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PROOF OF INSURANCE (2016) CLOSEDDATE (MMIDDIYYYY) C CERTIFICATE OF LIABILITY INSURANCE 05,/05/2015 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. U SUBROGAT'I'ON 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 endorser'nent(s). PRODUCER NAM, Siebe, Bill SL Insurance Associates Inc PHONE EA41, 408 - 776 -8600 (AIac,No):_ 40e- 776 -e602 - -- — 275 Tennant Ave, Suite 207 LMApr. AODRE:S5: bill @slinsure.com Morgan Hill. CA 95037 _. INSURED 949- 542 -7995 Pacific Services Inc dba: Pacific Datacom 927 Calls Negocio Ste L San Clemente, CA 92673 INSURER(S) AFFORDING COVERAGE INSURER A_: National Fire Insurance Co of Hartforc INSURER B: Hartford Casualty Ins. Cc INSURER C ;. INSURER D: INSURER NAIC # 524290 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN SW _ ADDL SUBR, POLICY e0r, POLBCY EkP LIMITS L "rR TYPE OF INSURANCE POLICY NUMBER (MpAPVyD85 ti YY ' dh$R4Y00ty'MYY - -. - wU ...._.. _ . �_.... GENERAL LIABILITY f EACH OCCURRENCE $ 2,000,000 A COMMERCIAL GENERAL LIABILITY v n B 4031343323 01/20/2015 ` (rAMA11IPI °N °p0.. 01/20/2016 d FJ( Nf 1$J: , (Ea occurrence) $ 300,000 CLAIMS M AIDE V OCCUR p MED EXP_ (Any one person) $ .. ._ .... 10,000 t` I i PERSON AL 8 ADV INJURY 2,000,000 '.. 'GENERALAGGREGATE $ 4,000,000 ET APPLIES PER i GEN'L AGGREGATE LIMIT h PRODUCTS - COMPIOP AGG y� T 4,000,000 � � � POLICY € V, i rT__- LOC { ? I E` - ...._.._... AUTOMOBILE LIABILITY . . q"✓hl b1N'N. 7 ~~ IN(,G I.IM.11 1,000,000 A � ANY AUTO I x B 4031343323 '... 01/20/2015 j 01/20/2016 ( person) $ I ALL OWNED SCHEDULED BODILY INJURY (Per r auident) $ 'AUTOS AUTOS ) x :NON -OWNED HIRED AUTOS d 'AUTOS " PRC`dPEAT'vDA1MA4;E �$ acc"160) — 1 it U MBRELLA LIAR -- OCCUR EACH OCCURRENCE S .( EXCESS LIAR,� CUA @rvM`a.AkRAq"Iq', j AGGREGATE $ Iadr6 HB T N'I Gwu" is ,... � WORKERS COMPENSATION t f ry�v�. yiIATU ��III Tolod LI" piM LT LIABILITY AND EMPLOYERS' LIABILITY y / N j I , ANY DPRIETCR/PARTNERIEXECUTIVE NIA i 57WECES7871 01/09/2015 E L EACH ACCIDENT $ 01/0912016 ) 1,000,000 OFFICERWEMBEREXCLUDED? Y ; (MuarrmJaEOay In NH) i j ; � EL DISEASE - EA L0'I O a"N r " ".I $ 1,000,000 it lug, describe under ! n SCRIP] z— N Or, 'OPERA ^^^^ITfiIT t')N, below �,_ ......�...w�......? i .._...... .._ ._.�,..���.�...,.�.,,,,... 7....E ,. ..L ._ DISEASE .. POLICY LIMIT 1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if mores ace is r............ed) .........mm......... pace is required) As it pertains to its California operations, and where required by contract for any and all locations for that contract, the following is named as additional insured interest. The City of E1 Segundo *30 Days notice of Cancellation* *10 day notice for Non -Pay CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The 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 (2010105) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: B 4031343323 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL I SU OWNERS, LESSEES O CONTRACTORS - SCHEDULED PERSON LQ_ • This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Name Of Additional Insured Person(s) Or Organization(s): The City of El Segundo 350 Main St El Segundo, Ca. 90245 SCHEDULE Location(s) Of Covered Operations Any Location where required by contract in the State of California 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 ongoing operations for the additional insured(s) at the location(s) 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 20 10 07 04 O ISO Properties, Inc., 2004 Page 1 of 1 POLICY NUMBER: B 4031343323 COMMERCIAL GENERAL LABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADD[TIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART, INCLUDING BUSINESS AUTO SCHEDULE Name of Additional Insured Person (s) Or Organization(s): The City of El Segundo 350 Main St El Segundo, Ca. 90245 Insurance is Primary and Non - Contributory with Respects to any other Insurance. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section If — Who 6 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, inwholeorin part, by "yourwork" 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 ". 4q CG 20 37 07 04 O 60 Properties, Inc., 2004 Page 1 of 1 POLICY NUMBER: 57 WEC ES7871 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Waiver of Transfer of Rights of Recovery against others to us (Waiver of Subrogation) The City of El Segundo 350 Main St El Segundo, Ca. 90245 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 (s) named in the schedule, but this waiver applies only with respect to bodily injury arising out of your ongoing operations, or "your work" done and included in the "products- completed operations hazard" under a contract described in the schedule where you are required by a written contract to obtain this waiver from us. Form 11112 0011 85 T S1;Q. NU. 002 Printed in U.S.A. Page 001 Process Date: 5/4/2015 ] ,xpiration Date: 1/9/2016 Sandoval, Lili From: Nguyen, Trang Sent: Thursday, June 04, 2015 10:41 AM To: Sandoval, Lili; Klingaman, Larry J. Cc: King, David; Shilling, Mona Subject: RE: Pacific Services Contract Hi Lili, After reviewing the scope of with, I'm ok with waiving the professional liability insurance because the contractor is only providing us with his technical expertise and not intellectual. Thank you, Trang From: Sandoval, Lili Sent: Thursday, May 28, 2015 3:02 PM To: Nguyen, Trang; Klingaman, Larry J. Cc: King, David; Shilling, Mona Subject: RE: Pacific Services Contract Trang /Larry, We spoke to David, as confirmed he did recommend the Professional Services Agreement. At this point he feels the decision for proof of professional liability (as indicated in the agreement) is the Risk Managers decision. He did state, feel free to contact him with any questions. Let me know what decision is made, Thank you. Lili Sandoval City Clerk's Office City of Ell Segundo 350 Main St. Ell Segundo, Ca 90245 310 -524 -2306 Isa tBovalgelsegundewm IRlllease Noiill City IIIIIIIIII .IIIIIIIII Is :Yllllosed oiir i IIC iirida- ys. Klingaman, Larry J. Sent: Wednesday, May 20, 2015 12:36 PM To: Sandoval, Lili