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PROOF OF INSURANCE (2016) CLOSEDLAYNE -2 OP ID: HB ACC>RL "" DATE (MMIODNYYY) Ils� CERTIFICATE OF LIABILITY INSURANCE 04/23115 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). PRODUCER E7- 925 -977- HAaaE; Easterly surety 4ns,8ucs.lnc Pri rrE � i 1,AX 925- 977 -9224 56 May flew Way I� s s, (I; ..t��YOI. Walnut Creek„ A 94597 E-MAIL ADDRFPI Kevin P. Easterly "' m, R _ m�ySIREA Ih NAIC a IiNSUPteRA,James River Insurance Company 12203 ENSURED C C Layne & Sons NNSUMx State Com ,lns.Fund of Ca 35076 "E "RB C. Craig Layne 9 Y INSURER C . 213 Richmond Street El Segundo, CA 90204 INSURER D_: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 I$ ' SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ A ,..... OOLISVIBR CJdlnry vrd POLM ..e, . INSR LIMITS TYPE OF INSURANCE POLICY NUMBER Md YY. I yFXP GENERAL LIABILITY. U,AL,IN 4bL:CUF4HkNCiw � 1,000,00 _ ' DAMIAC(~'TONENTCD A X OMMERCIAL GENERAL LIABILITY X X 00528483 I 04/14/15 1, 04114/16 Iro(I'LW�u'.e eraerroyt; .. 50',00 - _ �., ... M �c CLAIMS-MADE X OCCUR I ME L) rX4� gAaP one crsuu�tl 3 Exclude PERSONAL BTADV INJURY ,,,,.... .� I _ GENERAL AGGREGATE S ...$ _ 2 000 OO... ... , , ...� L.,— .. —.e. ... . w,,,. �,..... ..w ,... GATE LIMIT APPLIES PER PRODUCTS - COMPlOP AGO $ " ,,. ,... 2,000,00 ,., x .. i i'OLVCY_ AUTOMOBILE LIABILITY CtJMDINCL) INC,LE II NIdRIT '�. P n�iCi�I,rd4,� " " "" 1 BODILY INJURY (Per person) $ R I ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS NON OWNED iAOOti;TY "[*MAGE _ $ _ „® HIRED AUTOS AUTOS t4�rotid9 SI $ 1 II ... .. _ UMBRELLA LIAR X OCCUR j EACH OCCURN8 NCI.. $ 4,000,00 u A X . EXCESS LIAR CLAIMS -MADE 4 XL66037002 04/14/15 04/14/16 I AGGN�N.ATq I 4,000,00, X RETENTION$ ........ ._ DEO i f I WORKERS COMPENSATION 1wY hli`III'T bI«I�i9. ��.... AND EMPLOYERS' LIABILITY ,,,,,,...L,� B ANY PROPRIETORIPARTNERIEXECUTIVE YIN X 9088031 02/01/15 02/01116 1 L L EACH ACCIDENT S 1,000,00 OFFICERIMEMBER EXCLUDED? NIA EL DISEASE EA f MP i t'7YFt,, $ (Mandatory In NH) 1,000,00.: If yas, dirsvibe under I DSCRIIP'R'N N OF OPERATIONS below i ° L I WSI.:.ASIL F`00r'Y t lMI1 $ 1,000.00 77� DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, It more space Is required) PROJECT: WATER DIVISION CARPET REMOVAL AND REPLACEMENT. JOB NO. 13 -21. CITY OF EL SEGUNDO, ITS OFFICIALS AND EMPLOYEES ARE NAMED AS ADDITIONAL INSURED PER THE ATTACHED ENDORSEMENT FORMS CG2010 0704 AND CG2037 0704. THIS INSURANCE IS PRIMARY AND NON- CONTRIBUTORY. WAIVERS OF SUBROGATION APPLY. *10 DAYS NOTICE OF CANCELLATION FOR NON - PAYMENT OF PREMIUM BY CERTIFIED OR CERTIFICATE HOLDER CANCELLATION ELSEGUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF EL SEGUNDO ACCORDANCE WITH THE POLICY PROVISIONS. 350 MAIN ST EL SEGUNDO, CA 90245 AUTHORIZED REPRESENTATIVE ®1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD NOTEPAD: ISTE; ED MAIL. HOLDER CODE ELSEGUN INBURED'S NAME C C Layne & Sons LAYNE -2 OP ID: HB PAGE 2 DATE 04/23/15 /AK -1"1< " CERTIFICATE OF LIABILITY INSURANCE DATE(MMDD /YYYY) ' 03/10/2015 THIS CERTIFICATE IS ISSUED AS A NIA ER 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. the terms an dcconditions p diti nsrE sdsh "policy, certain policies may require aTp endorsement. L1ads�t Ire trndorsafd. tl1 SUBROGATION IS WAiVED sN1ta}errmm- -- N to y nt. A statement on this certificate does not confer rights to the PRODUCER pdenton WeS&tl REMON WASFI (PRONE ENI.310J22 1192 �.�.�. 7-g ik" 3otb -S'�roG 1tiV97 1..G4. 1 ... ... StafeFatm 432 MAIN ST nooaECC remon wasfi kOw3d�7,ry6 ugclDxgTl mspNp • EL SEGUNDO, CA 90245 NlsaRttT P NAICS� &-' �. ,n. ... 6NsAlIR &M11 t9 Slade Form Mutual Automobile Insurance � 25151 ;s AAFON4DIrN$ pVERAQE 11 INSURED - - -o-CC LAYNE SONS - *v�RaK A Ste tar Fann General Insurance .. —Ubrl yuLer "y 25178 213 RICHMOND ST lnsumnce �. EL SEGUNDO, CA 90245 - -.... -- .. .. .. .,.,.. Na $URERC. THIS IS TO C8'2Rn' Y THAT "IIIL POLIC;"EYw OF INSURANCC UISTTiD SELrpiu Ftl h+E ff1CI N 15 CD 'CO 'TFkE: IWStkdXCI D NAA,IFD At117Mir" FW:YR TAIL T'xCNp„ICW F"I F"aot INUICAFED Nll`�VdTluq'rANIAIN 3, ANY RTUUMEMEN�T, TERM OR C41ltNDITICIN OF ANY C'ONFRACT OR d111It.R. DOCUMENT WW1 "PH RFSPECT T'D MMLICH THIS CLRINFICATE. MAY 11F ISSUED MAY PERTAIN, T`HE wSuRANCE AF1aOR;DED BY THE POLICIES DE;9CR9RED ISE'RrIN IS SUBJIECfT 110 AUL THE 'TERMS, EXI I USIONS AND CONDITIONS OF Sd,10_H POLICIES, (LIMITS B%9 "MAY HAVEw'- DCLH HED19CEIR BY PAI'�O CI.AIMS, ., AOOi 1"- . i °mI Y «v s"uwF b�mmuErAtcRTtI LaMats$ R COMMERCIAL GENERALR ", POLICY NUMBER q^^^••°°— ^^^^^^ 7MPE CI'F "WSVRA _ L ABILITY CLAIMSWADE [j OCOUR PERSONAL & AD SIP Nil ACC rlL" JEAr PROF XP fA 1 $ CATt 4ROr AI F'I � $ F dl IC"( PRO I..00 GENORATS AGGREGATE & _ A AI)TOMOUNLE.L.M:DFUIY Y.... 019- 3457- F22 -75H - -- 1212212014 06/2212015 Cv Clrstn N "LMf'f""" $ WW 9 .ANVAUro 446- 1681- A31.75B 0113112015 0713112015 odnat,weraeaxRAar( verger ) $ LHIRED OWNED SCHEUULED -- '�° S . AUTOS 211- 9366- C26 -75X ' 03126!2015 0312512016 nOnlLVItd AjRY(P -'rr A0wl $ AUTOS NON -OWNED Y°R2}TrT'id5b^TIhNaVn -iF• ,., AurOS 470. 7387- FO6.75 0610612014 0610612015 U.. ELLA LIAR 1 w..m. S OC( UR ......... —,.. EACH fyt,F„IdRWYriN'F: $ E%CE$$ DAB , ,..,�...�.......�.... .. r ..,,... AND Nlg - II EL UI.SELASF CIEAIEYL YPI s DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES (ACORD 101, AVdilional Remarks Schedule, may be attached 11 mor<space Is required) ADDITIONAL INSURED: THE CITY OF EL SEGUNDO. ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS, AND VOLUNTEERS NAMED AS ADDITIONAL_ INSUREDS CITY CLERK SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF EL SEGUNDO ° THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS, EL SEGUNDO, CA 90245 AUTHORIZED Rel ^W L'JIkkYTAT9VL "- ✓ - ' ` f se 1,008.2014 AC'ORD CORPORATIOf All 6ghta reserved.. ACORD 25 (2014101) 14ACRCiaune and logo are registered marks of ACORD 4001406 132849 9 02 -04 -2014 CERTIFICATE OF LIABILITY INSURANCE 10 212015 ,RTIFICATE 19 MSUED AS A MA111UR OF INFORMATION ONLY AND CONFERS NO RIGHtS UPON 'THE CERTIFICXTF�&6ik—f4ili THIS Cr CERTIFICATE DOES NOT AFFIRMATWELY OR NEGATIVELY AMFNO, r-XTLND 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 lilt CFATIPICATC ItOlbrk I 11TANT; If 1, 1' I l the terms and conditions of the policy, certain pollrleg �ay requ 00001catv bohlor In IIGU Of such Olf1da"*Io Ire an endorsement, A Statement On this certificate does not Confer dghtc to the REMON WASH StateFarm 432 MAIN ST igt. 0 n lo h ma 0, Ow3tval nrl ELSEGUNDO, CA 90245 . .. . ......... ww ..... . . . . . OTC, INSURED mpt i'stl Im If'N O(Kw all 10 40CA" 04mli4fly Ct LAYN't- -&'8bs 213 RICHMOND ST ROMM9 �Sio��'Fartl Muloal Aotomob0(,r Inaufail �Iompahy 26178 EL SEGUNDO, CA 0246 Mr—F456Fy —io INDICATEC), NO "I rHSIVANOINO ANY OR (,ONCIII'l(Al 01, ANY CONTRACTOR 0110,`A DOCUMENI VIA 11", TO WHICH I'I4W CEl IOAY aer 830VOI OR MAY PCRIA��i� 1W �NWRANCC AFl By tillEft VP 0XIC LXCII USHY43, AN D COit(I "IES, urselftow"o HEREIN IS To ALL THE TERM8, 11111ONSOPSUOf POLICIES, UMITS MIOOffil M(WHAVE BEEN MiDIXED DY PAID�'t,AjMs Ul OIS b�' "'ll", OIL—, LIMITS YI, FAIA I C P CI Ill M 1C rIa�'AQVQl lrWAPPLIESPER. 4'U' LOC i �2-68464!1�9-75C 47" A AUTOMOBILE LIABIll 1000 000 06f1912016 a Boo ANYAUI`0 284-6408-E07.76E 111tolf2014 0610-112016 L SCHEDULED AL 11*Il AUTOS AUTOS N N-OIANEO 0 . . ....... AUTOS S UMUMli IA4 ------------- . . ..... CGUR EAqA0*r'.Ck*UII!NCF E -USLIAl. XCIII � a NIAI I I D E L ADDITIONAL INSURED: THE CITY OF EL SEGUNDO, IT OFFICERS, OFFICIALS, EMPLOYEES, AGENTS, AND VOLUNTEERS NAMED AS ADDITIONAL INSUREDS. LRTIFtCATEHO 1. DER CITY CLERK CITY OF EL SEGUNDO 350 MAIN STREET EL SEGUNDO, CA 90245 ACORD 25 (2014101) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Tilt EXPIRATION DATE THCREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, ......... 1988-s014 ACORD COrtPry All rIgins resel The ACORD name and logo are registered marks of ACORD 1001486 132848.9 0204-2014 POLICY NUMBER: 00052848 -3 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. • • "" • This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Addltlonal Insured Person(s) Or Organlzatlonfsl: Location(s) 01 Covered _qp2jatlons where required by written contract or written agreement all operations of the named insured Information re wired to com lets this Sdi�edtrle if not shown above, will be shown rn tiYe Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional exclu- organi,zat�on(s) shown in tits Schedule, but only sions apply: with respect to tdaktility for "bodily injury property This insurance does not apply to "bodily injury" or damage" or ° ,personal and advertising injury` "property damage" occurring after: caused, wn whole or in part, by', 1. All work, irgoVUding parts or equip - 1. Your acts or omissions; or ment furnished in cnnnection with such work, 2. The acts or omissions of those acting on your on the pr'ojec' (Vher than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operralions for the additional insured(s) at the location of the covered operations has been completed; or the additional insured(s) at the location(s) desig- nated above. 2. That portion of " "your work' out of which the injury or damage arrses has been prat to its in- tendod use by any person or orga i7atior rater, . er than another 0ontractor or, stabt:QMtTaC1ur engaged In performing operations for a princi- pal as a part of the same project. CG 20 10 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 0 POLICY NUMBER: 00052848 -3 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED D - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS S This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name 01 Additional Insured Person(s) Location And Description Of Completed Opera - Or Orosnlzation(s): tions where required by written contract or written agreement all operations of the named insured 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 organiza- tion(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 desig- nated and described in the schedule of this endorse- ment performed for that additional insured and included in the "products- completed operations hazard ". CG 20 37 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON CONTRIBUTORY ENDORSEMENT This endorsement modifies insurance provided under the following: ALL COVERAGE PARTS Any coverage provided to an Additional Insured under this policy shall be excess over any other valid and collectible insurance avallaUe to such Additional Insured whether primary, excess, contingent or on any other basis unless a written contract or written agreement specifically requires that this insurance apply on a primary and noncontributory basis. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. AP5031 US O4 -10 Page 1 of 1 POLICY NUMBER: 00052848.3 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF' RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAIu GIFNERAt hiABILITY COVERAGE PART PRODUCTS/COMPLETED PRODUCTS/C,'OMPLETED OPERATIONS l_IABIL ITY rOVERAGE PART SCHEDULE Name Of Person Or Organization: Where required by written contract or written agreement Ifs ie. if not shown 'The following is added to Paragraph 5, Transfer Of Rights Of Recovery Against. Others To Us of Section IV - Conditions: .w . We waive any righn of recovery we may have aga nw the person or organization shown in the Schedule above, because of paymenns we make for inyu " °y or damage arpsing out of your orrgoi II opol ation$ 01' "your work" done under a contract with that Berson or orgad7mtion and included in the `ppaioduots complotod operations ha7ti +'d ".. Tins waiver app,:lics only to the person Or 0I,gan,i Ut,orr shown in the Schedule ttt >ove, CG 24 04 05 09 0 Insurance Services Office, Inc., 2008 Page 1 of 1 E3 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION 9088031 -15 RENEWAL NA 0- 23 -53 -02 PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE FEBRUARY 3, 2015 �T 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING FEBRUARY 1, 2016 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME C C LAYNE & SONS`INC 213 RICHMOND ST EL SEGUNDO, CA 90245 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, THE CITY OF EL SEGUNDO WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, C C LAYNE & SONS INC IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03 %. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED, NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT, COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUTHORIZED REPRESENT SCIF FORM 10217 (REVD -204$ FEBRUARY 5, 2015 PRESIDENT AND CEO 2570