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PROOF OF INSURANCE (2016) CLOSED�-� SOUTH32 ACOR "` CERTIFICATE OF LIABILITY INSURANCE �.� OP ID: AC DATE(M2/20 02/02/20 6 16 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 poiicy(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 cerlificate holder in lieu of such endorsement(s).. PRODUCER CONTACT NAME: Orr and Associates Ins. Serv. CALIC #0E63493 PH(951)506 -5859 PH ,;951 -506 -5859 kF 26780 Single Oak Drive #255 E-MAIL . ... 'Temecula,, CA 92590 INSURERISI AFFORDING COVERAGE NAIC d INSURER A: U.S. Specialty Insurance Co. 29599 INSURED SOUTH COAST PAINTING INC. __..� INSURERB:INTEGON NATIONAL INS CO 29742 8364 S WEATERN AVE #465 INSURER C: STATE COMPENSATION INS. FUND 35076 RANCHO PALOS VERDES, CA 90275 INSURER D INSURER ,._._ .............. �......,..._ ,_. .....- _.............._..,,.,,,, INSURERF: COVERAGES CERTIFICATE NUMBER: 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. 1�1$`R _.._.. �.� w,�.- ..�..,,_„ ..w._ ........ ...._ ....__tii5"�'.....eR., ...„_ .._ .....m..e- _- ..�._,._.,_..�.m... LTR TVPEOFINSURANCE NSO WVO POLICY NUMBER MWDD/YYYY MM'JOD/YYYY. LIMBS A X COMMERCIAL GENERAL LIABILrrY EACH OCCI,JRRENCE $ 1,000,000 CLAIMS -MADE ❑X OCCUR X U15AC87GOS -00 05MI/2015 05/01/2016 mmP , �(E' ,.... a.„,_ Ea err:uareruGa $ 100,00 MED EXP (Any one Person) S 5,00 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 Y ' PRODUCTS COMP/O P AGG X POLICY PRO- � LOC $ 2,000,00 01 HEW S AUTOMOBILE LIABILITY C a COMBIN MG Y I III -. $ 1,000,000 B ANY AUTO 12002234 04/27/2015 04/2712016 BODILY INJURY (Per person) $ ALL OWNED +X SCHEDULED BODILY INJURY (Per accident) AUTOS AUTOS . $ NON -OWNED 5 HIRED AUTOS AUTOS rP er a— j-bnll S UMBRELLA LIAR X OCCUR ''. EACH OCCURRENCE S 1,000,00 A HEXCESS LIAR ._G cLAIMS�ngDE U15AC87006 -00 05/01 /2015 05/01/2016 ' gccRECaTE $ 1,000,00 DED -. .._ RETENTIO....... ._..._.,...._.......... �,..�.....�,- ..........w . ..... .... N$ ...-. .�.�.ro�. ..... ... .m.�. $ WORKERS COMPENSATION STATUTF FR AND EMPLOYERS' LIABILITY YIN, C ANY PR0PRIETORrPARTNERJEXECUT1VE � N /A 9125712- 2015 -2 06/01/2015 06/01/2016 E L EACH ACCIDENT OFFICERiMEMBER EXCLUDED? $ 1,000,00 (Mandatory In In NH) I E.L. DISEASE - EA EMPLOYEE S 1,000,00 Iyras doscr)Izo awWor 1) RPPT'tON OF OPERATIONS hek v E.L. DISEASE - POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached 'd more space Is required) CITY OF EL SEGUNDO ITS OFFICIALS, AND EMPLOYEES ARE ADDITIONAL INSURED. 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. ITS OFFICIALS, AND EMPLOYEES AUTHORIZED REPRESENTATIVE MAIN STREET EL SEGUNDO, CA 90245 y�M . u ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD lip ` .l CG 2010 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 13 POLICY NUMBER: U 1 5AC87006-00 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location And Description Of Completed Or Organization(s): Ooerations City of El Segundo its officials, and employees 350 Main Street, El Segundo, CA 90245 350 Main Street, El Segundo, CA 90245 commercial work - repaint Stevenson Field Snack Shack and Joslyn Center building 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 ". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 0 COMMERCIAL GENERAL LIABILITY HCS 040 06 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. A. PRIMARY AND NON - CONTRIBUTORY TO OTHER INSURANCE With respect to any person or organization that is an additional insured under this Coverage Part, the following is added to paragraph 4. of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: If you have agreed in writing in a contract or agreement that this insurance is primary and non- contributory relative to an additional insured's own insurance, then this insurance is primary and we will not seek contribution from that other insurance. For the purpose of this endorsement, the additional insured's own insurance means insurance on which the additional insured is a Named Insured. When this endorsement is attached to the policy it supersedes all other insurance conditions within. HCS 040 06 10 13 B. WAIVER OF SUBGROGRATION — BLANKET Under SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 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 any person or organization because of payments we make for injury or damage arising out of: a. Your ongoing operations; or b. "Your work" included in the "products - completed operations hazard ". However, this waiver applies only when you have agreed in writing to waive such rights of recovery in a contract or agreement, and only if the contract or agreement: a. Is in effect or becomes effective during the term of this policy; and b. Was executed prior to loss. Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION 9125712 -15 -2 RENEWAL SP PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE FEBRUARY 12, 2016 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING JUNE 1, 2016 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME SOUTH COAST PAINTING INC 2255 PALOS VERDES DR N ` ROLLING HILLS ESTATES, CA 90274., 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 WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, SOUTH COAST PAINTING 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 pVE SCIF FORM 10217 (REV.7 -2014) FEBRUARY 19, 2016 PRESIDENT AND CEO 2570 OLD DP 217