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PROOF OF INSURANCE (2017) CLOSEDCertificate of Insurance THIS CERTIFICATE IS ISSUED AS MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON YOU THE CERTIFICATE HOLDER. THIS CERTIFICATE IS NOT AN INSURANCE POLICY AND DOES NOT AMEND, EXTEND OR ALTER -ITfE COVERAGE AFFORDED BY TIfE POLICIES LISTED BELOW POLICY LIMITS ARE NO LESS THAN THOSE LISTED, ALTHOUGH POLICIES MAY INCLUDE ADDITIONAL SUBLIM11W,IMITS NOT LISTED BELOW This is to Certify that Sully-Miller Contracting Company 135 S. STATE COLLEGE BLVD., STE. 400 BREA CA 92821 is, at the issue date of (his maitcate, insured by the Company under the policy(ies) listed below The insurace ah."tuded by the listed pofley(ics) is subject to all thety Leams, exclusions and Conditions and is riot altered by any requircrimm, Larat or of any contract oi other document with respoeet to which this certificate may be issmA * If the certificate expiration date is continuous or extended teen, you will be notified if coverage is terminated of reduced before the certificate expiration date- NOTICE OF CANCFLLA 11 ION: (NOT APPLICABI 1: UNLESS A NUMBE'T, OF Lya.YS IS EI'll TIRED BFLOW EXP DATE Sr tA Br) EX X1 IRATION DA PL' THE COMPANY WILL. NOT` CANCEL OR RLIDUCE THE INSURANCE AIFFORDED f.)NDFI:Z THE ABOVE POI TCIFS UNTIL Al LEAS'1'30 DAYS NOTICE CONTINUOUS OF SUC[I CANCE'] L.A.TION HAS BEEN MAJI.A.,T) TO TYPE OF POLICY EXTENDED El POLICY NUMBER LIMIT OF LIABILITY 0 a R1 POLICY TERM 114 West 47th St. ff WORKERS New York NY WC7-631-004125-656 COVERAGE AFFORDED EMPLOYERS LIABILITY COMPENSATION 4/1/2017 UNDER WC LAW OFTHE FOLLOWING Bodily Inju ry b Accident S'L'ATES: S'L'ATES: $�,000,000 Each Accident CA, NV, AZ Bodily Injury $b� Disease i000,000 Pnlicv Limit Bodily Injury b DISQrt $ Each Person '000,000 COMMERCIAL, 4/1/2017 TB2-631-004125-666 General Aggregate $2,000,000 GENERAL LIABILITY llnNhitcis I Comploe, Optmoions Aggwgwc $2,00U00 OCCURRENCE RETRO DATE Occuence Occurrence $2 0,10 ,000,0 CLAIMS MADE 71'17'son,�Ill & Advertising irkpay $2,000,000 Per Person / Orgwiizalion Other Other Includes Per Job Aggregate Damages to Premises: $100,000 "XCU" Coverages and Medical Payments: $10,000 AUTOMOBILE 4/1/2017 AS2-631-004125-676 Each Accident -- Single Limit $2,000,000 LIABILITY B I. And RD Combined Each Person OWNED Each Accident or Occurrence NON-OWNED IIIRED Each Accident or Occurrence OTHER RE: PW 15-01, Richmond Street Improvements Project (from El Segundo Blvd, to Holly Ave.) Job# 10178538 1503 ADDITIONAL COMMENTS Added as additional insureds per endorsement attached, Certificate holder, City of El Segundo, its officers, officials, employees, agents and volunteers is/are additional insured with regards to general liability and auto liability as their interests may appear where required by written contract The insurance afforded by the Policies for the benefit of the Additional Insured is Primary, but only with respect to Claims and Loss of Liability arising out of the operations of the Named Insured and any insurance maintained by the Additional Insured shall be Non- Contributory, The auto liability coverage afforded applies separately to each insured who is seeking coverage, or against whom a claim or "suit" is brought. Waiver of subrogation in favor of the certificate holder on General Liability and/or Auto Liability applies only to specific jobs of the insured performed under written contract. Waiver of subrogation in favor of the certificate holder on WC where allowed by statute and applies only to the specific jobs of the insured performed under written contract (See attached endorsements to the policies) * If the certificate expiration date is continuous or extended teen, you will be notified if coverage is terminated of reduced before the certificate expiration date- NOTICE OF CANCFLLA 11 ION: (NOT APPLICABI 1: UNLESS A NUMBE'T, OF Lya.YS IS EI'll TIRED BFLOW BEFORL 1 HEI Sr tA Br) EX X1 IRATION DA PL' THE COMPANY WILL. NOT` CANCEL OR RLIDUCE THE INSURANCE AIFFORDED f.)NDFI:Z THE ABOVE POI TCIFS UNTIL Al LEAS'1'30 DAYS NOTICE Insurance Group OF SUC[I CANCE'] L.A.TION HAS BEEN MAJI.A.,T) TO Carmen Ayala Attn: Orlando Rodriguez, Public Works Dept. New York / 0202 0 a City of El Segundo 114 West 47th St. ff 350 Main Street New York NY 10036 212-391-7500 3/7/2016 ORWE, El Segundo CA 90245-3813 This certificate is executed by LIBERTY MUTUAL INSURANCE GROUP as respects such insurance as is afforded by those Companies NM 772 Liberty Mutual Insurance Group Carmen Ayala AUTHORIZED REPRESENTATIVE New York / 0202 114 West 47th St. New York NY 10036 212-391-7500 3/7/2016 ORWE, PHONE DATE ISSUED This certificate is executed by LIBERTY MUTUAL INSURANCE GROUP as respects such insurance as is afforded by those Companies NM 772 085201600017300479 Policy Number TB2- 631 - 004125 -666 Issued by Liberty Mutual Fire Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED — City of El Segundo This endorsement modifies insurance provided under the following: COMMERICAL GENERAL LIABIITY COVERAGE PART EXCESS COMMERICAL GENERAL LIABIITY COVERAGE PART A. City of El Segundo, 350 Main St, El Segundo, CA 90245 -3813 (Attn: Orlando Rodriquez), its officers, employees, agents and representatives are named as additional insureds ( "additional insureds ") with regard to liability and defense of suits arising from the operations and uses performed by or on behalf of the named insured. B. With respect to claims arising out of the operations and uses performed by or on behalf of the named insured, such insurance as is afforded by this policy is primary and is not additional to or contributing with any other insurance carried by or for the benefit of the additional insureds. C. This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the company's limits of liability. The inclusion of any person or organization as an insured shall not affect any right which such person or organization would have as a claimant if not so included. D. We waive any right of recovery we may have against the additional insureds because of payments we make for injury or damage arising out of the operations or work of the named insured under this policy. E. With respect to the additional insureds, this insurance shall not be cancelled, or materially reduced in coverage or limits except after thirty (30) days written notice has been given to the organization, department or individual listed in the Schedule below: Schedule Organization, Department or Individual: The City of El Segundo, its officers, officials, employees, agents and volunteers LD 20 26 01 12 8 2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. POLICY NUMBER: T62- 631 - 004125 -666 085201600017300330 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGESTHE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED �PERSON OR ORGAN IZATIOI �1 This endorsement modes insurance provided under the following', COMMERCIAL GENERAL LIABILITY COVERAGE PART 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, 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 additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law: and 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. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury' or "property damage" occurring after: Name Of Additional Insured Person(s) Or Organization(s): 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 person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement. the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; SCHEDULE whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Location(s) Of Covered Operations The City of El Segundo, its officers, officials, employees PW 15 -01, Richmond Street Improvements Project agents and volunteers (from El Segundo Blvd. to Holly Ave.) Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 20 10 04 13 m Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: TB2- 631 - 004125 -666 085201600017300440 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGESTHE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -- OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modes insurance provided underthe following: CG 20 37 04 13 m Insurance Services Office, Inc., 2012 Page 1 of 1 �" COMMERCIAL GENERAL LIABILITY COVERAGE PART , PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART, " A. Section 11 -- 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 organization(s) 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 a part, by required by a contract or agreement, the most we "your work" at the location designat ted 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 hazard ". 1. Required by the contractor agreement; or However: 2. Available under the applicable Limits of 1. The insurance afforded to such additional Insurance shown in the Declarations; insured only applies to the extent permitted by whichever is less. law; and This endorsement shall not increase the applicable 2. If coverage provided to the additional insured is Limits of Insurance shown in the Declarations. 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. SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operations The City of El Segundo, ds officers, officials, PW 15 -01, Richmond Street Improvements Project employees, agents and volunteers (From El Segundo Blvd. to Holly Ave.) information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 20 37 04 13 m Insurance Services Office, Inc., 2012 Page 1 of 1 085201600017300532 Policy Number T132 -631- 004125 -666 Issued by Liberty Mutual Fire Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, OTHER INSURANCE AMENDMENT — SCHEDULED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PROD UCTSICOMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART Schedule ... ... ........ w Person or Organizati. . on: The City of EI Se un' do its officers, officials, employees, a ants and volunteers If you are obligated under a written agreement to provide liability insurance on a primary, excess, contingent, or any other basis for any person or organization shown in the Schedule of this endorsement that qualifies as an additional insured on this policy, this policy will apply solely on the basis required by such written agreement and Paragraph 4. Other Insurance of Section IV - Conditions will not apply. If the applicable written agreement does not specify on what basis the liability insurance will apply, the provisions of Paragraph 4. Other Insurance of Section IV - Conditions will govern. However, this insurance is excess over any other insurance available to the additional insured for which it is also covered as an additional insured by attachment of an endorsement to another policy providing coverage for the same "occurrence ", claim or "suit ". LC 24 20 02 13 © 2013 Liberty Mutual Insurance. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission, 085201600017300129 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION CTIOI PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Project(s): PW 15 -01, RICHMOND STREET IMPROVEMENTS PROJECT (from El Segundo Blvd. to Holly Ave.) _ .................... Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. For all sums which the insured becomes legally 3. Any payments made under Coverage A for obligated to pay as damages caused by "occur- damages or under Coverage C for medical rences" under Section I — Coverage A, and for all expenses shall reduce the Designated Con - medical expenses caused by accidents under struction Project General Aggregate Limit for Section I — Coverage C, which can be attributed that designated construction project. Such only to ongoing operations at a single designated payments shall not reduce the General Ag- construction project shown in the Schedule gregate Limit shown in the Declarations nor above: shall they reduce any other Designated Con - 1. A separate Designated Construction Project struction Project General Aggregate Limit for General Aggregate Limit applies to each des- any other designated construction project ignated construction project, and that limit is shown in the Schedule above. equal to the amount of the General Aggregate 4. The limits shown in the Declarations for Each Limit shown in the Declarations. Occurrence, Damage To Premises Rented To 2. The Designated Construction Project General You and Medical Expense continue to apply. Aggregate Limit is the most we will pay for the However, instead of being subject to the sum of all damages under Coverage A, ex- General Aggregate Limit shown in the Decla- cept damages because of "bodily injury' or rations, such limits will be subject to the appli- "property damage" included in the "products- cable Designated Construction Project Gen - completed operations hazard ", and for medi- eral Aggregate Limit. cal expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits ". CG 25 03 05 09 0 Insurance Services Office, Inc., 2008 Page 1 of 2 E3 B. For all sums which the insured becomes legally C. obligated to pay as damages caused by "occur - rences" under Section I -- Coverage A, and for all medical expenses caused by accidents under Section I — Coverage C, which cannot be at- tributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. Any payments made under Coverage A for damages or under Coverage C for medical D. expenses shall reduce the amount available under the General Aggregate Limit or the Products - completed Operations Aggregate Limit, whichever is applicable; and Such payments shall not reduce any Desig- nated Construction Project General Aggre- gate Limit. 085201600017300130 When coverage for liability arising out. of the °products - completed operations hazard "' is pro- vided, any payments for damages because of "bodily injury" or "property damage" included in the "products- completed operations hazard" will reduce the Products - completed Operations Ag- gregate Limit, and not reduce the General Ag- gregate Limit nor the Designated Construction Project General Aggregate Limit. If the applicable designated construction project has been abandoned, delayed„ or abandoned and then restarted, or if the authorized contract- ing parties deviate from plans, blueprints, de- signs, specifications or timetables, the project will still be deemed to be the same construction pro- ject, E. The provisions of Section III — Limits Of Insur- ance not otherwise modified by this endorsement shall continue to apply as stipulated. This endorsement is crecuted by the LIBL'R7N MUTUAL. FIRE INSURANCE COMPANY Premium $ Effective Date For attachment to Policy No. Audit Basis Issued To Issued Expiration Date TB2- 641-004125 -666 Countersigned by Authorized Represmiatire Sales Officc and No. End. Serial No. Page 2 of 2 0 Insurance Services Office, Inc., 2008 CG 25 03 05 09 085201600017300205 Policy Number: TB2- 631 - 004125 -666 Issued by: Liberty Mutual Fire Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION OR MATERIAL CHANGE IN COVERAGE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART Schedule Name: Address: Number of Days: City of El Segundo 350 Main St. 10 El Segundo, CA 90245 -3813 (Attn: Orlando Rodriguez) We will not cancel this policy nor make changes that reduce the insurance afforded by this policy until written notice of cancellation or reduction has been mailed by certified mail, return receipt requested to those scheduled above at least: 10 days before the effective date of cancellation, if we cancel for non - payment of premium; or 2. the number of days indicated in the Schedule above before the effective date of the cancellation or reduction if we cancel or reduce the insurance afforded by this policyfor any other reason, LD 02 02 05 11 ® 2011 Liberty Mutual Group of Companies, All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Policy Number TB2- 631 - 004125 -666 Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, NOTICE OF CANCELLATION TO THIRD PARTIES This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE PART MOTOR CARRIER COVERAGE PART GARAGE COVERAGE PART TRUCKERS COVERAGE PART EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART SELF - INSURED TRUCKER EXCESS LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART COMMERCIAL LIABILITY — UMBRELLA COVERAGE FORM Schedule Name of Other Person(s) / Email Address or mailing address: Number Days Notice: Orcianization(s): City of El Segundo 350 Main St. 30 (Attn: Orlando Rodriquez) El Segundo, CA 90245 -3813 A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or organizations shown in the Schedule above. We will send notice to the email or mailing address listed above at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no event does the notice to the third party exceed the notice to the first named insured. B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to provide such advance notification will not extend the policy cancellation date nor negate cancellation of the policy. All other terms and conditions of this policy remain unchanged. LIM 99 01 05 11 © 2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 085201600017300064 WA OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US 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: The City of El Segundo, its officers, officials, employees, agents and volunteers Information reauiredmto complete this Schedule„ 6 not shown above, will be shown in 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. CG 24 04 05 09 0 Insurance Services Office, Inc., 2008 Page 1 of 1 POLICY NUMBER: AS2- 631 - 004125 -676 CONWRCIAL AUTO CA 04 44 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following, AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. SCHEDULE Name(s) Of Person(s) Or Organization(s): The City of El Segundo, its officers, officials, employees, agents and volunteers Premium: $ INCL Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the 'loss" under a contract with that person or organization. CA 04 44 10 13 0 Insurance Services Office, Inc., 2011 Page 1 of 1 Policy Number: AS2- 631 - 004125 -676 Issued by: Liberty Mutual Fire Insurance Co. THIS ENDORSENENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED - NONCONTRIBUTING This endorsement modes insurance provided underthe following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIERS COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage form. Schedule Name of Person(s) or Organizations(s): The City of E1 Segundo, its officers, officials, employees, agents and volunteers Regarding Designated Contractor Project: PW 15 -01, RICHMOND STREET IMPROVEMENTS PROTECT (from E1 Segundo Blvd. to Holly Ave.) Each person or organization shown in the Schedule of this endorsement is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section II of the Coverage Form. The following is added to the Other Insurance Condition: If you have agreed in a written agreement that this policy will be primary and without right of contribution from any insurance in force for an Additional Insured for liability arising out of your operations, and the agreement was executed prior to the "bodily injury" or "property damage ", then this insurance will be primary and we will not seek contribution from such insurance. AC 84 23 08 11 © 2010, Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA 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 0% of the California workers' compensation premium otherwise due on such remuneration. Schedule Additional premium is a percent of the California Manual Workers Compensation premium. Subject to a minimum premium charge of $ 0 Person or Or an'izafion � Job Description The City of EI Segundo, its�r� b PW 15 -01, Richmond Street officers, officials, employees,r` °i Improvements Project (from El agents and volunteers Segundo Blvd. to Holly Ave.) Premium is included in the state's blanket waiver charge. Issued by Liberty Insurance Corporation 21814 For attachment to Policy No. WC7- 631 - 004125 -656 Issued to Sully - Miller Holding Corporation WC 04 03 06 Ed: 04/1984 Effective Date 04/01/2016 Premium $ Page 1 of 1