Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
PROOF OF INSURANCE (2016) CLOSEDACC)IRO CERTIFICATE OF LIABILITY INSURANCE DATE (MM1OIXYYYY)
OLDER. THIS
321 D CONFERS NO RIGHTS UPON THE GESITIFICATE H
THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AN
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
9,) must be endorse . If SUBROGATION li—WWAIWVED� subject to
IMPORTANT if the cqjU--fIcst& ljo�r ii-an ADDITIONAL INSURED, the poll y(la onfer rights to the
the terms and conditions of the policy, certain policies may require an end moment A statement on this certificate does not e
certificate holder In lieu of suich endorse, KorlDsLeon
PRODUCER RTI Insurance Services, Inc.
1383 Redondo Avenue Suite 101 .. ........ .... ... . .......
OIL
Long Beach, CA 90804 ... . . ... . ...... NAICS
License #: OC16014 INSURARA Mercury Cosua4
INSURED ING t
J & L BUILDING MAINTENANCE LLC
INSU
6636 FLORENCE AVE
STE 337
BELL GARDENS, CA 902014990 UK I an F:
Cove iAGES ERTIFICATE NUMBERt 0000000D.150058 REVISION NUMBERL_16_
THIS IS: TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE DEEN IS$UEDTO THt INSURED NAM�ED ABOVE FOR THE POLICY PERIOD
MDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT NTH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
EXCLUSIONS AND CONDITIONS OF SU
01A ...... . . . . . ....... . ..... .. . —XYL "600"
1EY N U �Lo S R -=Xy UM116
OF INS 1 0
0312912015 0312912916 EAOi 0CCQHRENCE
A �COMM�VCIA 31E�N Y C CP0042411 Is 26 b4fi
L'IM'
MADE
MED 0XIM tlAAY W10 PfifSOM 0,00(
L AG43REGATE LIMIT APPLIES PER:
LOC
POLICY JE
PRO CT
AUTOMOBILE UABIUTY
ANY AUTO
ALLOWNED
SCHEDULED
SCHEDULED
AUTOS
AUTOS
NON-OW NED
H
UMBRELLA UAB OCCUR
EXCESS LIAM
AND EMPLOYERS' LIABILITY
m�'Y PR0PftT0RM4RT1IQPj
B Surety Bond
NIA
Y 71628867 10312812015 103128/2018
I A " L L s
BODILY INJURY (Per person) j$
. ........ .
BODILY INJURY (Per &=Iftnt) 1 $
095'fi0fY
FACHOCCUPPENCE S
AGGREGATE
F. Lr EACH ACC
L DISEASE
.E ..E OtlSEASE,
RIN
S
a roq ovd$
DOSCMPTION Of OPIERAT10140 I LOCATWINS d VEHICLES (ACORD 01, Addiflonat Remarks Sthodulo, Mmy bo aeldloo If 1110TV $Pao* i ul
See policy for actual limb, terms, conditions and llmfttlons as they may apply, Office, cleaning and maintenance. The City
of El Segundo, irs officials and employees and named as addiltonal insured under this policy In a primary and
non-contributory placement.
10,000
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS.
360 Main St.
EL SEGUNDO, CA 90245 AUT'HORIZ AEPREIENTATIVE
(KD
01"988 -2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
Printed by KD1 on April 29, 2015 at 10:35AM
POLICY NUMBER: CCP0042411
COMMERCIAL GENERAL LIABILITY
CG 20 26 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSPIRED - DESIGNATED
PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
City of El Segundo, It's Officials and Employees
350 Main Street Room 5
El Segundo, CA 90245
I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. I
A. Section 11 — 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 your acts or
omissions or the acts or omissions of those acting
on your behalf:
1. In the performance of your ongoing operations;
or
2. In connection with your premises owned by or
rented to you.
However:
1. The insurance afforded to such additional
insured only applies to the extent permitted by
law; and
B. With respect to the insurance afforded to these
additional insureds, the following is added to
Section III — Limits Of Insurance:
If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the
applicable Limits of Insurance shown in the
Declarations.
2. If coverage provided to the additional insured is
required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
Nk
CG 20 26 0413 © Insurance Services Office, Inc., 2012
Page 1 of 1
ELW DATh (&tMJDDi"YY)
CERTIFICATE OF LIAB�ILITY'INSU RANCE R054 5/5/2015
.. ...... ...
THIS —CERT-IF—ICATEIS 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
RCENTATIVS OR PRODUCER, AND THE CERTIFICATE HOLDER . . ......
c — be endorsed BROGATIONIS WAIVED, subject to the
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the poll
PRES� y(les) must - If SU
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 andorsetnent(S).
AUTO INS SPECIALISTS LLC/PHS
255261 P:(866) 467-8730 F:(888) 443-6112
PO BOX 33015
SAN ANTONIO TX 78265
J&L BUILDING MAINTENANCE
6635 FLORENCE AVE
BELL GARDENS CA 90201
A
K . - 6 �Ncy (888) 443-6112
�P,dy (866) 47-8730 P, Na
INSURER(S) AFFORDING COVERAGE
INSUMIRA: Rarti..d A..id..t' indemnity Co
INSURER 0
INSURER C
INSUfW-R 0
INSURER E
'ZURelk F
-- -N--- REVISION NUMBER.: E RTICATE NUMBER
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR VIE POLICY R1567
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,
9Z 75
73-30 TYPEOFINSUA4 UP, LIArrm
... vom
COMMERCIAL GENERAL LIABILMY EACH OCCuRRENCE ss
CLAIMS-MADE 7OCCUR DAMAGE t'O ReNIED
MED EXP (My one person)
PERSONAL & ADV INJURY 15
GENERAL AGGREGATE
GENIL AGGACGATE LIMIT APPLIES PEk
-�ROD�CTS - COMPIOP AGG
POLICY PRO- LOC ti
EIJECT
OTHER: ....... . . .
CM0NEDSINGLE U AT 000,000
AUTOMOBILE LIABILMY EM orvavw�
ANYAUTO BODILY INJURY (per person)
— ALL OWNED SCHEDULED —X 72 UP-C GZ0073 03/26/2015 03/28/2016 SWILY INJTRY (P.rwd..0
A AUTOS . .........
— AUTOS PEAMAE
X HIRED AUTOS X NON-OWNED
PRO RTY D G
AUTOS qpw � "6,
UMBRELLA LIAB
I [J _;C
C UR
EACH OCCURRENCE
EXCESS LIAR LAl M MADE AGGRE GATE
........ . . . . ...
L'a i Ian aC04 . ..... .
AND EMPLOYEASILUNILtTY ER
ANY PROPRIETORIPARTNER/EXECUT!"VE Y/N E.L. EACH ACCIDENT
L
OFFICIEWMEMSER EXCLUDED? F-1 NIA EMPLOYEE
(Mandatory In NM E.L. DISEASE- EA EMPLOYEE
yes, d `tae under E.L. DISEASE - POUCY LIMIT
2ESC RIK ON OF OPERAT I01NS bakp—,
EiS-6iPTtONOFOPe,RAnONS,ILOCATdONSI VEHICLES IACO,Roiol,A 16onal Remarks Schedule, maybe attached If mom space Is required)
Those usual to the Insured's Operations. Certificate Holder is an Additional
Insured per Designated Insured CA2048 attached to this policy.
-i5E IFICATE HOLDER CANCELLATIOW-'--'-'
i5E SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE
F ED .R— -AAC, -PRD WITH lff-29!619—ePRgVL�19N�,�.--
S,
CITY OF EL SEGUNDO AUTHORIZED REPRESUNrA TIVE
350 MAIN ST
EL SEGUNDO, CA 90245
0 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
Select Customer Insurance Center
3600 WISEMAN BLVD,
SAN ANTONIO TX 78251
Policyholder, please callus at: (866) 467 -8730
Agent, please call us at: (800) 447 -7649
SERVICE.TXQTHEHARTFORD.COM
INSURANCE ENDORSEMENT
ATTACHED
*** PLEASE REVIEW THE CHANGE * **
Enclosed is an endorsement for your business insurance policy. Please review it at your convenience. If you have
questions or need to make further changes:
Policyholder, please callus at: (866) 467 -8730
Agent, please callus at: (800) 447 -7649 between 7 A. m. and 7 P.M. CENTRAL TIME.
The premium billing will be mailed to you separately. You can expect to receive it soon.
Thank you for allowing us to service your business needs.
AUTO INS SPECIALISTS LLC /PHS
THE HARTFORD SELECT CUSTOMER INSURANCE CENTER
0
The Hartford
Hartford Fire Insurance Company and its Affiliates
One Hartford Plaza, Hartford, Connecticut 06155
POLICY NUMBER: 72 UEC GZ0073
CHANGE NUMBER: 001A
COMMERCIAL AUTO
CA 20481013
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified
by this endorsement.
This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage
under the Who Is An Insured provision of the Coverage Form, This endorsement does not alter coverage provided in
the Coverage Form.
This endorsement changes the policy effective on the Inception date of the policy unless another date is indicated
below.
Named Insured:
Endorsement Effective Date:
SCHEDULE
Name Of Person(s) Or Organization(s):
CITY OF EL SEGUNDO
350 MAIN STREET
EL SEGUNDO, CA, 90245
Information reQLJired to complete this Schedule„ if not shown above, will be shown in the Declarations.
Each person or organization shown in the Schedule is
an "insured" for Covered Autos Liability Coverage, but
only to the extent that person or organization qualifies
as an "insured" under the Who Is An Insured provision
contained In Paragraph A.I. of Section II — Covered
Autos Liability Coverage in the Business Auto and
Motor Carrier Coverage Forms and Paragraph D.2. of
Section 1 — Covered Autos Coverages of the Auto
Dealers Coverage Form.
■
CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1
DATE (MMIDD/YYYY)
`'"' C'" ` "" CERTIFICATE OF LIABILITY II SURANCE 5/7/2015
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 NAME, CONTACT Linda Goodyear
C &S Insurance Services PHONE All
,Air. F,f ( ) .,(310)517
3220 Sepulveda Blvd, #202 E-IDN .Lltda @inscenter.com
INSURER(M AFFORDING COVERAGE NAIC #
!Torrance CA 90505 wsURERA:State Compensation Fund 12345
INSURED
INSURER B
J &L Building Maintenance LLC INSURERC,
6635 Florence Ave
INSURER D:
Suite 337 INSURER E ;
,Bell Gardens CA 90210 INSURER F:
COVERAGES CERTIFICATE NUMBER:CL1542802700 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 'nnm:� POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE nice. POLICY N BER_.. IMMIDDIYYYYI fMtdJDDaYYYl LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$
COMMERCIAL
P I
/��ne
orP
MED EXP I,A ersonl
$
CLA
CLAIMS-MADE OCCUR
PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
$
GEN'L AGGREGATE LIMIT APPLIES PER:
PROD'IrdCTS • C+O'MPIOP AG(o�
$
PRO.
POLICY LOC
$
AUTOMOBILE LIABILITY
Ea acca�MOnX
BODILY INJURY (Per person)
$
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident)
$
NON -OWNED
HIRED AUTOS AUTOS
PROPERTY DAMAGE
'Per axid -rirl
$
UMBRELLA LIAB OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LIAB CLAIMS -MADE
$
'. DED RETENTION $
A
WORKERS COMPENSATION
WC STATU- 0TH-
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR /PARTNER /EXECUTIVE
TORV I IMITR FR
E.,L, EACH ACCIDENT
$ 1.000,000
OFFICER /MEMBER EXCLUDED?
(Mandatory in NH)
NIA
9096795 -15
4/22/2015
4/22 /2016
E,L, DISEASE - EA EMPLOYEE
$ 1.000,000
If yes describe under
DESCRIPTION OF OPERATIONS below
E.. L, DISEASE - POLICY LIMIT $ 1..000!000
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 1101, Additional Remarks Schedule, if more space is required)
Coverage applies to the above term only. See policy for actual coverage, terms, conditions, and
limitatations that may apply.
Re: Engineering Plan Check Services, City of E1 Segundo.
City of E1 Segundo, its officials, officers, agents & employees.
WOS to follow.
.TE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of E1 Segundo ACCORDANCE WITH THE POLICY PROVISIONS.
Attn: PW Dept
350 Main St AUTHORIZED REPRESENTATIVE
E1 Segundo, CA 90245
H INSURANCE /LINDA
ACORD 25 (2010/05) ©1988 -2010 ACORD CORPORATION. All rights reserved.
INS025 (201005),01 The ACORD name and logo are registered marks of ACORD
,wr
ENDORSEMENT AGREEMENT BROKER COPY
COMPENSATION WAIVER OF SUBROGATION
FUND 9096795 -15
RENEWAL
SC
HOME OFFICE 8-56 -31-19
SAN FRANCISCO PAGE 1 OF 1
ALL EFFECTIVE DATES ARE
AT 12:01 AM PACIFIC EFFECTIVE MAY 6, 2015 AT 12.01 A.M.
STANDARD TIME OR THE
TIME INDICATED AT AND EXPIRING APRIL 22 , 2016 AT 12.01 A.M.
PACIFIC STANDARD TIME
J & L BUILDING MAINTENANCE SER
6635 FLORENCE AVE STE 337
BELL GARDENS, CA 90201
ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING,
IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND
WAIVES ANY RIGHT OF SUBROGATION AGAINST,
CITY OF EL SEGUNDO
WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS
POLICY IN CONNECTION WITH WORK PERFORMED BY,
J & L BUILDING MAINTENANCE SER
IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN
PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION
OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE
EMPLOYER.
IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH
EMPLOYEES SHALL BE INCREASED BY 03 %.
NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE
OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS
POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE
HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR
LIMITATIONS OF THIS ENDORSEMENT.
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: MAY 8, 2015 2570
AUTHORIZED REPRESENT IVE PRESIDENT AND CEO
SCIF FORM 10217 (REV.7 -2014) OLD DP 217