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PROOF OF INSURANCE (2016) CLOSEDC CERTIFICATE OF LIABILITY INSURANCE 4IT'MM 011 . - r 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 CANS; Brigette Porter Harbor Insurance Agency PHONN F,t, (310) 832 -5311 Fob 1310)s3z -eo24 Mol; I lair- 1622 S. Gaffey * P.O. Box 671 E-MAIL Bra ette @inscenter.com ADDRESS� INSURER1Sl AFFORDING COVERAGE NAIC N San Pedro CA 90733 -0671 INSURERA:Colonv Insurance Co INSURED INSURER B: Rojas Construction, DBA: Rojas Construction INSURERC: 3539 S Carolina St INSURER D: San Pedro CA 90731 -6829 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1541302681 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. INSR. ADOL SUBR Y EFF PLICYEXP LTR TYPE OF INSURANCE 'ttusw wvn POLICY NUMBER /MMInONVVVI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 X PREMISES 'Me, urrencls' $ 100 , 000 COMMERCIAL GENERAL LIABILITY A CLAIMS -MADE Fx_1 OCCUR X GL4157741 /28/2015 4/28/2016 MED EXP (Any one oerson) .... $ 51000 PERSONAL & ADV INJURY S 11000,000 GENERAL AGGRE:GAT''✓••, S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000.1000 X POLICY PRA'@.. LOC AUTOMOBILE LIABILITY BA040000009864 10/13/2014 10/13 2015 "t- INGLE LIMIT I, $ 1.000,000 B ANY AUTO BODILY INJURY (Per person) $ ALL OWNED X SCHEDULED AUTOS AUTOS I BODILY INJURY (Per accident) S X X NON -OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I RFTFNTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY YIN rnav MiTC... FR ANY PROPRIETOR/PARTNER /EXECUTIVE E . EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E L DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E . DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate holder the City of E1 Segundo, it officers, officials, employees and volunteers are included as additional insured (general liability only) with liability limited to claims arising out of insured's operations only, with no assumption of liability to others. Operations for policy term 04 -28 -2015 to 04 -28 -2016. See policy for terms and conditions. JIU CERTIFICATE HOLDER CANCELLATION CITY OF EL SEGUNDO 350 MAIN STREET EL SEGUNDO, CA 90245 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 B Porter /BRIGIT";..- ®r ACORD 25 (2010/05) ©1988 -2010 ACORD CORPORATION. All rights reserved. INS025 (201005) 01 The ACORD name and logo are registered marks of ACORD 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 Additional Insured Person(s) or Organization(s) (Additional Insured): Location(s) of Covered Operations: All persons or organizations as required by a written Locations as required by a written contract or contract or agreement with the named insured. agreement with the named insured. 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 for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" casued, 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. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: Additional Insured Contractual Liability "bodily injury" or "property damage" for which the additional insured(s) are obligated to pay damages by reason of the assumption of liability in a contract or agreement. Finished Operations or Work "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. Negligence of Additional Insured "bodily injury" or "property damage" arising directly or indirectly out of the negligence of the additional insured(s). U156A -0313 Includes copyrighted material of ISO Properties, Inc., Page 1 of 2 with its permission. Insured C. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance is amended and the following added: The insurance afforded by this Coverage Part for the additional insured required by a written contract or agreement with the named insured is primary insurance and we will not seek contribution from any other insurance available to that additional insured. D. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 8. Transfer Of Rights Of Recovery Against Others To Us is amended and the following added: We waive any rights of recovery we may have against any person or organization because of payments we make for injury or damage resulting from your ongoing operations or "your work" done under a contract with that person or organizaticn and included in the "products- completed operations hazard" if: a. you agreed to such waiver; b. the waiver is included as part of a written contract or lease; and c. such written contract or lease was executed prior to any loss to which this insurance applies. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. U156A -0313 Includes copyrighted material of ISO Properties, Inc., Page 2 of 2 with its permission. POLICYHOLDER COPY SC P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 04 -28 -2015 CITY OF EL SEGUNDO SC CITY CLERK 350 MAIN ST EL SEGUNDO CA 90245 -3813 GROUP: POLICY NUMBER: 1904253 -2015 CERTIFICATE ID: 38 CERTIFICATE EXPIRES: 03 -01 -2016 03 -01- 2015/03 -01 -2016 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer„ We will also give you 30days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Auihoried IRepresentativo President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE, ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2015 -03 -01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF EL SEGUNDO, ITS OFFICIALS, EMPLOYEES, AGENTS, AND VOLUNTEERS. ENDORSEMENT #1600 - ROJAS, MARCO P,S T - EXCLUDED. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 03 -01 -2015 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2015 -03 -01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO, ITS OFFICIALS, EMPLOYEES, AGENTS, AND VOLUNTEERS. EMPLOYER ROJAS CONSTRUCTION SC 3539 S. CAROLINA ST SAN PEDRO, CA 90731 [KUW,CN] (REV.I -2012) PRINTED 04 -28 -2015 WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation: ENDORESEMENT Policy Period March 01, 2015 TO March 01, 2016 Effective Date March 01, 2015 Policy Number 1904253 Insured Rojas Construction Employer's Liability Limit Including Defense Cost: $1,000,000 Per Occurrence, Name of Additional Insured: CITY OF EL SEGUNDO, ITS OFFICIALS, EMPLOYEES, AGENTS, AND VOLUNTEERS. Endorsement #2570 Entitled Waiver of Subrogation Effective 2015 -03 -01 is Attached to and Forms A Part of This Policy. Third Party Name: City of El Segundo, Its Officials, Employees, Agents, and Volunteers. 1. Please be advised that a waiver of subrogation requires that a 3% surcharge will be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certificate holder who requested the waiver. (Note: if you have no employee payroll on that job, then there is no charge.) 2. To apply the 3% surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work on job /s for the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation: 1. Please be advised that a waiver of subrogation requires that a 3% surcharge will be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certificate holder who requested the waiver. (Note: if you have no employee payroll on that job, then there is no charge.) 2. To apply the 3% surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work on job /s for the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. Example: Payroll for job: $ 5,000.00 Sample Rate: 13.30% Regular Premium equals: $ 665.00 Surcharge: 3.00% Additional Waiver charge: $ 19.95 Total premium equals $ 684.95 (665.00 + 19.95) INSURANCE REQUIREMENTS [MUST BE SUBMITTED WITH PROJECT PROPOSAL] Company Name: To be awarded this contract, the successful bidder must procure and maintain the following types of insurance with coverage limits complying, at a minimum, with the limits set forth below: Type of Insurance Limits Commercial general liability: $2,000,000 Business automobile liability: $1,000,000 Workers compensation: Statutory requirement Commercial general liability insurance must meet or exceed the requirements of ISO -CGL Form No. CG 00 01 11 85 or 88. The amount of insurance set forth above must be a combined single limit per occurrence for bodily injury, personal injury, and property damage for the policy coverage. Liability policies must be endorsed to name the City, its officials, and employees as "additional insureds" under said insurance coverage and to state that such insurance will be deemed "primary" such that any other insurance that may be carried by the City will be excess thereto. Such endorsement must be reflected on ISO Form No. CG 20 10 11 85 or 88, or equivalent. Such insurance must be on an "occurrence," not a "claims made," basis and will not be cancelable or subject to reduction except upon thirty (30) days prior written notice to the City. The insurer will agree in writing to waive all rights of subrogation against the City, its officers, officials, employees and volunteers for losses arising from work performed by the Contractor for the City. Automobile coverage must be written on ISO Business Auto Coverage Form CA 00 01 06 92 or CA 00 01 01 87, including symbol 1 (Any Auto). The Consultant must furnish to the City duly authenticated Certificates of Insurance evidencing maintenance of the insurance required under this Agreement, endorsements as required herein, and such other evidence of insurance or copies of policies as may be reasonably required by the City from time to time. Insurance must be placed with admitted insurers with a current A.M. Best Company Rating equivalent to at least a Rating of "A:VlI." Certificate(s) must reflect that the insurer will provide thirty (30) day notice of any cancellation of coverage. The Consultant will require its insurer to modify such certificates to delete any exculpatory wording stating that failure of the insurer to mail written notice of cancellation imposes no obligation, and to delete the word "endeavor" with regard to any notice provisions. By signing this form, the bidder certifies that it has read, understands, and will comply with these insurance requirements if it is selected as the City's consultant. Failure to provide this insurance will render the bidder's proposal "nonresponsive." 2 Date Bidder's Signature I -C -15 Form (Rev. December 2011) Deparstnent of the Treasury Inlernal Revenue Service N aI CM ca Q C 0 aC 0 4_ o .G N C C C _ IL u CL0 N N n aa) M on your Request for Taxpayer Give Form to the Identification Number and Certification requester. Do not send to the IRS. name, Check appropriate box for federal tax classification: Individual/sole proprietor ❑ C Corporation above ❑ S Corporation ❑ Partnership ❑ Trust/estate ❑ Limited liability company. Enter the tax classification (C =C corporation, S =S corporation, P= partnership) ► ❑ Other (see instructions) ► Address (number, street, and apt. or suite City, state, and ZIP code Ci VO 0,, C, M name and Exempt payee Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line [ *oc3,at sacurtty number to avoid backup withholding. For individuals, this Is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other TU entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose Employer identification number number to enter. Certification M4-7 -131 A �-]� 31-�J I I Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. 1 am a U.S. citizen or other U.S. person (defined below). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally„ payments other than interest and dividends, you. re not required to sign the certification, but you must provide your correct TIN. See the instructions ors page 4. p Sign Signature of p r Here I U.S. person ► Date ► General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W -9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business Note. If a requester gives you a form other than Form W -9 to request your TIN, you must use the requester's form if it is substantially similar to this Form W -9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: • An individual who is a U.S. citizen or U.S. resident alien, • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, • An estate (other than a foreign estate), or • A domestic trust (as defined in Regulations section 301.7701 -7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners' share of income from such business. Further, in certain cases where a Forth W -9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W -9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. is not subject to the withholding tax on foreign partners' share of effectively connected income. Cat. No. 10231X Form - (Rev. 12 -2011)