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PROOF OF INSURANCE (2016) CLOSEDDATE (MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 4/21/2016 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: Joanne Cadarette InterWest Insurance Services PHONE FAX License #0601094 (XIC . . N -, _ 916- 609 -8362 ,o,r N ,; 916- 979 -7562 . ., _< .a. E-MAIL F std: P.O. Box 255188 opp ass:) cadare.tte iwins.com ,,jcadare.tte@iwins.com Sacramento CA 95865 -5188 INSURER(SI AFFORDING COVERAGE NAIC # INSURER A: Financial Pacific Ins Companv 31453 " _,.._. _._. .__ �.,e..__. .......... INSURED AMER126 INSURERB:Arch Insurance Company 11150 American Asphalt South, Inc INSURER C: 14436 Santa Ana Avenue Fontana CA 92337 INSURER D, '' INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 137465088 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. INSR . P0DDr EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD , POLICY NUMBER Rw'tlR4gdDd3f t"YYY 1 (MMODNYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y 60423382 12/31/2015 12/31/2016 ! EACH OCCURRENCE $2,000,000 _.cAMAor r�i RENTED.... PRF OCCUR TUIRaFS $100 000 ;_(Laoe�nrla)srra�... CLAIMS -MADE X „ X Contractual Liab MED EXP (Any one person) $5,000 ..... X.. 00 $5.0 .,.,., , _ w Ded ..,..... PERSONAL & ADV INJURY $2.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 ...... _ POLICY X I PRO- JECT LOG PRODUCTS - COMP /OP AGG $4.000.000 OTHER: A AUTOMOBILE LIABILITY Y Y 60423382 12/31/2015 12/31/2016 COMBINED $1.000.000 X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ ,.., HIRED AUTOS X a m .m !. P .. ..$,. " ".,P. OA.M /kOE ,. X AUTOS P�rs�CLelkf 71 ... . .., .... .. .." . $ A UMBRELLA LIAB X OCCUR 60423382 12/31/2015 12/31/2016 j EACH OCCURRENCE $6,000,000 EXCESS LIAR E AGGREGATE $6 000,000 CLAIMS MAD. " "" .,. .., DID I X I RETENTIONS None $ B WORKERS COMPENSATION Y ZAWC19373300 4/1/2016 4/1/2017 X 4ER ITF X ®RH- AND EMPLOYERS' LIABILITY YIN .. ,,..T... _ "�.. -, , OFFICER /M In BE EXCLUDED? NIA E.L. DISEAACCIDENT $1,000,000 (Mandatory ) SE - EA EMPLOYEE ANY PR R EL EACH $1 000,000 If yes, describe under DESCRIPTION OF OPERATIONS below [EL DISEASE -POLICY LIMITm $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: Project #PW 16 -09, 2015 -2016 Furnishing and Application of Slurry Seal on Various Streets. Additional Insured status applies if required by written contract per endorsement attached.City of El Segundo, its officials, officers, agents, employees and volunteers. Primary wording per attached endorsement. Waiver of Subrogation applies to General Liability, Automobile Liability & Worker's Compensation per the attached endorsements. 30 day notice of cancellation, except 10 day notice for non - payment of premium applies per policy provisions. 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 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 -3813 AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) ©1988 -2014 ACORD CORPORATION. All rights reserved, The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 60423382' - COMMERCIAL GENERAL LIABILITY Named Insured: American Asphalt ." )Uth, Inc THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED , LESSEES, CONTRACTORS (ISO M ) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Re: Project #PW 16 -09, 2015 -2016 Furnishing and Application of Slurry Seal on Various Streets. Additional Insured status applies if required by written contract per endorsement attached.City of E1 Segundo, its officials, officers, agents, �Rployees and volunteers. Pr mary y�ording pesw attached end pen Waiver of no entry appears above, Informatlon required to complete this en orsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization is held liable for your work" for that person or organization by or for you. This endorsement applies to the following work: Description of Job: See Above Location of Job: See Above All only Effective from: Effective Date: 12/31/2015 Expiration Date: 12/31/2016 When this endorsement applies, such insurance as is afforded by the general liability policy is primary insurance and other insurance shall be excess to the insurance afforded by this endorsement. CG 201011 85 Modified (07 -01) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY CG 24 0410 93 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF FIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Re: Project #PW 16 -09, 2015 -2016 Furnishing and Application of Slurry Seal on Various Streets. Additional Insured status applies if required by written contract per endorsement (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMMER- CIAL GENERAL LIABILITY CONDITIONS) 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 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 10 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 POLICY NUMBER: 60423382 ASDA AU 07 01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM SCHEDULE NAMED INSURED: American Asphalt South, Inc 14436 Santa Ana Avenue Fontana CA 92337 ADDITIONAL INSURED: Re: Project #PW 16 -09, 2015 -2016 Furnishing and Application of Slurry Seal on Various Streets. Additional Insured status applies if required by written contract per endorsement attached.City of El Segundo, its WHO IS AN INSURED (SECTION ll) is amended to include as an insured the organization shown in the Schedule above, but only with respect to the operation of vehicles owned by the named insured and operated on behalf of the named insured. This endorsement does not apply to any operations for other than the named insured. Each person or organization named above 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 of Section II Liability Coverage. The additional insured is not required to pay for any premiums stated in the policy or earned from the policy. Any return premium, if applicable, declared by us shall be paid to you. You are authorized to act for the additional insured in all mailers pertaining to this insurance. We will mail the additional insured notice of any cancellation of this policy. If the cancellation is by us, we will give thirty days notice to the additional insured. The additional insured will retain any right of recovery as a claimant under this policy.. ASDA AU 07 01 Page 1 of 1 POLICY NUMBER: 60423382 ASDA AU 07 02 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER, OF FIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM SCHEDULE City of E1 Segundo Name of Person or Organization: 350 Main Street E1 Segundo, CA 90245 -3813 The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV BUSINESS AUTO CONDITIONS) 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 be- cause of payments wE make for bodily injury or property damage arising out of losses or accidents which occur during the policy period. This waiver applies only to liability you assume pursuant to a contract with the person or organization shown in the schedule. ASDA AU 07 02 Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 0484) POLICY NUNISER: ZAWC19373300 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA have the right to reoove, our payments from anyone I'iable for art injury covered by this policy. We will not enforce our right against the person or organization narned in the Schedule. (This agreement applies only to the extent that you perform worts under a written contract that requires YOU to obtaln this agreement from us.) You must trraintaln 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 2 % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION WHERE WAIVER OF OUR RIGHT TO RECOVER IS PERMITTED BY LAW AND IS REQUIRED BY WRITTEN CONTRACT PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO DATE OF LOSS JOB DESCRIPTION ALL NOBS UNDER CONTRACT This endorsement changes the policy to which it is attached and is affective on the date issued unless otherwise stated,. (The kdornW!on below is required only when this endorsement is issued subsequent to pteperation of the po8cy.) Endorsement Effective 4 -1 -16 - r Polioy No.ZAWC193733bb' Endorsement No. Insured AMERICAN ASPHALT Premium $ INCL- Insurance Company ARCH INSURANCE COMPANY ° Countersigned By DATE OF ISSUE: 3 -25 -16 ©1908 by the Workere Conypetuallon Inwfance Ra ng Sumau d Calfforrrta, All rtghts rmrvad. From the WWCIRWs California Wo ers" Compollsaffon Insurance Form Idlttnual 0 1999.