PROOF OF INSURANCE (2015) CLOSEDvv
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WC>R0 CEIRTIFICA"! III OF UAB1111 I,,,, III III ! 4 / 3 0 / 2 015
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 cpndwseinenl& s).
01-'—C_
4ark Ball Insurance
22837 PCH #D
Aalibu, CA 90265
SIC 4OA96803
Pacific Architecture
25307 MALIBU ROAD
MALIBU, CA 90265
310 -280- 8218
IRK BALL
310 317 -4433
MBAf. L@ FARMERSAGENT . COM
,310 317 -4436
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OVERAGES _ CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS `0 — CERTIFY THAT THE POLICIES �
CIES 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 ! SSUED 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
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X COMMERCIAL GENERAL LIABILITY ''()00,000
r,n � t � 250 000
PSDO0100548 11/19/14 11/19/15
1,000000
AP PI ES PER 2,000,000
g: Fs GENERAL AGGREGATE �' S
�:'r LC�c Irar>II�.r ; - �r r.�l.F.c u,i 1 „ 000,000
000
A%YAUT CI
-- n C) ' `' X PSDO0100548
X
PROFESS'ION'AL PSDO0100548 11/19/14 11/19/15'$1, 000, 000
LIABILITY ICLAIMS MADE
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O�. OF O�F�AT IOYQ, _OCA',0 \S LS �ACORD 10' AdM onal Rema rkS sc ed,.le maybe aRached I+ more spaces reaUlredi
E: Covered CA Operations Performed By or On Behalf of the Named Insured.
he City of E1 Segundo, its officers, officials, employees, agents, and volunteers
re named additional insured as respects to general liability, and this insurance
s primary and non contributory with any other insurance of the additional insured;
nd waiver of subrogation applies as respects to workers compensation as required
y written contract, per endorsements attached. 401 Sheldon St E1 Segundo CA 90245
City of E1 Segundo
350 Main Street
E1 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
wtRs : i 4
The ACORD name and logo are registered marks of ACORD
I (D (,Zn °O')"'RA �:0,i All rights reserved
ATTACHING TO POLICY
NUMBER: PSD00100548
THE INSURED PACIFIC ARCHITECTURE & ENGINEERING
WITH EFFECT FROM. 19 Nov 2014
It is hereby understood and agreed that Principals are indemnified under this Policy as an
additional Insured, but only in respect of sums which they become legally obliged to pay (including
liability for claimants' costs and expenses) as a result of any claim arising solely out of any
wrongful act committed by you or accidental injury or damage in the course of your business
activities. provided that had a claim been made against you, then you would be entitled to
indemnity under this Policy.
When this clause applies it shall be primary and non - contributory to Principals' own insurance but
only if you and Principals have entered into a contract that contains a provision requiring this
It is a condition precedent to indemnity under this clause that Principals shall prove to our
satisfaction that the claim arose solely out of your business activities
Whilst Principals have been named under this Policy as an additional Insured, it is hereby noted
and agreed that any claim made by Principals against you shall be treated as if Principals were
a third party.
We shall also endeavour to provide 30 days notice of cancellation to Principals: however not
doing so shall not place any additional liability upon us
It is further understood and agreed that Principals are defined as follows.
City of El Segundo, its officers, officials, employees, agents and volunteers Recreation Park
(Effective From: 29 Apr 2015)
401 Sheldon St.
El Segundo, CA 90245
US
N_ SUBJECT OTHERWISE TO THE TERMS AND CONDITIONS OF THE POLICY
Authorised Signatory
CFC Underwriting Ltd
FARMERS
INSURANCE
WORKERS' COMPENSATION AND EMPLOYERS'
LIABILITY INSURANCE POLICY
Named PACIFIC ARCHITECTURE & ENGINEERING
Insured
25307 MALIBU ROAD
• MALIBU CA 90265
Eifcctive
Date 04197/15
Azerll A0947 -86 -70
29- 58 —C85 Policy Number
of the Lorllpaill
• �; 1 1 1 1 1 11' ,
WC 99 06 19
20 15
Policy
Y(-al
Nk'e have the right to recover our payments Irons mworle liable for au injury covered by this policy. We wil
not enforce our right against the person or orgaui -union for which you perform work under a written contract
that requires you ro obrain this agreenlcnr Irom its.
l-he additional premium for this eudolsemew shall be 3 • o % of the Workers' Coiiipenssuion premium
otherwise due for the state(s) listed below on Bitch renluneralion, subject to a n11uirutun charge of $250
All wrirten contracts in the state(s) of:
CA
City of El Segundo, its officers, officials, employees, agents and volunteers Recreation Park
(Effective From 29 Apr 2015)
401 Sheldon St.
El Segundo, CA 90245
US
ILE
VIIIS rndotse•nlent iF part of your policy. It supersedes and coutrols anything Io the contrary. II is olhrrwiSC
subject to all the terms of 11" f:oli I,%
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WORKERS' COMPENSATION GENERAL (H ENDORSEMENT
i'1.N'1,111i'd l JU011N,o uind alld Nlaihnk- Addres's
PACIF UC ARGI HTECTURE & ENIGNEEMNIG
25307 MX1 MU ROAD
1AM OU CA 90265
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22837 PACIFIC CST' #D
M,LIBU
CA 90265
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ADD WC990619 WAIVER OF RIGHT TO RECOVER - BLANKET
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