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PROOF OF INSURANCE (2016) CLOSEDA CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD/YYYY) 4/30/2015 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 Dealey, Renton & Associates 199 S Los Robles #540 Pasadena, CA 91101 Lic #0020739 INSURED Gale /Jordan Associates, Inc. 3858 Carson Street, Suite 200 Torrance, CA 90503 -5613 310 - 316 -4377 GALEJORDA Marie A:Westchester Surplus Lines Insurance C: E; CERTIFICATE NUMBER: 2044075391 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. INTR TYPE OF INSURANCE AINSD S WVD POLICY NUMBER POLICY EFF POLICY EXP IMM /DD/YYYYI I !MM!nn!YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y G24391656003 /28/2015 /28/2016 EACH OCCURRENCE $3,000,000 - �AM_A_GE 6_RENTECi ........ CLAIMS -MADE X I OCCUR PREMISES (Ea occurrence) $50 000 X Contr Poll Liab MED EXP Anyone person) $5 000 X . XCU Included PERSONAL & ADV INJURY VI .. $2 .. 000 GEN'LAGGREGATELIMITAPPLIESPER: GENERAL AGGREGATE $4,000,000 PRCr. POLICY � x )ROT LOC .... PRODUCTS COMPIOP AGG DU COMP/OP . ... .........,,,,,, $4,000,000 OTHER: Contr Pol. Liab $2,000,000 A AUTOMOBILE LIABILITY G24391656003 /28/2015 /28/2016 (Ea accident) b ................................................. $1;000,000 ............................... ANY AUTO BODILY INJURY (Per person) AUTOS�ED SCHEDULED BODILY INJURY (Per accident) $ NON -OWNED X X 61Cu'�t�d'"�TY QAI.Gi�C im ........ - -- $ HIRED AUTOS AUTOS ( d Intl - X NO OwnedAuto $ UMBRELLA LIAR OCCUR � EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE AGGREGATE $ DFn RFTFNTI� ON$ $ WORKERS COMPENSATION PER OTH- TI IT CTATI FR AND EMPLOYERS' LIABILITY YIN ,.... .. _,_ :.. .. .._ :. .... .... ..... ANY PROPRIETOR /PARTNER/EXECUTIVE E L EACH ACCIDENT $ OFFICER /MEMBER EXCLUDED? N / A �_��.u. - ........... ............ (Mandatory in NH) E L DISEASE - EA EMPLOYEE $ If yes, describe under ...... ........ ................. DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT $ ess o a Pfinl Liability ty ro a G24391656003 /28/2015 /28/2016 $2,000,000 Per Claim Claims made Form $2,000,000 Annual Aggregate DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) General Liability polic excludes cWrns arising, out of the performance of professional services. Contractors Polution & Professional Liability Endorsement: Fungi„ Lold, or Microbial Matter Coverage limit $1,000,000 each claim /$1,000,000 Fungi AA Limit (included in the gregate Generale Liability Aggregate) deductible $10,000 each clalrn„ retro date. 04128/2006. General Liability: XC included. Auto Limit is included in GL Limit. RE: All operations -- City of El Segundo, its officers, agents and employees are named as additional insured as respects general liability for claims arising from the operations of the named insured as required per contract or agreement. ICATE HOLDER CANCELLATION 30 Day NOC /10 Day for NonPay of Prem ( SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE r THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of El Segundo, Public Works Dept. f ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo CA 90245 AUTHORIZED REPRESENTATIVE ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Gale /Jordan Associates Inc Policy Symbol Policy Number 04/28/2015 - 04/28/2016 �ffe04/28/201 5 ECP 624391656003 5 Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED ENDORSEMENT - OWNERS, LESSEES OR CONTRACTORS (PRIMARY AND NON - CONTRIBUTORY) This endorsement modes insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE CONTRACTOR'S POLLUTION LIABILITY COVERAGE SCHEDULE: Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such parson or organization to you, wherein such request is made prior to commencement of operations. If no entry appears above, information ecl ( required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) SECTION II - WHO IS AN INSURED is amended to include: A. SECTION II - WHO IS AN INSURED is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to bodily injury or property damage occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) That portion of your work out of which the injury or damage arises has been put to its intended use by any, person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. The coverage provided hereunder shall be primary and not contributing with any other insurance available to those designated above under any other third party liability policy. ENV -3101 (08 -04) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 3 of 1 Insert the policy number. The remainder of the Information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART SCHEDULE Name of Person o Rgzat�. Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (it no entry appears above, Information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition is amended by the addition of the following: 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. All other terms and conditions remain the same. ENV -3143 (03 -05) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 1 of 1 POLICYHOLDER COPY SC P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 10 -20 -2015 CITY OF EL SEGUNDO, PUBLIC WORKS DEPT. Sc 350 MAIN ST EL SEGUNDO CA 80245 -3813 GROUP: POLICY NUMBER: 1118442 -2015 CERTIFICATE ID: 354 CERTIFICATE EXPIRES: 02 -01 -2018 02- 01- 2015/02 -01 -2018 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement. term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. 'ei;ieze, Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #1800 - CHRISTOPHER K. GALE PRESIDENT - EXCLUDED. ENDORSEMENT #1800 - THOMAS A. JORDAN SECRETARY TREASURER - EXCLUDED. ENDORSEMENT #2085 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 02 -01 -2000 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2015 -10 -28 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO. PUBLIC WORKS DEPT. EMPLOYER i GALE /JORDAN ASSOCIATES, It ORATED SC 3858 W CARSON ST STE 200 TORRANCE CA 80503 (P12,SC) (nEV.7 -2010 PRINTED : 10 -28 -2015 WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation: 1. Please be advised that a waiver of subrogation requires that a % suircharge will be applied by State Fund ONLY to the premium assessed on the pa roll of your employees earned while engaged in work for that certificate holdyer who requested the waiver. (Note: if you have no employee payroll on that job, then there is no charge.) apply ", surcharge, you must also agree holder segregated payroll records for empiloyees engaged in work on, job/s for the certificate • has the waiveir. The payroll r w verification by w Example: Payroll for job: $5,000.00 Sample Rate: 13.301s Regular Premium equals: $ 665.00 Surcharge: 3.00% Additional Waiver charge: $ 19.95 Total premium equals $ 684.95 (665.00 + 19.95) ENDORSEMENT AGREEMENT STATE WAIVER OF SUBROGATION 1118442 -15 FUNO RENEWAL SC HOME OFFICE 2- 70 -70 -25 SAN FRANCISCO PAGE 1 OF 1 ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC EFFECTIVE OCTOBER 26, 2015 AT 12.01 A.M. STANDARD TIME OR THE TIME INDICATED AT AND EXPIRING FEBRUARY 1, 2016 AT 12.01 A.M. PACIFIC STANDARD TIME GALE /JORDAN ASSOCIATES, INC. 3858 W CARSON ST STE 200 TORRANCE, CA 90503 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, PUBLIC WORKS DEPT. WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, GALE /JORDAN ASSOCIATES, INC. 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: AUTHORIZED REPRESENT IV SCIF FORM 10217 (REV.7.2014) OCTOBER 28, 2015 PRESIDENT AND CEO 2570 OLD DP 217 1118442 -15 RENEWAL SC PLEASE KEEP THIS ENDORSEMENT WITH YOUR POLICY Dear Policyholder. These endorsements amend and are part of your policy. Please keep them with your documents for future reference. If you have any questions concerning these endorsements, Please contact your local State Fund office.