Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
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