Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
PROOF OF INSURANCE (2016) CLOSED=`�"R '9 [ CERTIFICATE OF LIABILITY INSURANCE °AT /201 ° "YYY'
10/30/2015
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.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(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
PRODUCER
NAME:v
First National Insurance
_
PHONE 412- 359 -2530 1 Fo rJ 1 412-231-0249
12 Federal St., Suite 405
,�. c . ,�. ��...__..____- ----------- ____ —� �N��, ,. �.... .�..
Pittsburgh PA 15212
E -MAIk.
�� � .. __ - . .... ,............ .
yy INSURERI$1 AFFORDING COVERAGE
NAIC #
.. ----
INSURER A : NB IS
�INSURED
- . .... ....... .. .. ____
GRAIN -2
INSURER B: Ironshore .. ........
Crainco, Inc.
I ER �._ rican Famil - --
sURC:Amey Home Ins Co
23450
DianeSmith
�.�W�W�W�W�W�W�W...... � ._._...... �.----- �___ ......... ..........._................... . ........................................ �. �.............
...............................
P.O. Box 3008
INSURER D
Whittier CA 90605
_INSURER E:
COVERAGES CERTIFICATE NUMBER: 1571299583 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,.
,W9 m ...... ................_,_.._..._..... w -_ . C ILITR TYPE OF INSURANCE SD WVD POLICY NUMBER MMID YYYFM MMYDDf ExP-,
MJODlYYYY LIMITS
B X COMMERCIAL GENERAL LIABILITY NBG- 00871 -00 11/1/2015 11/1/2016 EACH OCCURRENCE $1,000,000
CLAIMS -MADE LretLTSrr� � ... ... _
l X �.VI I OCCUR PRFMICFClF _ I $100,1000
MED EXP_(Any one person) $Excluded
------- PERSONAL... ....__ . .
& ADV INJURY $1.000.000
GEN'L AGGREGATE LIMIT APPLIES P ���� ��00.000�0�������
ER: GENERAL AGGREGATE $2,...... 0
I li� ( COMP/OP AGG $2 000 000
POLICY L._X.....V ECT LOC PRODUCTS - COM.. - ...........
_..
OTHER: Riggers Liability $1,000,000
C AUTOMOBILE LIABILITY 2LA5CA0000079 -00 11/1/2015 11/1/2016
COMBINED a ac: kienl) $1.000000
-- ''...... BODILY INJURY P '.'.' -,..._ ..._._.- __......._
ANY AUTO (Per person) $
ALL OWNED X.. SCHEDULED.... WWWWW ........ ............................r._ - BODILY INJURY (Per accident) $
AUTOS —
AUTOS NON -OWNED P}�OPRy Y (tAtyryOL
X HIRED AUTOS x AUTOS ar ac to rrel $
$
A UMBRELLA LIAB X OCCUR NXS00144 -00 11/1/2015 11/1/2016 EACH OCCURRENCE $4,000,000
X EXCESS LIAB CLAIMS -MADE AGGREGA
... ...DE❑ RFTF_NT ....
TE $4,000,000
ION$0 $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS' LIABILITY Y / N crap lTE ..., ..�. FR,...,...,. .... ...... ..... .. ... .._.._..... - -.
OFFICE / / /MEMBER EXCLUDED? SEASECEA EMPLOYEE $
ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.. DA $
If yes, describe under
DFSCRIPTION OF OPERATIONS below E., L. DISEASE - POLICY LIMIT $
A Motor Truck Cargo 1LA3CM0000051 -00 11/1/2015 11/1/2016 MTC Limit $250,000
B Riggers Liability NBG- 00871 -00 11/1/2015 11/1/2016 Riggers Limit $1,000,000
Deductible $5,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
The below is named as Additonal Insured boat only with respects to the operation of the named insured as per written contract.
OVER THE ROAD coverage for mobile equipment: $1,000,000 bodily injury and property damage provided by General Liability. The below is
named as an additional insured but only with respect to general liability and to the covered operations of the named insured where liability for
the additional insureds is assumed by the named insured under a written contract provided that the contract is executed prior to loss.
PROFESSIONAL LIABILITY EXCLUDED.
City of Segundo is named as 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 Segundo h ACCORDANCE WITH POLICY PROVISIONS.
Public rks Dept
Street /
AUTHORIZED REPRESENTATIVE.
El Segundo CA 90245
©1988 -2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
r
your safe lit 60
IRONSHOE SPECIALTY INSURANCE COMPANY
75 Federal Street
Boston, MA 02110
Toll Free: (877) IRON411
Policy Number: NBG00871 -00
TIfl15 I1EN1! RSE III °`NT CZ 'E'.Sj rl °IE' F" LILY. PLEASE RIIE;EA1[) IT :AREFULLY.
nG)I IT10NAL INSIYII1E,';D —, O INE;11S, LESS1E 1:..'S OR CON° R TORS -- S H1° DUI ED I l`- -,RSOIN Oil
ORGANIZATION
RINHIMM
�... ,o� .. ... .r
Name of Person or Organization:
Additional Insured shown In a written contract, or wrltten agreement that Includes Primary and Non - Contributory
wording. The inclusion of one or more Insured under the terns of this endorsement does not Increase our limits of liability, All other terms and
conditions remain unchanged.
(if no entry appears above, mation required to complete this endorsement will be shown In the Declarat n- }
ti as
applicable to this endorsement)
SECTION II — WHO IS AN INSURED is amended to include as an insured the person or organization shown in the Schedule, but only
with respect to liability arising out of your ongoing operations performed for that insured.
1. With respect to the insurance afforded to the additional insureds shown In the Schedule, the following exclusion Is added:
Exclusions
This insurance does not apply to "bodily injury" or "property damage" occurring after:
(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 site 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 organizatlon other than another contractor or subcontractor engaged in performing operations for a
principal as a part of the same project.
B. Coverage afforded under this endorsement is primary and non - contributory, but only with respects to the sole negligence of
the name insured.
ALL OTHER TERMS, CONDITIONS AND EXCLUSIONS REMAIN UNCHANGED.
Authorized Repiresentative
TGt. 2010 10 Dt. hnciudes colp°yrighted irnateirW of hisurancc:r Sery ces Office, Page 1I. of 1.
Inc:-- with its i.,.)eirniNs "oin,
COMMERCIAL CIAL ENERAL LIABILITY
CG 2010 10 01
THIS ENDORSEMENT CHANGES 1141E POLICY. PLEASE READ II'f AREIF"ULLY.
ADDITIONAL N Ilh D ERS, LESSE111=8
CONTRACTORS - IP 11EINJI ED PERS014
,,,1,,, 101114
This endorsement modifies Insurance provided under the foli'owing:
MMERCIIAIL GENERAL LIABILITY COVERAGE PARTT
ISr '1ULE
Larne of person or Organization:
Aa alit` anal Insureds shown In a written contract, or written agreement. The Inclusion of one or more Insured under the
trai,rns,, of this endorsement does not Increase our limits of liability. All other terms and conditions remain unchanged.
(if no entry aplmars above Information required to cornpIeta this endorsement will) be shown In the IDecl!aratlons as appilcablle to
this endorsement.)
A. Section 11 - Who Is An Insured is amended to include as an
Insured the person or organization shown In the Schedule, but
only with respect to liability arising out of your ongoing operations
performed for that insured.
B. With respect to the Insurance afforded to these additional
Insureds, the following exclusion Is added:
2. Exclusions
This insurance does not apply to "bodily injury" or
"property damage" occurring after:
(1) All work, Including materials, parts or equipment fumished In
connei :,Mnr with such work, on the Irrcojeoat (uather than s;ervIce,
ma kgaanance or repairs) to be perrormed by ar on behalf of the
a, dditdrar" W Insured(s) at flan site of the covered operations s ha s
been cornpletcA;; or
(2) I hart portion of "your work" out of whia:h the Injury or damage
arises has been punt to Its intended use by aruy prurs,an or
orgaanIzatlon other than aaiaorther contractor or subcontractor
engaged In performing operations for a principal as a part of the
same project.
CG 20 110 10 01 0 ISO Properties, Irv., 2000 Fl e I of 1
POLICY NUMBER: NBG- 00871 -00
COMMERCIAL GENERAL LIABILITY
CG 20 37 07 04
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
...... ..........
.,, ... - ............._............. ,
Name Of Additional Insured Person(s)
Or Organizations) Location And Description Of Completed Operations
Additional I...... a � _ ........�.....m. ..� -s ,_�.... _ .......... .......................,...w��.
nsured shown in a written contract,
or written agreement.
The inclusion of one or more Insured under the terms
lof this endorsement does not increase our limits of liabili y,
All other terms and conditions remain unchanged.
Information reguired.to.com l trm this Scl'i duln above, shown in the Declarations.
eclarations.
if not shown above will be
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 Q ISO Properties, Inc., 2004 Page 1 of 1 ❑
POLICY NUMBER,' 300871-00 COMMIERCML GENERAL UA1111LW'
CG 24 04 10 93
rl M ENDORSEMENT CHANGES ['HE POLICY. PLEASE READ IT CAREFU11Y.
WAIVER OF I IRS I ITS OF RECOVERY THE 1
us
This endorsement irrio dffles urasu rar -nee provWed Linder the foHow n&
COMMEROALGENERA� UABIlUTY COVERAGE FORM
HEDU lIE'
We waive arly right of rem(,)v ry we may have against the p erswl 01' rtt �nrzr.atsawn shown n bra the Sr. haardua e above
because of dw yaamntra' r� make for hjury or darn age arisIng out of ymir angoing operations or ",y ra¢° wa)rkl` don
aawar er ra raranb, acl wRh that person on organization and aaa k i d'e d ara the a wd.ar.,rratkmis hazard",
TlhY s w adv r app0es ora y to the person gar organzabon shown dra 0-m S ctoeduw e t:arave,
ALL orHER TERMS, CONMT ON ND LUSH O S RIC AN &wd UNCHANGED.
CG 2404 10 93 C Insurance t , Inc., 1992 Page
CRAIINC -01 VOLIVARES
DATE(MMIDD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 4/25/2016
......
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 policy(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
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME. Jenna Hinnen
BoWerrnaster & Associates Insurance Agency, Inc. ,P,,HONN E:tl (714) 733-6200 a Nal (714) 252-8253
10806 Holder' Street„ Suite 350 N s....µ..... .
Cypress, CA 90630 A gDDRESs.
INSURER(S) AFFORDING COVERAGE NAIC #
----- -- m. - ---- -_- ... .... __..... ,... ,. .
_... __...- .,.. -- .._ -- ._.._.. . .... ---------.. -- .. -_._ ,_, - -.. .
INSURER A:Starstone National Insurance Company
INSURED'� __ _,.,... -.n .���,�....._ ---- ,�,.,.--------
INSURER B:
Crainco, Inc. INSURER C
10702 Painter Avenue __INSURER D:
– – – —
Santa Fe Springs, CA 90670
'.. INSURER E
_ INSURER F :
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 VVITH 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,
R TYPE OF INSURANCE �Ati n Swyn POLICY NUMBER IMM /DD/YYYYI p� q PppIYYYY'j LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
I E TO-RENTED
CLAIMS -MADE OCCUR PREMISES (Ea ccc un enre)
i $
GEN'L AGGREGATE LIMIT APPLIES PER:
❑ PRO- ❑ LOC
POLICY JE T
OIHR.
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
UMBRELLA LIAB
EXCESS LIAB
SCHEDULED
AUTOS
NON -OWNED
AUTOS
OCCUR
CLAIMS -MADE
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
A ANY PROPRIETOR /PARTNER /EXECUTIVE YIN
X T10160319
OFFICER /MEMBER EXCLUDED? �Y NIA
(Mandatory in NH)
If ves. describe under
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
PRODUCTS,- COMPIOP AGG $
$
01/01/2016 01/0112017 E L EACH ACCIDENT $ 1
E L DISEASE - EA EMPLOYEE $ 1
E L DISEASE - POLICY LIMIT $ 1
DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
Waiver of Subrogation applies to Work Comp per form WC040306.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
350 Main Street, Room 5
City of Segundo- City Clerk �' ACCORDANCE WITH THE POLICY PROVISIONS.
Main ,�-
El Segundo, CA 90245 -3813
AUTHORIZED REPRESENTATIVE
©1988 -2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06
(Ed. 4 -84)
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 —*—% of the California workers' compensation premium otherwise
due on such remuneration.
Schedule
Person or Organization
Job Description
WHERE YOU ARE REQUIRED BY WRITTEN CONTRACT TO
OBTAIN THIS AGREEMENT FROM US, PROVIDED THE
CONTRACT IS SIGNED AND DATED PRIOR TO THE DATE OF
LOSS TO WHICH THIS WAIVER APPLIES. IN NO INSTANCE
SHALL THE PROVISIONS AFFORDED BY THIS
ENDORSEMENT BENEFIT ANY COMPANY OPERATING
AIRCRAFT FOR HIRE.
*The premium charge for this endorsement shall be 2% of the premium developed in the State of California, but not less
than $500 policy minimum premium.
This endorsement changes the policy to which it is attached and is effecfive, the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective 01/01/16 Policy No. T10160319 Endorsement No. 11
Insured Crainco, Inc. Policy Effective Date 01/01/16
Insurance Company Torus National Insurance Company
Countersigned By
WC 04 03 06
(Ed. 4 -84)
01998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved.