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PROOF OF INSURANCE (2016) CLOSEDCertificate of Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON YOU THE CERTIFICATE HOLDER„ THIS CERTIFICATE IS NOT AN INS URANi I' POLICY AND DOES NOT AMEND, EX ITND„ OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED BELOW, POLICY LIMITS ARE NO LESS THAN THOSE LNTED AI.99id }tJGN 11CD'1ACIFS ks�fwY INC "LIJI)E, ADDITIONAL SUBLIMI "A AM1"Y"S PviC1 "T LISTED BFI t" W This is to Certify that I WEST COAST ARBORISTS, INC 2200 EAST VIA BURTON NAME AND �' ANAHEIM CA 92806 ADDRESS 1 its OF INSURED ._ ....... ... ..... wU - -- _._., L INSURANCE is, at the issue date of this certificate, insured by the Company under the policy(ies) listed below. The insurance afforded by the listed poficy(ies) is subject to all their terms, exclusions and Conditions and is not altered by any requirement, term or condition of any contract or other document with respect to which this certificate n'tuny be issued. TYPE OF POLICY EXP DATE ❑ CONTINUOUS ❑ EXTENDED POLICY NUMBER LIMIT OF LIABILITY Elaine Ulan ❑ POLICY TERM El Segundo CA 90245 d WORKERS COMPENSATION Statutory Limits 7/1/2016 WA7 -66D- 039499 -075 COVERAGE AFFORDED UNDER WC EMPLOYERS LIABILITY LAW OF THE FOLLOWING STATES: All States Except: Bodily In ury by Accident ND, OH, WA, WY QI /ryp /� /y �aI j0A..PV 4 00F hA d-1 Bodily Injury By Disease $1.000.000 0_ Bodily Injury By Disease $1.000000 F.'h Pa.'.,;., COMMERCIAL GENERAL LIABILITY 7/1/2016 TB2- 661 - 039499 -015 General Aggregate $2,000.000 m OCCURRENCE Products / Completed Operations Aggregate ❑ CLAIMS MADE $2,000.000 Each Occurrence $1.000.000 RI -,J'R 0 DATE Personal & Advertising Injury 1,000,000 Per Person/ Organization Other Damage to remises rented to V9 ann nlin tier Medical Expense $5,000 AUTOMOBILE LIABILITY 7/1/2016 AS7- 661 - 039499 -035 Each Acsid ut— single Limit $2,000,000 B.I. Awl I'':D, Combined Each Person ❑ OWNED Each Accident or Occurrence ❑ NON -OWNED ❑ HIRED Each Accident or Occurrence OTHER Umbrella Excess Liability 7/1/2015 - 7/1/2016 TH7- 661 - 039499 -045 $5,000,000 Per Occurrence /Aggregate ADDITIONAL COMMENTS See Addendum. 3 If the certificate expiration date is continuous or extended term, you will be notified if coverage is terminated or reduced before the certificate expiration date. NOTICE OF CANt I I JLATI(N, (NOT APPLICABLE UNLESS A NUMBER OF DAYS IS R N l l RI ^D BELOW.) BEFORE THE STATED EXPIRATION DATE THE COMPANY WILL NOT CANCEL OR REi) &,. THE INSURANCE AFFORDED UNDER THE ABOVE POLICIES UNTIL AT LEAST 30 DAYS NOTICE OF SUCH CANCELLATION HAS BEEN MAILED TO: Liberty Mutual Insurance Group This certificate is executed by LIBERTY MUTUAL INSURANCE GROUP as respects such insurance as is afforded by those Companies NM 772 07 -10 25113417 I LM 2619 1 7/15 -7/16 - GL /2/1, AL /2, WC /1, U/5 I Nicholas Misoni 1 6/16/2015 12:06:22 PM (CDT) I Page 1 of 2 LDI COI 268896 02 11 FCity of El Segundo 350 Main Street Elaine Ulan x El Segundo CA 90245 d Los Angeles 0603 / 818 W 7th Street, Suite 850 Los Angeles CA 90017 OFFICE AUTHORIZED REPRESENTATIVE 0564408 213 - 624 -1171 6/16/2015 PHONE DATE ISSUED This certificate is executed by LIBERTY MUTUAL INSURANCE GROUP as respects such insurance as is afforded by those Companies NM 772 07 -10 25113417 I LM 2619 1 7/15 -7/16 - GL /2/1, AL /2, WC /1, U/5 I Nicholas Misoni 1 6/16/2015 12:06:22 PM (CDT) I Page 1 of 2 LDI COI 268896 02 11 AGENCY CUSTOMER ID: LM 2819 ..... ._...._............ LOC #: ADDITIONAL REMARKS SCHEDULE Page of '.AGENCY NAMED INSURED TI ROVNTS, INC Liberty Mutual Insurance Co. National Insurance West 200 EAST BUR ANAHEIM CA 92806 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: N'AL KtIVIAMIX0 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: NM FORM TITLE: Certificate of Casualty Insurance . . . . . . ..................... HOLDER: City of El Segundo ADDRESS: 350 Main Street El Segundo CA 90245 Per forms CG 2010 and CG2037 for General Liability and CA 2048 for Automobile Liability The City of El Segundo, its officials, and employees are included as Additional Insured, but only if required by written contract with the Named Insured prior to an occurrence and as per attached endorsements. Per form IN 2001 this insurance shall be excess over any other coverage available to the additional insured, unless a written agreement obligates the named insured to provide insurance to the additional insured on another basis. In that event, this policy will apply on the basis required by written contract. Waiver of subrogation in favor of the City of E1 Segundo, its officials, and employees included on WC where allowed by statute and applies only to the specific jobs of the insured performed under written contract. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ADDENDUM 25113417 1 LM_2019 1 7/15 -7/16 - GL /2/1, AL /2, WC 11, U/5 I Nicholas Misoni 1 6/16/2015 12:06:22 PM (CDT) I Page 2 of 2 POUCY NUMBED: "TB2..661 -039 -0'15 CG 20 10 04 13 IIP���� �� ,�I° Ilq'��������� ���T"Hili, P L, ICY IP1111�11"E SE MEAD i 2. The acts or omissions of those acting on your f 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. following additional exclusions ;y4,,. CG 20 10 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY II4UMBEI�,'k:'T 2—,6'6 - 0394439 -. 1 G 20 37 04 1° I Eiii..:.] 00RSEM 111Y1, l4 ON ENE....' THE NIA ' E a Il"LEA D RE [7 IlflEFUL NI,,,,,, Y. VIII LESSEES CONTRACTORS Liar COMPLETED OPERNTIONS „n-iis, eindorsement niodifies kisurance provided undeir the fallowing: ,r o n Any owner, lessee, or contractor for whom you have agreed In writing prior to a loss to provide liabilky insurance respect afforded to theie additional insureds, the following is added ,, SCH EDIU Ll..' "0 37 04 13 0 Insurance of P LII Y I II II R:AS .. 661 .- 039499 - r COMMERCIAL " CA 20 48 1013 "MIS I 'N I:..:.. :i °r ci °1 N E I I fE POLICY. IIN„111 READ IV r CARIEFUl „,, E, Y. DESL IGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE AUTO DEALEI °EU' I F ell' BUSINESS „T,. COVERAGE FORM respect MOT01:1 CARRIER COVERAGE FORM With . coverage provided by o provisions of rt re: Form apply modified by the endorsement. s , , iU 36 Ti b - ' f . , i7 k 4 ";,” , .- w ' r > s h ► :, M, f,',, V7. under the Who Is An Insured provision of th e Coverage Form. This endorsement doz...y, not alter coveragt provided In the Coverage Form. Narrie Of Porson(sl Or �� +sue �� � � �” *�, �; � ��• .;k;ir k� '4 � information roquhmd to parr ::)Iete this SchedUII W Gf not shown above, wEfl Ile shown Gin the Ded r floe , CA 20 48 10 13 0 2011 Policy Number "TI32-661-0.3-9499-0-15 Issued by Weq Mutmai Fire Insurance Co. �'HIS ENDORSEMENT CHANGES "T"FlE POLICY NCI,,,. E,4SE RE,,4D IT CMEFU LL Y. BLANKET ADDITIONAL INSURED "I'lils endorsement modifies Insurance provided under the,foilowing. COMMERCIAL GENERAL LIABILITY COVII:..:.RAGE 1:::::OIR.M Alz WAIVER OF OUR 8101 -11" TO t)V EEN I° 11 011 "HERS ';', D RSEMEN ' CAN'IFORINI remuneration You must maintain payroll records accurately segregating the the work deabribed in the Schodule. The additional pr rniurn for this endorsement shall be m of the Callfomis workers' compensation premium otherwise due on such remuneration. Additional premium Is a percent of the California Manuel Workers Compensation premium, -Subject to a minimum prerniurmcharge of S 250. rs v D° r nJLaJ d a tC7Pw � rliikkc l`. Where required by contract or written agreement prior to lose and allowed la 18809d by Liberty Insurance Corporation 21614 For attachment to Policy No. A7 6 ®03 -0°75 kedive rata Premium WC 04 03 06 Page t of a Ede 04/1904