Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
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