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PROOF OF INSURANCE (2016) CLOSED
ACC)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