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PROOF OF INSURANCE (2016) CLOSEDRESCHUL -01 TEMPPC CERTIFICATE OF LIABILITY INSURANCE °12/17/2015 �......... 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. the terms„ end conditions the policy, der s an ADDITIONAL INSURE an endorsement. ...... �..R .bj to ,.. . IMPORTANT: If the y(ient A statement on this certificate does not confer subject to e endorsed. If SUBROGATION IS WAIVED, ter rights to the certificate holder In lieu of such endorsement(s), Peter C�Foy ti Associates Insurance Se... ..... JUIURYAO& ME : µ.........81..8..... _..._ 703- 80......... eeeeeee ,vvv,.�._ .......aww w .�...... NAME: fvicesInc. PHQN! PAX 6200 Cano a Ave. A/ , No, Ext): ( ) _ 57 (AIC, Nop (818) 703 -0935 -ueu Noodland Hills, CA 91367 - -'w -' INSURER(S) AFFORDING COVERAGE NAIC N INSURER A: Houston Specialty Insurance Co. 12936 INSURED INSURER a: United Financial Casualty Company ,11770 R.E. Schultz Construction Services INSURER C:Topa Insurance Company 18031 P.O. BOX 6 INSURER D: Sllverado, CA 92676 INSURER E: - .-.- -,-- ,,._ _ ................ COVERAGES CERTIFICATE_ NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURE NAME .. ABOVE - POLICY 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. IN SR ADDL SUER POLICY FrF POLICY EXP L TYPE OF INSURANCE tlNYO.4dYO POLICY NUMBER �MMM70.APYWYi (4kaMIi�11fMYY) o LIMITS A X COMMERCIAL GENERAL LIABILITY ,EACH OCCURRENCE $ 4M1O.W CLAIMS -MADE X OCCUR X X :TEN -15782 05/10/2015 0511012016 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,0'010 PERSONAL & ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,0010 POLICY X JEC LOC PRODUCTS - COMPIOP AGG $ 2,000,000' LIIXLRLi�. Per Project Agg S 3,000,000....., �. .... ..,.. .......... ......... _...._ .. .. ...._ AUTOMOBILE UABILITY (Ea I�d7I, Rk $It'4G"t 11'0 'VI Y.......... a 1,000,000'... B ANY AUTO X 021860902 0510112015 05/01/2016 BODILY INJURY (Per person) '$ X ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident)' X HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE (Per accident) I, UMBRELLA IAB X OCCUR X05/1012015 OCCURRENCE C X EXCESS LIAB IMS MADE XL 6606998 05/10/2016 AGGREGATE E 1,000,000 DIED RETENTION S 31 ....... .. .......... .. ..... .......,., .w., ,. e .,.... �,.,�, ,®.... � .. . ..WO..R_ NERSCOMP&fNSA11ON. . .. -. ......�,,..w„ IS'J'�tA�+IEIT, _......... .................... . AND EMPLOYERS' LIABILITY Y / N P. ' ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED ?�� N lA E L EACH ACCIDENT yr,. /Mon tory In NH) E L DISEASE - EA EMPLOYEE $ It p es dasrwobe undor al"", t.. G II tlV4, trN ',�9 G7PFA� +�T4CMJh)' gIiMnw E L DISEASE POLICY LIMIT $ DESCRIPTION OF .. „ ._., ...... ....... ......,,,w. ..., ..... n... . w .. .. .....�._... „_ ........... OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addldonal Remarks Schedule, may be attached If more space Is required) ..... ......... .......... . ..... ,,, ._....... - - --- .. City of El Segundo, its officials and employees are named as Additional Insured as respects General Liability operations of the Named Insured. General Liability is primary and non - contributory. General Liability Waiver of Subrogation. Project: Hilltop Park Playground Improvement, No. PW -16 -05. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El S egundo �I" ,I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. 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 COMMERCIAL GENERAL LIABILITY CG 2010 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. «, This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Oraanlzation(s): Location(s) Of Covered Ooeratlons �., ..... .,a Only those parties required to be named as an Addl- ALL tlonal Insured In a written contract with the Named Insured under this policy, entered into prior to loss or," occurrence",,ti Information re wired to corn lete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional exclu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage "personal personal and advertising injury' "property damage" occurring after: caused, in whole or in part, by: 1. Your acts or omissions; or 1. All work, including materials, parts or equip - ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project (other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) desig- covered operations has been completed; or nated above. 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 2010 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 E3 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. III � This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) E,— -� Or Oroanization(s): Location And Description Of Completed Operations Only those parties required to be named as an ALL Additional Insured In a written contract with the Named Insured under this policy, entered Into prior to loss or "occurrence ". Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — 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" or "property dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sched- ule of this endorsement performed for that additional insured and included in the "products- completed , operations hazard ". C CG 20 37 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 a POLICY NUMBER: TEN -15782 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 VM1714:15411 wl� &I 1030*0101TI n_ "" to 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: Only such Person or Organization where required in a written contract with the Named Insured under this policy, entered into prior to the loss or "occurrence ". to complete this Schedule, if not The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV —Conditions: 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. V;pu CG 24 04 05 09 0 Insurance Services Office, Inc., 2008 Page 1 of 1 ❑ COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. TEN0215 01 14 PRIMARY AND NON - CONTRIBUTING INSURANCE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE FORM The following is added to SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, Paragraph 4: Section IV: Commercial General Liability Conditions 4. Other Insurance: d. Notwithstanding the provisions of sub - paragraphs a, b, and c of this paragraph 4, with respect to the Third Party as defined below, it is understood and agreed that in the event of a claim or "suit" caused in whole or in part by the Named Insured's negligence, this insurance shall be primary and any other insurance maintained by the additional insured named as the Third Party below shall be excess and non- contributory. The Third Party to whom this endorsement applies is: Absence of a specifically named Third Party above means this endorsement applies only to those third parties required to be named as an Additional Insured as Primary and Non - Contributory coverage specified in a written contract with the Named Insured under this policy, entered into prior to the "loss" or "occurrence ". All other terms, conditions and exclusions under this policy are applicable to this Endorsement and remain unchanged. uti* Mx� Y TEN0215 0114 Includes copyright material of Insurance Services Office, Inc. Page 1 of 1 0 Policy Number: Date Entered: 04 zi0 L201 ACXW?" CERTIFICATE OF LIABILITY INSURANCE DATE (MWDDIYYYY) 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. Mod Rf .— If thi� I icats holder is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. It SUBROOATION 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 enclorsoment(s). PRODUCER The Hulett Agency NAME: PHONE (858)618-5442 FAX (858) 618 -5444 m. NIOmflti�.�„-11,,,,-",-.---.,--,—...-.--,""'ll'-,,.-,.l,�!9�,No),!,,—,. 13959 Saddletwood Drive LmAIL hulettagencryl3abinglobal. not Poway, CA 92064 INBURER(S) AFFORDING COVERAGE NAIC 0 INSURER A! St0t* Compensation Insuranom, Fund INSURED R E Schultz INSURER 0: PLichard Sahultz INSURER C i P 0 Box 6 INSURER 0 Silverado, CA 92676 INSURER E: 11JAIJarle r COVERAGE$ CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CEW'IFY fl,lAr THE POLICICS OF' INSURANI,"E USTF",D BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR VIBE 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 I OR ADOL SUOR N TYPE OF INSURANCE POLICY NUMBER M. CE � _ "_ q1g), yyyp, VOUVYEfF POI,ICYr4XP IMMOVO YyyJ tmmyoniryy Y) _ LIMITS ly Y . ........ ...................... COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 3 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES (Ea occurrenco) S MED EXP (Any one person) 4 PERSONAL & ADV INJURY 0 1 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S • POLICY PRO RO. JECT I PRODUCTS - COMPIOP AGG 3 OTHER I ­­ . . . . .......... . AUTOMOBILE LIABILITY ANY AUTO BODILY INJURY (Per person) 11. ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) S NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS fPer accident) . ..... . .............. ....... ... ............... . . .... ... .............. UMBRELLA LIAB OCCUR E ............ ................. ..... ....... . . . ....... EACH OCCURRENCE It EXCESS LIAB CLAIMS-MADE AGGREGATE F"_']DED'7 RETENTION S . .... . . . . .............. . . . ...... .. WORKERS COMPENSATION AND E MPL OYER S' LIABILITY Y d N ANY PROPRIETORIPARTNERIEXECUTIVE . ..... EL EACH ACCIDENT 1,000,000 A OFFICIEWMEMBER EXCLUE NIA 9118707-15 04114/2015 04/141201 (Mandatory In NH) E L DISEASE - EA EMPLOYEE $ 1,000,000 '�J�Ici4 �VOC RP�ON under ho� 01"OF�'RATIONS ­ I� ................ I ­ E L DISEA E - POLICY IT I 11 I 11­ ­ DISEASE � .... -.... 111 11 I '_. . DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remerk& Schedule, may be allathed If more space Is required) Project: Hilltop Park Playground Improvement, No. PW-16-05 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 ............................. AUTHORIZED REPRESENTATIVE AOTFORIZEC REPRESEVATI K" � 0 1980-2014 ACORD CORPORATION, All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD Produoticlusing Forms Boss Plus software www FormsBosB romimpressivePublishingBOO-208-1977 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS 9118707 -15 FUND RENEWAL SP HOME OFFICE SAN FRANCISCO EFFECTIVE APRIL 14, 2015 AT 12.01 A.M. PAGE 1 OF 1 ALL EFFECTIVE DATES ARE AND EXPIRING APRIL 14, 2016 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME R E SCHULTZ CONSTRUCTION PO BOX 6 SILVERADO, CA 92676 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. THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 2.00% OF THE TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION BLANKET WAIVER OF FOR WHOM THE NAMED INSURED SUBROGATION HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER 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: APRIL 3, 2015 AUTHORQED REPRESENT IVE PRESIDENT AND CEO 2572 SCIF FORM 10217 (REV.7 -2014) OLD DP 217