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PROOF OF INSURANCE (2016) CLOSED
DATE (MMIDONYYY) CERTIFICATE OF LIABILITY INSURANCE 3/11/2016 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 pollcy(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 Ileu of such ondorsomontisl. Western Republic Insurance Services 19900 Beach Blvd Suite F1 Huntington Beach CA 92648 INSURED Manule Alba Moreno dba Golden Meters Service 14812 Hunter Lane Midway City CA 92655 Dustin Kouney 7_71' ",536,050 . 0 duslln6ft6nsurasire.4 -on, NAIC p Ce' /' COVERAGES CERTIFICATE NUMBER; INSUR'EIR'IS) AFFORDING COVERAGE INSuRERA: NORGUARD INS CO INSURER B: KINSALE INS CO INSURER C CALIFORNIA AUTOMOBILE INS CO INSURER D: NATIONAL UNION FIRE INS CO OF PITT, PA INSURER E: ,:'C'i. LIMITS IMMOofyYYY IN1M)DoiYy Y) INSURER F: COMMERCIAL GENERAL LIABILITY NAIC p Ce' /' 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. TYPE OF INSURANCE Oil L R IN$D IAM, � POLICY NUMBER ,:'C'i. LIMITS IMMOofyYYY IN1M)DoiYy Y) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS -MADE 2 OCCUR IV RE r'i PREMISE a occckw nc(0 S 100,000 MED EXP (Any one eersonM S 5,000 B X X 01000320090 09/09/2015 09/09/2016 PERSONAL d ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2,000,000 9RO. LOG POLICY I PRODUCTS - COMP /OPAGG S 2,000,000 OTHER: CGIL S AUTOMOBILE LIABILITY df r aatfq 9dp S 1,000,000 ANY AUTO BODILY INJURY (Per person) S ALL OWNED '""''SCHEDULED C AUTOS AUTOS X X BA040000002873 11/02/2015 11/02/2016 BODILY INJURY (Per accidenO S NON -OWNED OVrt'TMrD kVXM"s•""""':.:.:..::.: HIRED AUTOS AUTOS (Par acc.,rdern) S UMBRELLALIAB OCCUR EACH OCCURRENCE 5 2,000,000 D Excess LIAB AIM EBUO11414645 CLAIMS-MADE _RETENTION 09/09/2015 09!0912016 AGGREGATE S 2,000,000 DED $ S WORKERS COMPENSATION N/ STATUTE E. ND EMPLOYERS' LIABILITY Y / N �. NY PROP I - rORM f'ARTNERIEXECLr TIVE A oFFICCRWEI0BEREXCLULDEDr NIA X MAWC701550 E.L. EACH ACCIDENT S 03107/2016 03/07/2017 1,000,000 Mandatory In NH) E.L. DISEASE - EA EMPLOYEE S 1,000,000 4 es, describe undor CRIPTlON OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Those usual to the insured's operations. A blanket additional insured endorsement is included with the general liability policy. Additional insured status is automatically granted where required by written contract. The certificate holder is named as additional insured where required by written contract. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN • , " ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St. f - AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 Duyfi,l,. Kee,wey ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, Attached To and Forming Putt of Policy Effective Date of Endorsement Numed lnsuted 0100032069 -0 09/09/2015 12:01AM at the Named Insured Manuel Alba Moreno address shown on the Declarations ..Additianal.Pre.... Premium: m ...............m..�,�, _. �........... �.........,.,.,.,.,.,. m..................,.._.................................. _................_.......Neturn Premi. um............�...�...�..��.,.m m.,.,..................... �,.,., �.........,.,.......,.,..............._. ..............._..............m m SD ;o This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE A. SECTION II - WHO IS AN INSURED is amended to include any person or organization you are required to include as an additional insured on this policy by written contract in effect during the policy period and executed prior to the "occurrence" of the "bodily injury" or "property damage" but only for the vicarious Irabllfty Imposed on the Additional Insured provided that such liability is caused bythe sole negligent conduct of the Named Insured and is proximately caused by "your work" or "your product" for the Additional Insured. B. The insurance provided to the Additional Insured under this endorsement is limited as follows; 1. In the event the written contract requires limits of insurance in excess of the Limits of Insurance provided by this policy, the Limits of Insurance provided by this policy shall apply and not the limits required by the written contract. This endorsement shall not increase the Limits of Insurance stated in the Declarations of this policy. 2. This insurance does not apply to "bodily injury" or ''property damage" arising out of "your work" or "your product" included in the "products- completed operations hazard" unless you are required to provide such coverage by written contract. If such insurance is required by written contract, the insurance provided to the Additional Insured is limited to the alleged or actual vicarious liability imposed on the Additional Insured as a result of the alleged or actual negligent conduct of the Named insured as a result of liability solely caused by "your work" or "your product" for the Additional Insured. 3. Any insurance provided by this endorsement to an Additional Insured shall be excess over any other valid and collectible insurance available to the Additional Insured whether primary, excess, contingent or on any other basis unless a written contract specifically requires that this insurance apply on a primary or primary and noncontributory basis. 4. Where there is no duty to defend the Named Insured, there is no duty to defend the Additional Insured. Where there is no duty to indemnify the Named Insured, there is no duty to indemnify the Additional Insured. 5. This insurance does not apply to "bodily injury" or "property damage." arising out of the sole negligence of the Additional Insured or any employees of the Additional Insured. G Duties of the Additional Insured in the event of "occurrence ", clafm or "suit 1. The Additional Insured must promptly give notice of an ''occurrence ", a claim which is made or a "suit ", to any other insurer which has insurance for a loss to which this insurance may apply. 2. The Additional Insured must promptly tender the defense of any daim made or "suit" to any other insurer which also issued insurance to the Additional Insured as a Named Insured or to which the Additional Insured may qualify as an Additional Insured for a loss to which this insurance may apply. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. CAS5010 0110 Page 1 of 1 V1TrO1-:T1rfq:FR�9 (Ed. 4-84) 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,) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be of the California workers' compensation premium otherwise due on such remuneration. City of El Segundo SIC' U��� Meter testing This endorsement changes the policy to which it is attached and is effective on the date issued unless olherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. MAWC701550 Endorsement No. Insured Insurance Company Countersigned By