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PROOF OF INSURANCE (2016) CLOSEDN SANCTEC -01 DLOPEZ ACORN DATE (MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 2/10/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF .........._mm ... F 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 li .... -) ..... ............... poliy(' c Les 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 License # OD79613 CONY NAMECT Denise Lopez Bowermaster & Associates Insurance Agency, Inc. PHONE 714 733 -6200 rAAJ( 10805 Holder Street, Suite 350 Aec, N.r, E�ty: _ trUC„ Na) (714) 252 -8253 Cypress, CA 90630 ADDRF S, diopez@bowermaster.com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN y 9 ACCORDANCE WITH THE POLICY PROVISIONS. Public Works 350 Main Street El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE �. ........, w .. w . . ....... .............. ... ....... .............. ._... © 1988 -2014 ACORD CORPORATION. All rights reserved, ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Evanston Insurance Company ''.. INSURED INSURER B: American Fire 8r Casualty Company Sancon Technologies, Inc INSURER C: RSUI Indemnity Company 5841 Engineer Drive INSURER D: State Compensation Insurance Fund Huntington Beach, CA 92649 INSURER E: . ...........................�... INSURER F : ..�......_............. ...--- -_.... COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: . THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW RED NAMED ABOVE FOR THE POLICY HAVE BEEN ISSUED TO THE INSURED AMED R THE 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. TYPE OF INSURANCE ll AOD4 SUkirC _._._,_. .._._- - - - -- m ...... ....... ........... ............................... ........ ........ 4�'_�- POLICY NUMBER ..,9OLICYFr�LICYCXP).,,... ........ .— ,,,,..,.,,.. _..... MiMtdDDfYYYY M�M /DC1�"IYYY _ MT __ ....._. ''... A X I COMMERCIAL GENERAL LIABILITY = EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR X 15PKGWE00603 07/03/2015 07/03/2016 PREMISES, u r, g 100,000 MED EXP (Any one person) $ .PERSONAL 5,000 &ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ =- 2,000,000 -. ...... POLICY X � jE LOC ....._ ... PRODUCTS - COMP/OP AGG $ 2,000,000 OTHER: Deductible $ 5,000 _ _ AUTOMOBILE LIABILITY TBAA56177090 _ L B 1'000'000 ......... B -X ANY AUTO 07/01/2015 07/01/2016 ODILYdNdIURY((Per(pe son) $ ALL OWNED ' SCHEDULED AUTOS _ _ i AUTOS BODILY INJURY (Per accident); $ NON -OWNED X 'HIRED X PROPERTY DAMAGE._ S AUTOS AUTOS (Par accodant) - - -'--°- ............. ........ . ..... ......... UMBRELLA LIAB X OCCUR .... .... .. .... .... .............,.........., ...... ,. ... EACH OCCURRENCE . S 2,000,000 C X EXCESS LIAB CLAIMS-MADL INHA238285 07/03/2015 07/0312016 AGGRLGA °IE $ 2,000,000 tl1�P X wau'rr�wPdrPJN $ WORKERSCOMPENSATION _ X ST'AI'Ur'E ! tl' =RH'^ D EXCLUDED PROPRIETOR/PARTNER/EXECUTIVE �Y' N 901817215 D ANY 07/1312015 ! 07113/2016 E.L. EACH pWIM8ER to / A CM . E L. DISEASECEA NIawPP OYPµE $ 1,000,000 II ^,-; ISn5�CPbkIG'� N noel' r .. AYtlON„� Irzrlraw� �� x G RIP $'K'k,� OPERATIONS tx.... _.,...'____r .. ....._...._ ....... C ._. E L C.)I EASF POq tli`Y LIMpY : - ...� °0'00,000 „......,..,..._..._._. Commercial Pollution 15PKGWE00603 07/0312015'07/03/2016 Each Occurrence 1,000,000 A ��. Commercial Pollution 15PKGWE00603 07/03/2015 07/03/2016 Deductible -Each 5,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, ' may be attached if more space is requir ed) , Project: Trenchless Sewer Main Improvement - Eastern Residential Zone Project No.: PW 16 -03 City of El Segundo, its officials, and employees are Additional Insured with respects to General Liability per form CG20370413 and MEGL15430411, Primary and Non - Contributory included per same form. Waiver of Subrogation applies to General Liability per form MEE122250810 and WorkComp per form 10217. 30 day cancellation notice applies as per policy terms and conditions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN y 9 ACCORDANCE WITH THE POLICY PROVISIONS. Public Works 350 Main Street El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE �. ........, w .. w . . ....... .............. ... ....... .............. ._... © 1988 -2014 ACORD CORPORATION. All rights reserved, ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 15PKGWE00603 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. • 01,111,111, ! "' • This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or ra ni tion(s) Any erson(s) or organization(s) to whom the insured r s to provide Additional Insured status g in a written contract signed by both parties and executed prior to the commencement of operations Location And Description Of Completed Operations Not Applicable `. Information required to complete 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 is added to organizations) shown in the Schedule, but only Section III — Limits Of Insurance: with respect to liability for "bodily injury" or If coverage provided to the additional insured is "property damage" caused, in whole or in part, by required by a contract or agreement, the most we "your work" at the location designated and will pay on behalf of the additional insured is the described in the Schedule of this endorsement amount of insurance: performed for that additional insured and included in the "products - completed operations 1. Required by the contract or agreement; or hazard ". 2. Available under the applicable Limits of However: Insurance shown in the Declarations; 1. The insurance afforded to such additional whichever is less. insured only applies to the extent permitted This endorsement shall not increase the applicable by law; and 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. CG 20 37 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED WITH PRIMARY AND NON - CONTRIBUTORY WORDING OWNERS, LESSEES OR CONTRACTORS (FORM C) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name of Person or Organization: Any person(s) or organization(s) to whom the insured agrees to provide Additional Insured with Primary and Non- Contributory status in a written contract signed by both parties and executed 2rior to the commencement of o stations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule above, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused in whole or in part by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf, in the performance of your ongoing operations for the addi- tional insured(s) scheduled above. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury", "property damage ", or "personal and advertising injury" occurring af- ter: 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 location 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 per- son or organization other than another contractor or subcontractor engaged in performing operations for a princi- pal as a part of the same project. C. It is further agreed that coverage provided for the Additional Insured shown above shall be primary insurance and any other insurance maintained by the Additional Insured shall be excess and non - contributory, but only as respects any claim, loss or liability arising out of your operations, and only if such claim, loss or liability is determined to be solely your negligence or responsibility. All otherterms and conditions remain the same, MEGL 1543 04 11 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1 with its permission. This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE FORM PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE FORM SCHEDULE Name of Person or Oganization, Any person(s) or organization(s) to whom the insured agrees, in a written contract, signed by both parties and executed prior to the commencement of operations to provide a waiver of transfer of rights of recovery. The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition of the respective coverage form(s) 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 written 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. This waiver shall not apply for occurrences resulting from the sole negligence of the person or organization shown in the schedule. All other terms and conditions remain unchanged MEEI 2225 08 10 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1 with its permission ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS HOME OFFICE SAN FRANCISCO EFFECTIVE JULY 13, 2015 AT 12.01 A.M. AND EXPIRING JULY 13, 2016 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME SANCON TECHNOLOGIES, INC. 5841 ENGINEER DR HUNTINGTON BEACH, CA 92649 9018172 -15 RENEWAL SC 1- 47 -88 -16 PAGE 1 OF 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 ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER JOB DEa QRJPTIQ N BLANKET WAIVER OF SUBROGATION 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: AU °I °I °��7Rk2ED @�E�'I�ESEd`�T u SCIF FORM 10217 (REV.7 -2014) JUNE 24, 2015 PRESIDENT AND CEO 1 2572 OLD DP 217