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PROOF OF INSURANCE (2016) CLOSED, DATE (MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 10/9/2015 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 Frank Crystal & Co of CA, Inc. dba Crystal & Company Ins Srvc 9OB64537 633 West Fifth Street, 26th Floor Los Angeles CA 90071 INSURED CLINLA Clinical Labratory of San Bernardino, Inc. 21881 Barton Road Grand Terrace CA 92313 Pabla Barros 310- 981 -0820 FAX . „ „,. 310- 981 -0832 INSURER A:Transportation Insurance Companv INSURER B :Haford Underwriters Insurance Co m w ... ............. INSURER C: Contlnenta lCasualty Com a nv E: 04 d COVERAGES CERTIFICATE NUMBER: 1952689919 RE'VIStON 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. iNTR TYPE OF INSURANCE ............ NSO SMiVD b POLICY NUMBER.... ,_. IMMIDD/YYYYI (M!MIDDIYYYY�. mM. LIMN. . ... ... TS -A X COMMERCIAL GENERAL LIABILITY Y Y 5088208188 2/1/2015 2/1/2016 EACH OCCURRENCE t7 $$1,000,- 000 ..... AMAG� i� �(= NiE[� CLAIMS MADE [X ] OCCUR P,1RW!aFC rF $$100 000 ,.. ., ._w,,. r ...,.... µ, _ . _ .. a. ., , ------ --- MED EXP (Any one person) $$10,000 PERSONAL & ADV. .. .. .. .. . .. .. . -, GE INJURY $$1,000,000 .. . .. .. .. ........ N'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE X �I „m $$2 ,000,000 .... POLICY PRO - LOC PRODUCTS COMP /OP AGG $$2 0001000 µ 1 JECT OTHER: $ • AUTOMOBILE LIABILITY Y Y 5088208224 211/2015 21112016 Ca eccdeJani $$1.000.000 ......, ..,,,I. . - - -- X ANY AUTO BODILY INJURY (Per person) $ X ALL OWNED NED SCHEDULED BODILY INJURY (Per accident) $ ...,...,.,.. ...._. NON -OWNED .. - AUTOS . ........ X HIRED AUTOS $ PaR rice d�k�rdq A X UMBRELLA LIAB X OCCUR 5088208269 2/1/2015 2/1/2016 EACH OCCURRENCE $$5,000,000 ..... EXCESS LIAB - -. CLAIMS -MADE AGGREGATE $$5,000,000 DED X RETENTION$$10,000 $ B WORKERS COMPENSATION Y 10WECAN1623 2/1/2015 2/1/2016 X PER OTH- AND EMPLOYERS' LIABILITY n STATI ITF ER YIN ANY PROPRIETOR /PARTNER /EXECUTIVE j"� N / A E..L. EACH ACCIDENT $$1,000,000 OFFICER /MEMBER EXCLUDED? - - - - - -- `. " ° ° ". ". ". " "" (Mandatory in NH) E DISEASE - EA EMPLOYE $$1,000,000 If yes, describe under - DESCRIPTION OF OPERATIONS below E L, DISEASE - POLICY LIMIT $$1.000.000 I, C Environmental Professional Liab EEH276170923 2/1/2015 2/1/2016 $3,000,000 Per Claim $3,000,000 Agg Claims Made Coverage Deductible: $100,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Re: Engineering Plan Check Svcs, City of El Segundo. The City of El Segundo, its officials, officers, agents and employees are added as additional insured under General Liability and Automobile Liability policies where required by written contract. Primay wording on General Liability policy is included. Waiver of Subrogation apply to General Liability, Automobile Liability and Workers Compensation Policies. CERTIFICATE HOLDER CANCELLATION 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. Attn: Floriza Rivera, PW Dept 350 Main Street �'�° AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 ., ' c►yy"LG tt e__.� ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD G- 17957 -H (Ed. 01/13) BLANKET ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - WITH PRODUCTS - COMPLETED OPERATIONS COVERAGE - LIMITED LIABILITY It is understood and agreed that this endorsement amends the COMMERCIAL GENERAL LIABILITY COVERAGE PART as follows: SCHEDULE (OPTIONAL) Name of Additional InsureO rsons 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" and only to the extent caused by: a. Your negligent acts or omissions, or the negligent acts or omissions of those acting on your behalf, in the performance of your ongoing operations specified in the "written contract'; or m 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: m (1) The "written contract' requires you to provide the additional insured such coverage; and 0 0 (2) This Coverage Part provides such coverage. 0 2. We will not provide the additional insured any broader coverage or any higher limit of insurance than: a. The maximum permitted by law; b. Required by the "written contract'; c. Described in B.1. above; or d. Afforded to you under this policy, whichever is less. 3. 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. 4. The insurance provided to the additional insured does not apply to "bodily injury," "property damage," or "personal and advertising injury" arising out of: G- 17957 -H (01/13) Page 1 of 2 Copyright, CNA All Rights Reserved, G- 17957 -H (Ed. 01/13) a. Acts or omissions of the additional insured, or of anyone, other than you, acting on the additional insured's behalf. b. 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 c. 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 B.3 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. G- 17957 -H (01/13) Page 2 of 2 Copyright, CNA All Rights Reserved. �qL l POLICY NUMBER: COMMERCIAL AUTO CA 20 48 02 99 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. M lik This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS 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" 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. Endorsement Effective: Countersigned By: Named Insured: (Authorized Representative! SCHEDULE Name of Person(s) or Organization(s): Any person or organization whom you are required to add as additional insured on this policy under a written contract or written agreement. You must agree to these contracts prior to the date of loss. See Endt (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section II of the Coverage Form. CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 N O m O N m O N O O O O N O O POLICY NUMBER: A COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 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: The City of El Segundo, its officials, officers, agents and employees Information required to complete 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:;q,�, 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 under 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 Page 1 of 1 This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. 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(s) Of Person(s) Or Organization(s): ANY PERSON OR ORGANIZATION FOR WHOM OR WHICH YOU ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT TO OTBAIN THIS WAIVER FROM US. YOU MUST AGREE TO THAT REQUIREMENT PRIOR TO 'LOSS. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization. CA 04 44 03 10 Copyright, Insurance Services Office, Inc., 2009 Page 1 of 1 n- THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number: 10 WEC AN1623 '� Endorsement Number: 03 Effective Date: 02/01/15 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: CLINICAL LABORATORIES OF SAN BERNARDINO, INC PO BOX 329 SAN BERNARDINO, CA 92402 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 premium otherwise due on such remuneration. SCHEDULE Person or Organization ANY PERSON OR ORGANIZATION FROM WHOM YOU ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT TO OBTAIN THIS WAIVER OF RIGHTS FROM US. Countersigned by % of the California workers' compensation Job Description BLANKET OPERATIONS Authorized Representative Form WC 04 03 06 (1) Printed in U.S.A. Process Date: 02/10/15 Policy Expiration Date: 02/01/16