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PROOF OF INSURANCE (2016) CLOSED
da, DATE (MM /DD /YYYY) C'R CERTIFICATE OF LIABILITY INSURANCE �.• 6/23/2015 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. 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 T Adamson &McGoldrick Insurance Solutions NAME'AMq- ., .. o -yp,w Belmer 1800 E. Lambert Rd., Ste 225 ��� PHONE 71457 0644 FAX Brea, CA 92821 _� ����.X)) lal �. 714 �+ -9808 Ibelmer snalns com THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PO LIUY t'ERIUU INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS ADD SS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS „ ....... TYPE OF INSURANCE ,,,,,,,� iDE. SUBR, .. ,.. POLICY NUMBER ........ -MMdDDPYEW POI ICY EXP,.....1„ R �DII"YYY LIMITS R pL7 COMMERCIALGENEkRA L uoccu ✓ ✓ INSURER(S) AFFORDING COVERAGE 4/17/2015 NAIC # www,snains.com ... . INSURERA National Fire Insurance Company of Hartford 20478 INSURED ...... .. B The ante Com any Continental Insurance w 1100,000 35289,,,,, Ramona, Inc. INSURER c ce Company Torus National Insurance 660219 $ 15,000 ....._......_. --- _25496 Arcadia CA 91006 INSURER D Rockhlll Insurance Co Company ,,...... _ 28053, pLPIMOITA,PLIESPER: INSURER E: Valley Forge Insurance Company 20508 GENERALAGr�pdCGACh $ 2,O�t0wt�q0 INSURER IF :. POLICY I PRO- LOC JECT COVERAGES CERTIFICATE NUMBER: 25213191 REVISION NUMBER: PRODUCT S COMP /OP AGG THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PO LIUY t'ERIUU 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 „ ....... TYPE OF INSURANCE ,,,,,,,� iDE. SUBR, .. ,.. POLICY NUMBER ........ -MMdDDPYEW POI ICY EXP,.....1„ R �DII"YYY LIMITS R pL7 A COMMERCIALGENEkRA L uoccu ✓ ✓ 5095015632 4/17/2015 4/17/2016 1 (_ rwr l....... w 1100,000 CLAIMS -MADE ✓ Ded $101000 PD per OCC,,,- MED EXP, (Anyone P�r�ts�an) ,.,., $ 15,000 ....._......_. --- PER. O SONAL & ADV INJURY $ 1 1�00u6Q�I pLPIMOITA,PLIESPER: GENERALAGr�pdCGACh $ 2,O�t0wt�q0 POLICY I PRO- LOC JECT PRODUCT S COMP /OP AGG $ 266 ,60 ®,,,. — $ 1l•IE" R B AUTO MOBILE LIABILITY ✓ 6012568827 4/17/2015 : 4/17/2016 ` COMBINED a.ao; SpNGL •pM91 Ike acG��p111 ®BODILY $ 1'900,,090, __. ANY AUTO INJURY (Per person) ... $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED Y A P Pr3OPLR DAMAGE � pP46r ' HIRED AUTOS AUTOS � u grJt) - - $ $ A ✓ UMBRELLA un6 OCCUR 6012568813 4/17/2015 4/17/2016 $$ 56'66,60 11 EXCESS LIAB � CLAIMS MADE AGGREGATERRENCE 5,000,000 1:E ✓ RETENTION$10,000 C WORKERS COMPENSATION �/ T10150'019 4/17/2015 4/'I7/2016 I/ �6PR�'��r4 /E¢` Ep�)"p" , AND EMPLOYERS' LIABILITY YIN ANY PEPIM EI TNER'+LXEr"IV.11'IVB ."".... H ACCIDENT E L EACH $ .. ,t)00, .$ ,,, .,,,,,,. ER EXV' r FpSy4.toryp. MH1.°'N"p' EXCLUDED? ..Y.. IManrc9ak�ry In hrHl NIA E L. DISEASE EA EMPLOYEE 9 _..... 1 ,000000 It esdescnbeunder If ies IP'1prJN 17k OPERATIONS below 1,000,0tJ0 D Pollution Liabli ty ENV8009182 4/17/2015 4/17f2016 Limitl$1000000/Dedp$10g000 E Installation Floater 6012568794 4/17/2015 4/17/2016 Limit $1,000,000 / Ded $1,000 E Leased 1B orrowedJRerlted Equipment 6012568794 4/17/2015 4/17/2016 Limit $100,000 / Ded $1,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: PROJECT NO.: PW 15 -08 / WATER MAIN IMPROVEMENT AT VIRGINIA, OAK AND BAYONNE The City of El Segundo, its officials, employees and volunteers are named additional insured as respects general liability, this insurance is primary and non - contributory, and waiver of subrogation applies as required by written contract, per endorsements attached. *10 days notice of cancellation for non - payment. 30 days otherwise„ CERTIF WATER MAIN IMPROVEMENT AT VIRGINIA, OAK AND' BAYONN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Public Works THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Llfan Xu 350 Main Street, AUTHORIZED REPRESENTATIVE El Segundo CA 90245 J__/1_ Brian McGoldrick ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD 25213191 1 15 -16 All Lines I Gloria Gabriel 1 6/23/2015 9:55:04 AM (PDT) I Page 1 of 8 G- 140331 -D AJPWN�A 5095015632 (Ed.01/13) BLANKET ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS — WITH PRODUCTS - COMPLETED OPERATIONS COVERAGE It is understood and agreed that this endorsement amends the COMMERCIAL GENERAL LIABILITY COVERAGE PART as follows: SCHEDULE (OPTIONAL) Name of Additional Insured Persons Or Organizations (As required by "written contract" per Paragraph A. below.) Locations of Covered Operations (As per the "written contract," provided the location is within the "coverage territory" of this Coverage Part.) A. Section II - Who Is An Insured is amended to include as an additional insured: 1. Any person or organization whom you are required by "written contract" to add as an additional insured on this Coverage Part; and 2. The particular person or organization, if any, scheduled above. B. The insurance provided to the additional insured is limited as follows: 1. The person or organization is an additional insured only with respect to liability for "bodily injury," "property damage," or "personal and advertising injury" caused in whole or in part by: a. Your acts or omissions, or the acts or omissions of those acting on your behalf, in the performance of your ongoing operations specified in the "written contract "; or b. "Your work" that is specified in the "written contract" but only for "bodily injury" or "property damage" included in the "products- completed operations hazard," and only if: (1) The "written contract" requires you to provide the additional insured such coverage; and (2) This Coverage Part provides such coverage. 2. If the "written contract" specifically requires you to provide additional insurance coverage via the 10/01 edition of CG2010 (aka CG 20 10 10 01), or via the 10/01 edition of CG2037 (aka CG 20 37 10 01), or via the 11/85 edition of CG2010 (aka CG 20 10 11 85), then in paragraph B.1. above, the words 'caused in whole or in part by' are replaced by the words 'arising out of. 3. We will not provide the additional insured any broader coverage or any higher limit of insurance than: a. The maximum permitted by law; b. That required by the "written contract "; c. That described in B.1. above; or G- 140331 -D (Ed. 01/13) Page 1 of 2 25213191 1 15 -16 All Lines I Gloria Gabriel 1 6/23/2015 9:55:09 AM (PDT) I Page 2 of 6 Ad d. That afforded to you under this policy, whichever is less. G- 140331 -D (Ed. 01/13) 4. Notwithstanding anything to the contrary in Condition 4. Other Insurance (Section IV), this insurance is excess of all other insurance available to the additional insured whether on a primary, excess, contingent or any other basis. But if required by the "written contract" to be primary and non - contributory, this insurance will be primary and non - contributory relative to insurance on which the additional insured is a Named Insured. 5. The insurance provided to the additional insured does not apply to "bodily injury," "property damage," or "personal and advertising injury" arising out of: a. The rendering of, or the failure to render, any professional architectural, engineering, or surveying services, including: (1) The preparing, approving, or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and (2) Supervisory, inspection, architectural or engineering activities; or b. Any premises or work for which the additional insured is specifically listed as an additional insured on another endorsement attached to this Coverage Part. C. SECTION IV— COMMERCIAL GENERAL LIABILITY CONDITIONS is amended as follows: 1. The Duties In The Event of Occurrence, Offense, Claim or Suit condition is amended to add the following additional conditions applicable to the additional insured: An additional insured under this endorsement will as soon as practicable: (1) Give us written notice of an 'occurrence" or an offense which may result in a claim or "suit" under this insurance, and of any claim or "suit" that does result; (2) Except as provided in Paragraph 113.4. of this endorsement, agree to make available any other insurance the additional insured has for a loss we cover under this Coverage Part; (3) Send us copies of all legal papers received, and otherwise cooperate with us in the investigation, defense, or settlement of the claim or "suit "; and (4) Tender the defense and indemnity of any claim or suit to any other insurer or self insurer whose policy or program applies to a loss we cover under this Coverage Part. But if the "written contract' requires this insurance to be primary and non - contributory, this provision (4) does not apply to insurance on which the additional insured is a Named Insured. We have no duty to defend or indemnify an additional insured under this endorsement until we receive from the additional insured written notice of a claim or "suit." D. Only for the purpose of the insurance provided by this endorsement, SECTION V — DEFINITIONS is amended to add the following definition: "Written contract" means a written contract or written agreement that requires you to make a person or organization an additional insured on this Coverage Part, provided the contract or agreement: 1. Is currently in effect or becomes effective during the term of this policy; and 2. Was executed prior to: a. The "bodily injury" or "property damage "; or b. The offense that caused the "personal and advertising injury," for which the additional insured seeks coverage under this Coverage Part. All other terms and conditions of the Policy remain unchanged. Material used with permission of ISO Properties, Inc. G- 140331 -D (Ed. 01/13) Page 2 of 2 a 25213191 1 15 -16 All. Lines I Gloria Gabriel 1 6/23/2015 9:55:04 AM (PDT) I Page 3 of 8 AIPWNAA 6012568827 CN(Ed 04912) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CONTRACTORS EXTENDED COVERAGE ENDORSEMENT - BUSINESS AUTO PLUS - This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM I. LIABILITY COVERAGE A. Who Is An Insured The following is added to Section II, Paragraph A.1., Who Is An Insured: 1. a. Any incorporated entity of which the Named Insured owns a majority of the voting stock on the date of inception of this Coverage Form; provided that, b. The insurance afforded by this provision A.1. does not apply to any such entity that is an "insured" under any other liability "policy" providing "auto" coverage. 2. Any organization you newly acquire or form, other than a limited liability company, partnership or joint venture, and over which you maintain majority ownership interest. The insurance afforded by this provision A.2.: a. Is effective on the acquisition or formation date, and is afforded only until the end of the policy period of this Coverage Form, or the next anniversary of its inception date, whichever is earlier. b. Does not apply to: (1) "Bodily injury" or "property damage" caused by an "accident" that occurred before you acquired or formed the organization; or (2) Any such organization that is an "insured" under any other liability "policy" providing "auto" coverage. 3. Any person or organization that you are required by a written contract to name as an additional insured is an "insured" but only with respect to their legal liability for acts or omissions of a person, who qualifies as an "insured" under Section II — Who Is An Insured and for whom Liability Coverage is afforded under this policy. If required by written contract, this insurance will be primary and non - contributory to insurance on which the additional insured is a Named Insured. 4. An "employee" of yours is an "insured" while operating an "auto" hired or rented under a contract or agreement in that "employee's" name, with your permission, while performing duties related to the conduct of your business. "Policy," as used in this provision A. Who Is An Insured, includes those policies that were in force on the inception date of this Coverage Form but: 1. Which are no longer in force; or 2. Whose limits have been exhausted. B. Bail Bonds and Loss of Earnings Section II, Paragraphs A.2. (2) and A.2. (4) are revised as follows: 1. In a.(2), the limit for the cost of bail bonds is changed from $2,000 to $5,000; and 2. In a.(4), the limit for the loss of earnings is changed from $250 to $500 a day. C. Fellow Employee Section II, Paragraph B.5 does not apply. Such coverage as is afforded by this provision C. is excess over any other collectible insurance. I1. PHYSICAL DAMAGE COVERAGE A. Glass Breakage — Hitting A Bird Or Animal — Falling Objects Or Missiles The following is added to Section III, Paragraph A.3.: With respect to any covered "auto," any deductible shown in the Declarations will not apply to glass breakage if such glass is repaired, in a manner acceptable to us, rather than replaced. B. Transportation Expenses Section III, Paragraph AA.a. is revised, with respect to transportation expense incurred by you, to provide: a. $60 per day, in lieu of $20; subject to b. $1,800 maximum, in lieu of $600. CNA63359XX Copyright, CNA Corporation, 2000. Page 1 of 3 (Ed. 04/12) Includes copyrighted material of the Insurance Services Office used with its permission. 25213191 1 15 -16 All Lines I Gloria Gabriel 1 6/23/2015 9:55:04 AM (PDT) I Page 4 of 8 ANNA C. Loss of Use Expenses Section III, Paragraph A.4.b. is revised, with respect to loss of use expenses incurred by you, to provide: a. $1,000 maximum, in lieu of $600. D. Hired "Autos" CNA63359XX (Ed. 04/12) Section III, Paragraphs B.4.c and B.4.d. are deleted and replaced by the following: c. Physical Damage Coverage on a covered "auto" also applies to "loss" to any permanently installed electronic equipment including its antennas and other accessories. The following is added to Section III. d. A $100 per occurrence deductible applies Paragraph A.: to the coverage provided by this provision. 5. Hired "Autos" G. Diminution In Value If Physical Damage coverage is provided under The following is added to Section III, this policy, and such coverage does not extend Paragraph B.6.: to Hired Autos, then Physical Damage Subject to the following, the "diminution in coverage is extended to: value" exclusion does not apply to: a. Any covered "auto" you lease, hire, rent a. Any covered "auto" of the private or borrow without a driver; and passenger type you lease, hire, rent or b. Any covered "auto" hired or rented by borrow, without a driver for a period of your "employee" without a driver, under 30 days or less, while performing duties a contract in that individual related to the conduct of your business; "employee's" name, with your and permission, while performing duties b. Any covered "auto" of the private related to the conduct of your business. passenger type hired or rented by your c. The most we will pay for any one "employee" without a driver for a period "accident" or "loss" is the actual cash of 30 days or less, under a contract in value, cost of repair, cost of that individual "employee's" name, with replacement or $75,000, whichever is your permission, while performing less, minus a $500 deductible for each duties related to the conduct of your covered auto. No deductible applies to business. "loss" caused by fire or lightning. c. Such coverage as is provided by this d. The physical damage coverage as is provision is limited to a "diminution in provided by this provision is equal to value" loss arising directly out of the physical damage coverage(s) accidental damage and not as a result provided on your owned "autos." of the failure to make repairs; faulty or incomplete maintenance or repairs; or the installation of substandard parts. e. Such physical damage coverage for hired "autos" will: d. The most we will pay for "loss" to a covered "auto" in any one accident is 1 Include loss of use, provided it is () P the lesser of: the consequence of an "accident" for which the Named Insured is (1) $5,000; or legally liable, and as a result of (2) 20% of the "auto's" actual cash which a monetary loss is sustained value (ACV). by the leasing or rental concern. III« Drive Other Car Coverage — Executive Officers (2) Such coverage as is provided by this provision will be subject to a The following is added to Sections II and III: limit of $750 per "accident." 1. Any "auto" you don't own, hire or borrow is a E. Airbag Coverage covered "auto" for Liability Coverage while being used by, and for Physical Damage The following is added to Section III, Coverage while in the care, custody or control Paragraph B.3.: of, any of your "executive officers," except: The accidental discharge of an airbag shall not a. An "auto" owned by that "executive officer" be considered mechanical breakdown. or a member of that person's household; or F. Electronic Equipment CNA63359XX Copyright, CNA Corporation, 2000. Page 2 of 3 (Ed. 04/12) Includes copyrighted material of the Insurance Services Office used with its permission,. 25213191 1 15 -16 All Lines I Gloria Gabriel 1 6/23/2015 9:55:04 AM (PDT) I Page 5 of 8 avp► b. An "auto" used by that "executive officer" while working in a business of selling, servicing, repairing or parking "autos." Such Liability and /or Physical Damage Coverage as is afforded by this provision. (1) Equal to the greatest of those coverages afforded any covered "auto "; and (2) Excess over any other collectible insurance. 2. For purposes of this provision, "executive officer" means a person holding any of the officer positions created by your charter, constitution, by -laws or any other similar governing document, and, while a resident of the same household, includes that person's spouse. Such "executive officers" are "insureds" while using a covered "auto" described in this provision. IV. BUSINESS AUTO CONDITIONS A. Duties In The Event Of Accident, Claim, Suit Or Loss The following is added to Section IV, Paragraph A.2.a.: (4) Your "employees" may know of an "accident" or "loss." This will not mean that you have such knowledge, unless such "accident" or "loss" is known to you or if you are not an individual, to any of your executive officers or partners or your insurance manager. The following is added to Section IV, Paragraph A.2.b.: (6) Your "employees" may know of documents received concerning a claim or "suit." This will not mean that you have such knowledge, unless receipt of such documents is known to you or if you are not an individual, to any of your executive officers or partners or your insurance manager. B. Transfer Of Rights Of Recovery Against Others To Us CNA63359XX (Ed. 04/12) The following is added to Section IV, Paragraph A.5. Transfer Of Rights Of Recovery Against Others To Us: We waive any right of recovery we may have, because of payments we make for injury or damage, against any person or organization for whom or which you are required by written contract or agreement to obtain this waiver from us. This injury or damage must arise out of your activities under a contract with that person or organization. You must agree to that requirement prior to an "accident" or "loss." C. Concealment, Misrepresentation or Fraud The following is added to Section IV, Paragraph B.2.: Your failure to disclose all hazards existing on the date of inception of this Coverage Form shall not prejudice you with respect to the coverage afforded provided such failure or omission is not intentional. D. Other Insurance The following is added to Section IV, Paragraph B.5.: Regardless of the provisions of Paragraphs 5.a. and 5.d. above, the coverage provided by this policy shall be on a primary non - contributory basis. This provision is applicable only when required by a written contract. That written contract must have been entered into prior to "Accident" or "Loss." E. Policy Period, Coverage Territory Section IV, Paragraph B. 7.(5).(a). is revised to provide: a. 45 days of coverage in lieu of 30 days. V. DEFINITIONS Section V. Paragraph C. is deleted and replaced by the following: "Bodily injury" means bodily injury, sickness or disease sustained by a person, including mental anguish, mental injury or death resulting from any of these. CNA63359XX Copyright, CNA Corporation, 2000. Page 3 of 3 (Ed. 04/12) Includes copyrighted material of the Insurance Services Office used with its permission, 25213191 1 15 -16 All Lines I Gloria Gabriel 1 6/23/2015 9:55:09 AM (PDT) I Page 6 of 8 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4 -84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT — CALIFORNIA 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.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be _ *_% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description WHERE YOU ARE REQUIRED BY WRITTEN CONTRACT TO OBTAIN THIS AGREEMENT FROM US, PROVIDED THE CONTRACT IS SIGNED AND DATED PRIOR TO THE DATE OF LOSS TO WHICH THIS WAIVER APPLIES. IN NO INSTANCE SHALL THE PROVISIONS AFFORDED BY THIS ENDORSEMENT BENEFIT ANY COMPANY OPERATING AIRCRAFT FOR HIRE. *The premium charge for this endorsement shall be 2% of the premium developed in the State of California, but not less than $500 policy minimum premium. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 04/17/15 Policy No. T10150019 Insured Ramona, Inc. Insurance Company Torus National Insurance Company Countersigned By WC 04 03 06 (Ed. 4 -84) ©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. 25213191 1 15 -16 All Lines I Gloria Gabriel 1 6/23/2015 9:55:04 AM (PDT) I Page 7 of 8 Endorsement No. 10 Policy Effective Date 04/17/15 POLICY NUMBER: 5095015632 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER SFE R OF' RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization :. Any person or organization with whom you have agreed in writing in a contract or agreement to waive any right of recovery against such person or organization, but only if the contract or agreement: 1. Is in effect or becomes effective during the term of this policy; and 2. Was executed prior to loss. Information required to comr)lete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work "" done Linder a contract with that person or organization and included in the " products- completed operations hazard," This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 Copyright, Insurance Services Office, Inc., 2008 25213191 1 15 -16 All Lines I Gloria Gabriel 1 6/23/2015 9:55:04 AM (PDT) I Page 8 of 8 Page 1 of 1 Substitute W 9 Request for Taxpayer Form "" (Rev March 2002) Identification Number and Certification Name (See Specific Instructions on page 2.) m a 0 c a m at a Business name if different from above. (See Specific Instructions on page 2,) Ramona Inc. ❑ LLC id al /S Ile Pr prie or ❑ Corporation ❑ Partnership ❑ Other ► Check appropriate box: ❑ ❑LLC filing as Corporation ❑LLC filing as Partnership Address (number, street, and apt, or suite no 302 N. First Ave., Suite # 1 City, state, and ZIP code Arcadia. Ca 91006 Ta Number (TIN Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). However, for a resident alien, sole Proprietor, or disregarded entity, see the Part instructions on page 2. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 2. Note: If the account is in more than one name, see the chart on page 2 for guidelines on whose number to enter. social security number or Employer identification number 7 13 11 17 11 12 0 11 Give form to the requester. Do not send to the IRS. Requestor's name and address (optional) List account number(s) here (optional) M For U.S. Payees Exempt From Backup Withholding (See the instructions on page 2.) 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. person (including a U.S. resident alien). 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 you 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 are not required to sign the Certification, but you must provide your correct TIN. (See the instructions on page 2) Here U.S, oars Signature 0- , gate ► 06/23/2015 g Purpose of Form A person who is required to file an information return with the IRS must get 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 give your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If you are a foreign person„ use the appropriate Form V"Wd -8, See Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Corporations. Note: If a requester gives you a form other than Form W-9 to request your'I'W, you must use the requester's foon if it is substantially similar to this Form W -9 What is backup withholding? Persons making certain payments to you muSt withhold and pay to the IRS 31 % of such payments under certain conditions. This is called "backup withholding." Payments that may be sub,pect to backup withholding include interest, dividends, broker and barter exchange transactions, rents royalties, non - employee pay„ and certain payments front fishing boat operators. Real estate transactions are not subject to backup withholding. If you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return, payments you receive will not be subject to backup withholding, Payments you receive will be subject to backup withholding if: 1. You do not furnish your TIN to the requester, or 2. You do not certify your TIN when required (see the Part III instructions on page 2 for details), or 3. The IRS tells the requester that you furnished an incorrect TIN, or 4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or 5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable Interest and dividend accounts opened after 1983 only). Certain payees and payments are exempt from backup withholding. See the Part II instructions and the separate Instructions for the Requester of Form W -9. Penalties Failure to furnish TIN. If you fail to furnish your, correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty. Criminal penalty for falsifying information. Willful y falsifying certifications or affirmations may subject you to criminal penalties including fines and /or imprisonment. Misuse of TINs. If the requester discloses or uses TINS in violation of Federal law, the requester may be subject to civil and criminal penalties, Substitute Form -9 (Rev 03 -2002)