBI,NLDS INCLt LIMIT a I RITI $ 5, 000, 000 ......... X ANYAUTO BODILY INJURY(Per person) $ ALLOWNED ”' " ". " °' SCHEDULED BODILYINJ..........m........ -- _ - --.-- URY(Peraccldent) ......... ..... ,...... $ X AUTOS _.. AUTOS HIRED AUTOS X NON -OWNED hUI��I�T�I�A�E IPP' oa accldara ):. $ $ B X UMBRELLALIAS X IOCCUR Y Y G22049860009 /31/2014 7 /31 /2015'',EACHOCCURRENCE $ 5.000.000 EXCESS LIAB.. CLAIMS -MADE GGREGATE $ 5 000 000 DED RETENTION $ $ C WORKERS COMPENSATION Y WA763DO04266034 7/31/2014 7/31/20154 PER X . . IU= =o EMPLOYERS' ABILITY C N/A Y WC7631004260044 7/31/2014 7/31/2015 "E..L. $ 1 000 000 ml OF ICER/MEMBEREXCLNER&XECU'TNVE. anCERI , MB jrsndatory SEAACCIIDENT EMPLOYEE $ 000 000 c efl D SCRtlFaflON O OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000 0,000 DESCRIPTION OF OPERATIONS,ILOCATIONS I VENICL:ES, (ACORD 1104, Additenal Rernarks Sohadulo, may be aftaehod I( more space Is required) THIS VOIDS AND REPLACES PREVIOUSLY ISSUED CERTIFICATE DATED: 3/26/2015 WITH ID: 22971562 Workers'Compensation in State of Washington is Self Insured. City of EL Segundo is included as an Additional Insured as respects to General Liability, Auto Liability and Umbrella Liability as required by Written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE d / THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN r ACCORDANCE WITH THE POLICY PROVISIONS. �0 AUTHORIZED REPRESENTATIVE City of EL Segundo.' 350 Main St EL Segundo, CA 90245 Coll:4667005 Tp1:1845494 Cert:: eserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 800350G .............�..........�... _ .. ........ _ ... __ LOC#:._........................... ................... .......... �.......... AC" ADDITIONAL REMARKS SCHEDULE Page 9 of � AGENCY NAMED INSURED VCI Utility Services, Inc. Willis of Pennsylvania, Inc. _ dba Vantage Utility Services POLICY NU M MBER BER �....... 1369 West Ninth Street Upland, CA 91786 See First Page CARRIER NAIC CODE See First Paae EFFECTIVE DATE: See First P8se ACORD 101 (2008101) Coll:4667005 Tpl:1845494 Cert: 23090437 © 2008 ACORD CORPORATION. All rights reserved, The ACORD name and logo are registered marks of ACORD Policy Number: TB2631004260014 & AS2631004260024 Endorsement Number: LA 99 224 09 10 Issued by: Liberty Mutual Fire Insurance Company & Liberty Mutual Fire Insurance Company Endorsement Effective Date: 7/31/2014 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF - INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule below. We will send notice to the email or mailing address listed below at least 10 days, or the number of days listed below, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. SCHEDULE Name of Other Person(s) / Email Address or mailing address: Number Days Notice: Organization(s): City of EL Segundo 350 Main St ❑EL Segundo, CA 90245 30 ..... All other terms and conditions of this policy remain unchanged. LA 99 224 09 10 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO THIRD PARTIES A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule below. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance email notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. SCHEDULE i Name of Other Person(s) / Email Address or mailing address: Number Days Notice: Organization(s): City of EL Segundo 350 Main St ❑EL Segundo, CA 90245 30 WA7 -63D- 004260 -034 (AOS) WC7- 631 - 004260 -044 (OR & WI) Effective: 7/31/2014 Expiration: 7/31/2015 All other terms and conditions of this policy remain unchanged.. WM 90 18 09 10 2010 Liberty Mutual Group of Companies Page 1 of 1 Ed. 09/01/2010 All Rights Reserved Policy Number: TB2631004260014 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) Or Organization (s): of EL Segundo Location(s) Of Covered Operations as required by written contract Information required to complete this Schedule, if not shown above, will be shown in the Declarations. 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 on oLing operation for the additional insured(s) at the locations) designated above. ��� 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: 1. 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 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. CG 2010 07 04 © ISO Properties, Inc., 2004 POLICY NUMBER: TB2631004260014 COMMERCIAL GENERAL LIABILITY CG20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ED - 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) Location And Description of Completed Operations Or Organization(s) City of EL Segundo as required by written contract Information required to complete this Schedule, if not shown above, 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 r w rK", 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 © ISO Properties, Inc., 2004 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, WAIVER OF TRANSFER RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: Business Auto Coverage Form Garage Coverage Form Truckers Coverage Form Motor Carrier Coverage form SCHEDULE Premium: Name of Persons or Organization: Any person or organization for whom you perform work under a written contract if the contract requires you to obtain this agreement from us, but only if the contract is executed prior to the injury or damage occurring. City of EL Segundo The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your operations of a covered auto done under contract with that person or organization. This waiver applies only to the person or organization shown in the Schedule above. Effective Date 7/31/2014 Expiration Date 7/31/2015 For attachment to Policy No. AS2631004260024 Issued To VCI Utility Services, Inc. Issued By: Liberty Mutual Fire Insurance Company AX 12 10 02 05 Page 1 of 1 POLICY NUMBER: TB2631004260014 INSURED: VCI Utility Services, Inc. COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. Name of Persons or Organization: City of EL Segundo Information reouired to SCHEDULE not shown in the Declarations. The following is added to Paragraph 8. Transfer of Rights of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products- completed hazard ". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 ©ISO Properties, Inc. 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 of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization ANY PERSON OR ORGANIZATION WHERE THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO THE DATE OF THE ACCIDENT, TO WAIVE RIGHTS OF RECOVERY AGAINST SUCH PERSON OR ORGANIZATION. This endorsement is executed buy the Liberty Insurance Corporation Premium $ Effective Date 7/31/2014 as required by written contract Expiration Date 7/31/2015 For attachment to Policy No WA763DO04260034 WC 04 03 06 ED: 4/1984