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PROOF OF INSURANCE (2016) CLOSEDDATE (MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE r ,W
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
Arthur J. Gallagher Risk Management Services, Inc.
1 W. 4th Street, Suite 1300
Cincinnati OH 45202
INSURED I INSURER B :
Landrum & Brown, Inc. INSURER C:
c/o Dennis Peters INSURER D:
11279 Cornell Park Drive
INSURER E
Cincinnati OH 45242 �...••....�------------ ----••.
INSURER F:
COVERAGES CERTIFICATE NUMBER: 1195313279 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 IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
...................... �... mTYPEmOFINSURANCE .. .�.,. ^ _i .., .._._,... ..,.E _...�.LIC _.. .... . ..,.,...... LIMITS . .............................
NNSR I(L. R POL4'CY EFF POLICY EXP
LTR !NSR. WVD POL,IC, NUMBER. MM(DD(''MY MMIDDrMY)
,4
GENERAL LIABILITY
Y
35786142
1/23/2015
/2312016
49ACH OCCURRENCE
$1.000.000
I ERALLIOCCUR
i'r'nc'�-Titlrr
„ rxriirrfnrel
$1 ODO 000
TCLAIMS-MADE X
((Fa
Any one person)
MEDEXPS,,,,, ...
$10.000
_ ........, ,,,......................................... .............
X Ohio Stop Gap
L & ADV INJURY
PERSONA .... ..... .....�..,
$1.000.000
...... _...... ................................. _...
GENERAL AGGREGATE
.................... ....
$2.000.000
.......... _................. ............................................. ---------
—
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP /OP AGG
''.. $2.000.000 i
,,,.
POLICY X JECT ', LOC
.............. ......
Employee Benefits
,........ -- - ----- `------- --
$1 000,000
A
AUTOMOBILE
_
.X
LIABILITY
Y
74968374
1/23/2015
1/23/2016
CO accident 1
$1.000,000
BODILY INJURY (Per person)
$
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident)
$
,,.,�..
NON -OWNED
HIRED AUTOS AUTOS
PROPERTY DAMAGE
(Per accident)
$
A
X
UMBRELLA LIAB X OCCUR
Y
79839506
1/23/2015
1/23/2016
EACH OCCURRENCE
$9,000,000
X
AGGREGATE
$9,000,000
EXCESS LIAB CLAIMS -MADE
DED RETENTION $
$
A
WORKERS COMPENSATION
71709699
112312015
1I23I2016
X rnrzv i nnrUrc OFa
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR /PARTNER /EXECUTIVE
''.. OFFICER/MEMEER EXCLUDED? E]
NIA
E,L., EACH ACCIDENT
$1,000,000
_____..,,,......._ .... __
(Mandatory in NH)
E,L. DISEASE_- EA EMPLOYEE
$1,000,000
If Y
DFSCRIPTION OF OPERATIONS below
E L, DISEASE - POLICY LIMIT
$m �.�m mm.. .._
1,000,000
B
Professional Liability
V11CU315PNPM
1/23/2015
1/23/2016
Limit 5,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
*Additional Insured for General Liability applies per policy form #80 -02 -2367 05/07 where required by law"
The City of El Segundo is named as aditional insured on a primary and non- contributory basis.
CERTIFICATE HOLDER
The City of El Segundo
350 Main Street
El Segundo CA 93010 USA
q Y1k �d
ACORD 25 (2010/05)
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
F''���7/
©1988 -2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
CHUME3 Liability Insurance
Endorsement
This appliel to �hc' folloMng lbrnjs�
GENEIRAV HABILFTY
I �ndcr Who Is An Illnsured, dic following pirovkion k added,
Who 1.9 Art Insured
Liability Insurance Additional Insured, - Scheduled Person Or Organization conto
80 02-2367 (Rev- 5-07) Endorsement Pace i
orm
such insurance as is afforded by (his policy.
All other terms and conditions remain unchanged,
Authorized Representative
Liability Insurance Addolional Insured - *Scheduled Person Or Organization
Form 80-02-2367 (Rev. 5-07) Endorsement
M2
w
WORKERS' COMPENSATION AND EMPLOYERS' LIABILMY INSURANCE POLICY
WC 124
(4 -84)
WC 00 03 13
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a
different date is indicated below.
(rhe following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the poky.)
This endorsement, effective on 01/23/15 at 12:01 A. M. standard time, forms a part of
(DATE)
Policy No. (16)7170 -96 -99 of the FEDERAL INSURANCE COMPANY
(NAME OF INSURANCE COMPANY)
issued to LANDRUM & BROWN INC
Endorsement No,
Authorized Representative
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.'
This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule.
Schedule
N1111".1
PER SCHEDULE ON FILE WITH COMPANY
AND ANY WRITTEN CONTRACT OR AGREEMENT
THAT IS AN INSURED CONTRACT, PROVIDED
THE BODILY INJURY OR PROPERTY DAMAGE,
TO WHICH THIS INSURANCE APPLIES, OCCURS
AFTER THE EXECUTION OF SUCH CONTRACT
OR AGREEMENT.
WC 124 (4 -84)
WC 00 03 13 Copyright 1983 National Council on Compensation Insurance, Page 1 of 1
cHUrata
Name & Mailing Address of the Insured
LANDRUM & BROWN INC
11279 CORNELL PARK DR
CINCINNATI OH 45242
FEIN 311095645
Name & Address of the Producer
Attached to and Forming Part of
Policy Number (16)7170 -96 -99
Policy Period 01/23/15 to 01/23/16
Effective Date 01/23/15
ARTHUR J GALLAGHER RISK MANAGEMENT SERV Name of Company
1 WEST FOURTH ST., #1300 FEDERAL INSURANCE COMPANY
CINCINNATI OH 45202 Endorsement Number
Producer Number 6 -48828 999
EXTENSION OF INFORMATION PAGE
ITEM 3.A.
COVERED STATES
It is agreed that Item 3.A of the Workers Compensation and Employers Liability Policy Information Page includes the
following states;
State
Risk I.D. State I.D. No.
CALIFORNIA
917615608
FLORIDA
917615608
ILLINOIS
917615608
INDIANA
917615608
KENTUCKY
917615608
MASSACHUSETTS
917615608
NEW MEXICO
917615608
NEW YORK
917615608
TEXAS
917615608
VIRGINIA
917615608
All Other Terms and Conditions Remain Unchanged L.., dLk'
Authorized R,epr esen atiwe
Issue Date 01/29115 CIN CLD
WC 00 00 01 A (Rev. 5 -88)
Sandoval', Liil'i
From: Garcia, Angelina
Sent: Thursday, April 30, 2015 1:29 PM
To: Sandoval, Lili
Subject: FW: City of El Segundo & L &B
Attachments: Landrum & Brown.pdf
Angelina Garcia
From: O'Neill, James
Sent: Thursday, April 30, 2015 11:22 AM
To: Garcia, Angelina
Subject: FW: City of El Segundo & L &B
- James
From: Tricia M. Rollins II o® t Ulit l n_ _m -ht nMco
Sent: Thursday, April 30, 2015 11:10 AM
To: O'Neill, James
Subject: FW: City of El Segundo & L &B
Hi James — fingers crossed on this one.
Let me know if this is not sufficient.
Thanks
Trish
From: Joyce Lieske rinailtojoyce Lieske0aig.coml
Sent: Thursday, April 30, 2015 1:21 PM
To: Tricia M. Rollins
Subject: RE: City of El Segundo & L &B
Tricia,
I have attached an updated state schedule showing the Risk ID # and agent signature. There is defiantly workers
compensation coverage in CA. The carrier just left off the Risk ID. Hopefully they will be ok with this one, if not I will be
happy to talk to them, if that will help.
Thank you..
Joyce Lieske, ACSR, CISR
Client Service Manager Senior
Joyce lieske@,gg.com
Arthur J Gallagher & Co,
�f
1 W. 4th Street, Ste 1300 1 Cincinnati, OH 45202
P: 513.977.31161 F: 513.977.4752
www-ajg,cpM I www.aigrms.com/cincinnati
Arthur J. Gallagher Risk Management Services, Inc.
Formerly Schiff, Kreidler -Shell Insurance Inc.
From: Tricia M. Rollins [mailto:trollins@ ndrt.im -brot n.cogm]
Sent: Thursday, April 30, 2015 9:07 AM
To: Joyce Lieske
Subject: FW: City of El Segundo & L &B
Good morning Joyce — seems this waiver is not going to do it.
Can you please check into the items James indicated in his email below and the corresponding attachment..
Thank you
Trish
From: O'Neill, James [ ailt :J N' _ ill else undo.or !]
Sent: Wednesday, April 29, 2015 8:56 PM
To: Tricia M. Rollins
Subject: RE: City of El Segundo & L &B
Trish —
The waiver actually seems to indicate that L &B does not have insurance in the state of California.
See attached.
There is no Risk I.D. listed for California.
Additionally, the form is unsigned
James
From: Tricia M. Rollins [mailto:trolli la r m- brown.com]
Sent: Tuesday, April 28, 2015 12:18 PM
To: O'Neill, James
Subject: FW: City of El Segundo & L &B
Hi James — let me know if this is not sufficient.
Trish
From: Joyce Lieske [mailto:Jo ce. Lies e" , ]
Sent: Tuesday, April 28, 2015 3:13 PM
To: Tricia M. Rollins
Subject: RE: City of El Segundo & L &B
Tricia,
Here is the page from the policy that shows the states covered. It does show California, does this work for the proof.
Let me know if the City wants anything else.
Thank you.
Joyce Lieske, ACSR, CISR
Client Service Manager Senior
Joyce ligs orrt
Arthur J. Gallagher & Co.
X 4 1, `,) `,qv l , ".0 S 416 , "1" V 4 <,'1 1 T R A F R 111' P1 n .,..
1 W. 4th Street, Ste 1300 1 Cincinnati, OH 45202
P: 513.977.31161 F: 513.977.4752
www.ajg.com I www.a" ris_cora�incinnt
Arthur J. Gallagher Risk Management Services, Inc.
Formerly Schiff, Kreidler -Shell Insurance Inc.
From: Tricia M. Rollins [mail o:froltlins I n r m- r wn,.c ]
Sent: Tuesday, April 28, 2015 1:25 PM
To: Joyce Lieske
Subject: RE: City of El Segundo & L &B
Hi Joyce — see snipit below. "Can you provide evidence that the Workers' comp is for the state of California ?"
Can you help me on this?
Trish
From: I :O'Neill, James <JON . @1dse undo.or >
To: IN T'rida M. Rollins
Cc:
Subject: Fes': L &6 - contract/ March billings
m , , 2 , . N , I p , , , 4 , , . n . , , , , . � , . . .6..
Trish —
From: Garcia, Angelina
Sent Monday, April 27, 2015 4:44 PM
To: O'Neill, James
Cc: Nguyen, Trang
Subject: RE: L &B - contract/March billings
Angelina Garcia
From: Joyce Lieske [mail o. o e Li ske a` m,
Sent: Monday, April 27, 2015 2:34 PM
To: Tricia M. Rollins
Subject: RE: City of El Segundo & L &B
3
Hi Tricia,
I have attached the forms requested. Please let me know if you need anything else at this time.
Thank you.
Joyce Lieske, ACSR, CISR
Client Service Manager Senior
Jo . e lieske a aia..com
Arthur J. Gaaher Co.
„d 4fi','r!5 CHf11i4 I,,fP1,Ailf:�
1 W. 4th Street, Ste 1300 l Cincinnati, OH 45202
P: 513.977.31161 F: 513.977.4752
M8"_,dLqS.om 1 w .a' rrns.00m1cincinnati
Arthur J. Gallagher Risk Management Services, Inc.
Formerly Schiff, Kreidler -Shell Insurance Inc.
From: Tricia M. Rollins [ma!Ito:tr!olli+n a rum r wn. ]
Sent: Monday, April 27, 2015 2:08 PM
To: Joyce Lieske
Subject: City of El Segundo & L &B
Hi Joyce! Welcome to the L &B account. The City of El Segundo has come back and said we need the highlighted below
in regards to the insurance. He has attached samples of what they are looking for.
I've attached correspondence between Tricia K and I for reference and the contract.
Can you please look into this?
Thanks so much!
Trish
Trish M. Rollins I Landrum & Brown
11279 Cornell Park Drive
Cincinnati, OH 45242
P: 513.530.1247 1 F: 513.530.2247
From: O'Neill, James [inailfo° N ill Is undo.or ]
Sent: Monday, April 27, 2015 12:44 PM
To: Tricia M. Rollins
Subject: FW: L &B - contract /March billings
Trish —
Sorry for the delay, as our Risk Manager was out of the office last week.
Attached are samples of the needed endorsement for Commercial General Liability and Waiver of Subrogation for
workers' comp forms.
- James
From: Tricia M. Rollins mailt :trollins landrummm wn. n3
Sent: Tuesday, April 21, 2015 10:32 AM
To: O'Neill, James
Cc: Alan Hass
Subject: RE: L &B - contract /March billings
James — is this what you need?
Trish
From: O'Neill, James n "il o JO et@ 15 un orcfl
Sent: Tuesday, April 21, 2015 1:28 PM
To: Tricia M. Rollins
Cc: Alan Hass
Subject: RE: L &B - contract /March billings
The City needs the endorsement for Commercial General Liability and Waiver of Subrogation for workers' comp to
execute the contract.
Please provide a scanned copy as soon as possible to help expedite the process.
Thank you.
- James
From: Tricia M. Rollins [mail : r llins landru , r vary. mtt]
Sent: Monday, April 20, 2015 2:21 PM
To: O'Neill, James
Cc: Alan Hass
Subject: RE: L &B - contract /March billings
Hi James — I am hoping this invoice sent to you on 04/15/15 was ok and you've received the information from Alan to
correspond.
I have included this invoice on our books unless I hear otherwise.
Thank you,
Trish
Trish M. Rollins 1 Landrum & Brown
11279 Cornell Park Drive
Cincinnati, OH 45242
P: 513.530.1247 1 F: 513.530.2247
From: Tricia M. Rollins
Sent: Wednesday, April 15, 2015 2:58 PM
To: 'O'Neill, James'
Cc: Alan Hass
Subject: RE: L &B - contract /March billings
Hi James — attached is the invoice billing for Landrum & Brown that I would like your approval on beings this is the first one.
Alan will have the March 301h reports to you by the end of the week. This invoice takes into account those reports.
Let me know your thoughts.
Trish
Trish M. Rollins I Landrum & Brown
11279 Cornell Park Drive
Cincinnati, OH 45242
P: 513.530.1247 1 F: 513.530.2247
From: O'Neill, James [m it . ON ill else un t_, ]
Sent: Monday, April 13, 2015 8:37 PM
To: Tricia M. Rollins
Cc: Alan Hass
Subject: RE: L &B - contract /March billings
For billing, please invoice according to the cost schedule provided by Alan.
Please include a list of homes tested for each of the weeks of testing performed.
If you would like me to look at a sample, I'd be happy to look at it and provide more detailed feedback if that is
necessary.
- James
From: Tricia M. Rollins [mailto:trollins o)l ndrum- brown.com]
Sent: Thursday, April 09, 2015 2:54 PM
To: O'Neill, James
Cc: Alan Hass
Subject: L &B - contract /March billings
Hi James — wanted to do a follow up on the contract between L &B and the City to see if there is a signed copy in the
works and on its way back to Alan and I here at L &B?
We also have some charges in March for Alan Hass, Eric Seavey, & Michael Holritz.
Would you like me to go ahead and invoice those labor and expense charges for Acoustical Testing Services and
Analysis & Documentation?
Is there a special way you would like us to provide that invoice? I am not seeing any special instructions with the
paperwork that I have so if you prefer us to bill in a specific format, pass that along.
I will wait to hear from you.
Thank you,
Trish
Trish M. Rollins I Landrum & Brown
11279 Cornell Park Drive
Cincinnati, OH 45242
P: 513.530.1247 1 F: 513.530.2247