PROOF OF INSURANCE (2017) CLOSEDSTEPH -1 OP ID: RH
DATE (MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 05/3112016
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 endorsements .
PRODUCER NAME; Certificate Dept
Wright, Finnegan & Sommer Ins. PHONE FAR
Associates, lic# 0534315 �(n P–No Exg 714 283 1999 iArO� No) 714-283-1997
23001 La Palma Ave, Suite 100 EMAIL
Yorba Linda, CA 92887r?oass ceftrfacatL*S WfIns.COm
John Carter INSURER(S) AFFORDING COVERAGE NAIC p
- - - -__ ____. - -__
-- - —
INSURER A_: Travelers lndem n it)I Com pang of
- -- _ -- _.._______.._________ —.
...
_ .......
INSURED DOreck Construction Inc.
INSURER 13: Connecticut
Stephen Doreck Equipment
_ ...__..._..
INSURER C: Westchester Surplus Lines Ins
.............
Rentals, Inc.
.........
....._
9075 Telegraph Road
1. INSURER D: Safeco Insurance_Company
Pico Rivera, CA 90660
INSURER E: First National Insurance Co
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 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS.
...... ADDC'SUB .. _ .... ... IYOUCTE ... �....
....... .._....
TYPE OF INSURANCE MWVD MDDIYYYY LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
1,000,00
A X COMMERCIAL L
LIABILITY X X OT22- CO- 720OP538- TCT -16 03101/2016 03101/2017 pR M sE,�Any
30 0, 000
CLAIMS- MADE X OCCUR M ED EXP one person) $
00
X Contractual Liab PERSONAL & ADV INJURY $
1,000,00
C X Pollution Liabi G27153136003 03101/2016 03/01/2017 GENERAL AGGREGATE $
2,000,
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS COMP roP AGG $
2,000,000
POLICY X .� LOC 'Pollutl n $
2,000,00
AUTOMOBILE
LIABILITY
'OMSINED SINGLE LIM.I
(Ea acadent)
$
1,000,000
000
A
X
ANY AUTO
X
X
OT- 810- 8D457897- TTL -16
03/0112016
03/01/2017
BODILY INJURY (Per person)
$
ALL OWNED" SCHEDULED
AUTOS ''. AUTOS
BODILY INJURY (Per acaden t)
$
X
NON-OWNED
X............
�'( s19 1^IHIi DAMAGE
...
$
.. ... ...
..x
HIRED AUTOS AUTOS
1 i,„FI' 1,rm aLN4 hY1
....
X
Hired Auto Phy Damage
$
UMBRELLA LIAB X _ OCCUR
EACH OCCURRENCE
$
5,000,000
A
X
....... ,...._...._..,
EXCESS LIAB CLAIMS -MADE
.- ....--- - ---... - -- ... ----- --- -:
OTSM-CUP-720OP538-TIL-16
03/01/2016
03101/2017
AGGREGATE
.... .... ..
$
...........
5,000,000
...., . ,......,.......
DED RETENTION $
$
WORI(ERSCOMPENSATION X WCSTA'rU- OTH-
Y
T��ASEIEA
A X B-720O 03101/2016 03101/2017 EACE
1,000,000
DTJ-
OFFICER/MEMBER RIMEMBER EXCLU D? Y NIA -$
(Mandatory in NH)IPARTNERlEXECUTIVE ❑
53NCLUDED E L EMPLOYEE,
.... 1,000,00
DESCRIPTION OF OPERATIONS below E L DISEASE- POLICY LIMIT $
1,000,000
E EQUIP RENTED FROM OTHERS 25- CC- 227754 -8 08118/2015 08/18/2016 ACV
130,00
D EQUIPMENT 25 -CC- 227754 -8 03/01/2016 03/01/2017 DED 1000
855,06
._.......
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required)
CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS AND
OLUNTEERS ARE NAMED AS ADDITIONAL INSURED AND PRIMARY WORDING APPLIES PER
THE BLANKET ADDITIONAL INSURED ENDORSEMENT ATTACHED TO THE POLICY — AS
REQUIRED BY WRITTEN CONTRACT. ADDITIONAL INSURED APPLIES TO AUTO LIABILITY.
WAIVER OF SUBROGATION APPLIES TO GENERAL LIABILITY, AUTO LIABILITY AND
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.
CITY CLERK
350 MAIN STREET AUTHORIZED REPRESENTATIVE
EL SEGUNDO, CA 90245 -3813 A-
O 1988 -2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
Insured: Doreck Construction, Inc.; Stephen Doreck Equipment Rentals, Inc.
Policy#:I DT22- CO- 7200P538- TCT -16
tiw � "" r ' — • -�! „ �i dw
*1 14 11111
A. SectIM, U.— Who 1* An Is onvwxWl In Include the peram(s) of o Iw (a) shown In to
0462 -0106 Includes ooVAhted MOWW of ISO IRMPUMN, Inc., 2004 Page 1 of 1
with Iii powdWon.
Insured: Doreck Construction, Inc.: Stephen Doreck Equipment Rentals, Inc. COMMERCIAL GENERAL LIABILITY
P01Icy #: ' DT22- CO- 7200P538- TCT -16
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
(CONTRACTORS) CITY OF EL SECUNDO, ITS OFFICERS, OFFICIALS,
EMPLOYEES AGENTS AND VOLUNTEERS
350 MAIN STREET EL. SEGUNDO, (.A 902'45 -3813
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL, LIABILITY COVERAGE PART JOB: ON CALL WATER SYSTEM MAINTENANCE
AND REPAIR SERVICE, PROJECT NO PW 16 -21.
1. WHO IS AN INSURED — (Section II) Is amended
to include any person or organization that you
agree in a %vritten contract requiring insurance"
to include as an additional insured on this Cover-
age Part, but:
a) Only with respect to liability for "bodily injury ",
"property damage" or "personal Injury"; and
b) If, and only to the extent that, the injury or
damage is caused by acts or omissions of
you or your subcontractor in the performance
of "your work" to which the "written contract
requiring Insurance" applies. The person or
organization does not qualify as an additional
Insured with respect to the independent acts
or omissions of such person or organization.
2. The insurance provided to the additional insured
by this endorsement is limited as follows:
a) In the event that the Limits of Insurance of
this Coverage Part shown in the Declarations
exceed the limits of liability required by the
"written contract requiring insurance ", the in-
surance provided to the additional insured
shall be limited to the limits of liability re-
quired by that "written contract requiring in-
surance". This endorsement shall not in-
crease the limits of insurance described in
Section III —Limits Of Insurance.
b) The insurance provided to the additional In-
sured does not apply to "bodily injury", "prop-
erty damage" or "personal injury" arising out
of the rendering of, or failure to render, any
professional architectural, engineering or sur-
veying services, including:
I. The preparing, approving, or failing to
prepare or approve, maps, shop draw-
ings, opinions, reports, surveys, field or-
ders or change orders, or the preparing,
approving, or failing to prepare or ap-
prove, drawings and specifications; and
ii. Supervisory, inspection, architectural or
engineering activities.
c) The insurance provided to the additional in-
sured does not apply to "bodily injury" or
"property damage" caused by "your work"
and included in the "products-completed op-
erations hazard" unless the "written contract
requiring insurance" specifically requires you
to provide such coverage for that additional
Insured, and then the insurance provided to
the additional Insured applies only to such
"bodily injury" or "property damage" that oc-
curs before the and of the period of time for
which the "written contract requiring insur-
ance" requires you to provide such coverage
or the end of the policy period, whichever is
earlier.
3. The Insurance provided to the additional insured
by this endorsement is excess over any valid and
collectible "other insurance ", whether primary,
excess, contingent or on any other basis, that is
available to the additional insured for a loss we
cover under this endorsement However, if the
"written contract requiring Insurance" specifically
requires that this insurance apply on a primary
basis or a primary and non-contributory basis,
this insurance is primary to "other insurance"
available to the additional insured which covers
that person or organization as a named insured
for such loss, and we will not share with that
"other insurance ". But the insurance provided to
the additional insured by this endorsement still is
excess over any valid and collectible "other in-
surance", whether primary, excess, contingent or
on any other basis, that is available to the addi-
tional insured when that person or organization is
an additional insured under such "other insur-
ance".
4. As a condition of coverage provided to the
additional insured by this endorsement:
a) The additional insured must give us written
notice as soon as practicable of an "occur-
rence" or an offense which may result in a
claim. To the extent possible, such notice
should include:
CG D2 46 08 05 ® 2005 The St. Paul Travelers Companies, Inc. Page 1 of 2
COMMERCIAL GENERAL LIABILITY
i. How, when and where the "occurrence"
or offense took place;
11. The names and addresses of any injured
persons and witnesses; and
iii. The nature and location of any injury or
damage arising out of the "occurrence" or
offense,
b) If a claim is made or "suit" Is brought against
the additional insured, the additional insured
must:
I. Immediately record the specifics of the
claim or "suit" and the date received; and
Ii, Notify us as soon as practicable.
The additional Insured must see to it that we
receive written notice of the claim or "suit" as
soon as practicable.
c) The additional insured must immediately
send us copies of all legal papers received in
connection with the claim or "suit", cooperate
with us in the investigation or settlement of
the claim or defense against the "suit", and
otherwise comply with all policy conditions.
d) The additional insured must tender the de-
fense and indemnity of any claim or "suit' to
any provider of "other insurance" which would
cover the additional insured for a loss we
cover under this endorsement. However, this
condition does not affect whether the Insur-
ance provided to the additional insured by
this endorsement Is primary to "other insur-
ance" available to the additional insured
which covers that person or organization as a
named insured as described In paragraph 3.
above.
a. The following definition is added to SECTION V.
— DEFINITIONS:
"Written contract requiring insurance" means
that part of any written contract or agreement
under which you are required to include a;
person or organization as an additional in-
sured on this Coverage Part, provided that
the "bodily injury" and "property damage" oc-
curs and the "personal injury" is caused by an
offense committed:
a. After the signing and execution of the
contract or agreement by you;
b. While that part of the contract or
agreement Is In effect; and
c. Before the end of the policy period.
Page 2 of 2 0 2005 The St. Paul Travelers Companies, Inc. CG D2 46 08 03
Insured: Doreck Constructlon, Inc.; Stephen Doreck Equipment Rentals, Inc. COMMERCIAL GENERAL LIABILITY
Policy#.. DT22- CO- 7200P538- TCT -16
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies Insurance provided under the following:
COMMERCIAL GENE=RAL LIABILITY COVERAGE PART JOB: ON CALL WATER SYSTEM MAINTENANCE
AND REPAIR SERVnE, PROJECT NO PW 16 -21,
GENERAL DESCRIPTION OF COVERAGE — Provisions A.4i. and J. -N. of this endorsement broaden coverage,
and provision I. of this endorsement may limit coverage. The following listing is a general coverage description
only. Limitations and exclusions may apply to these coverages. Read ell the PROVISIONS of this endorsement
carefully to determine rights, duties, and what is and is not covered.
A. Broadened Named Insured
B. Extension of Coverage — Damage To Premises
Rented To You
• Perils of fire, explosion, lightning, smoke, water
• Limit increased to $300,000
C. Blanket Waiver of Subrogation
D. Blanket Additional Insured — Managers or Lessors
of Premises
E. Incidental Medical Malpractice
F. Extension or Coverage — Bodily Injury
G. Contractual Liability— Railroads
PROVISIONS
A. BROADENED NAMED INSURED
1. The Named Insured in Item 1. of the Declara-
tions is as follows:
The person or organization named in Item 1.
of the Declarations and any organization,
other than a partnership, joint venture or lim-
ited liability company, of which you maintain
ownership or in which you maintain the major-
ity interest on the effective date of the policy.
However, coverage for any such additional
organization will cease as of the date, if any,
during the policy period, that you no longer
maintain ownership of, or the majority interest
in, such organization.
2 WHO IS AN INSURED (Section II) Item 4.a.
is deleted and replaced by the following:
a. Coverage under this provision is afforded
only until the 180th day after you acquire
or form the organization or the end of the
policy period, whichever is earlier.
H. Additional Insured — State or Political Subdivisions
I. Other Insurance Condition
J. Increased Supplementary Payments
• Cost of bail bonds increased to $2,500
• Loss of earnings increased to $500 per day
K. Knowledge and Notice of Occurrence or Offense
L. Unintentional Omission
M. Personal Injury -- Assumed by Contract
N. Blanket Additional Insured Lessor of Leased
Equipment
3. This Provision A. does not apply to any per-
son or organization for which coverage is ex-
cluded by endorsement.
B. EXTENSION OF COVERAGE — DAMAGE TO
PREMISES RENTED TO YOU
1. The last paragraph of COVERAGE A. BOD-
ILY INJURY AND PROPERTY DAMAGE LI-
ABILITY (Section I -- Coverages) is deleted
and replaced by the following:
Exclusions c. through n. do not apply to dam-
age to premises while rented to you, or tem-
porarily occupied by you with permission of
the owner, caused by:
a. l=ire;
b. Explosion;
c. Lightning;
d. Smoke resulting from such fire, explosion,
or lightning; or
e. Water.
A separate limit of insurance applies to this
coverage as described in Section III Limits Of
Insurance.
CG D316 07 04 Copyright, The Travelers Indemnity Company, 2004 Page 1 of 6
COMMERCIAL GENERAL LIABILITY
2. This insurance does not apply to damage to
premises while rented to you, or temporarily
occupied by you with permission of the
owner, caused by:
a. Rupture, bursting, or operation of pres-
sure relief devices;
b. Rupture or bursting due to expansion or
swelling of the contents of any building or
structure, caused by or resulting from wa-
ter,
c. Explosion of steam boilers, steam pipes.
steam engines, or steam turbines.
3. Paragraph 6. of LIMITS OF INSURANCE
(Section Ill) is deleted and replaced by the
following:
Subject to 5- above, the Damage To Prem-
ises Rented To You Limit is the most we will
pay under COVERAGE A. for the sum of all
damages because of "property damage' to
any one premises while rented to you, or
temporarily occupied by you with permission
of the owner, caused by: fire; explosion; light-
ning; smoke resulting from such fire, explo-
sion, or lightning; or water. The Damage To
Premises Rented To You Limit will apply to all
"property damage" proximately caused by the
same Occurrence', whether such damage
results from: fire; exploslon; lightning; smoke
resulting from such fire, explosion, or light-
ning; or water, or any combination of any of
these causes.
The Damage To Premises Rented To You
Limit will be the higher of:
a. $300,000; or
b. The amount shown on the Declarations
for Damage To Premises Rented To You
Limit.
4. Paragraph a. of the definition of "insured con-
tract" (DEFINITIONS — Section V) is deleted
and replaced by the following:
a. A contract for a lease of premises. How-
ever, that portion of the contract for a
lease of premises that indemnifies any
person or organization for damage to
premises while rented to you, or tempo-
rarily occupied by you with permission of
the owner, caused by: fire; explosion;
lightning; smoke resulting from such fire,
explosion, or lightning; or water, is not an
"insured contract";
5. This provision S. does not apply If coverage
for Damage To Premises Rented To You of
COVERAGE A. BODILY INJURY AND
PROPERTY DAMAGE LMILi7Y (Section I —
Coverages) is excluded by endorsement.
C. BLANKET WAIVER OF SUBROGATION
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: premises owned or occupied by or rented
or loaned to you; ongoing operations performed
by you or on your behalf, done under a contract
with that person or organization; "your work "; or
"your products ". We waive this right where you
have agreed to do so as part of a written contract,
executed by you before the "bodily Injury" or
"property damage" occurs or the "personal injury"
or "advertising injury" offense is committed.
D. BLANKET ADDITIONAL INSURED — MANAO-
ERS OR LESSORS OF PREMISES
WHO IS AN INSURED (Section 11) is amended to
include as an insured any person or organization
(referred to below as "additional insured ") with
whom you have agreed in a written contract, exe-
cuted before the "bodily injury" or "property dam-
age" occurs or the "personal injury" or "advertis-
Ing Injury' offense is committed, to name as an
additional insured, but only with respect to liability
arising out of the ownership, maintenance or use
of that part of any premises leased to you, subject
to the following provisions:
4. Limits of Insurance. The limits of insurance
afforded to the additional insured shall be the
limits which you agreed to provide in the writ-
ten contract, or the limits shown on the Decla-
rations, whichever are less.
2. The insurance afforded to the additional in-
sured does not apply to:
a. Any "bodily Injury' or "property damage"
that occurs, or "personal injury" or "adver-
tising injury" caused by an offense which
is committed, after you cease to be a ten-
ant in that premises;
b. Any premises for which coverage is ex-
cluded by endorsement; or
c. Structural alterations, new construction or
demolition operations performed by or on
behalf of such additional insured.
3. The insurance afforded to the additional in-
sured is excess over any valid and collectible
Page 2 of 6 Copyright, The Travelers Indemnity Company, 2004 CO D3 16 07 04
"other insurance" available to such additional
insured, unless you have agreed in the writ-
ten contract that this Insurance must be pri-
mary to, or non-contributory with, such 'other
insurance ".
E. INCIDENTAL MEDICAL MALPRACTICE
1. The following is added to paragraph 1. Insur-
ing Agreement of COVERAGE A. — BODILY
INJURY AND PROPERTY DAMAGE LIABIL-
ITY (Section I — Coverages):
"Bodily injury" arising out of the rendering of,
or failure to render, the following will be
deemed to be caused by an "occurrence ":
a. Medical, surgical, dental, laboratory, x-ray
or nursing service, advice or Instruction,
or the related furnishing of food or bever-
ages:
b. The furnishing or dispensing of drugs or
medical, dental, or surgical supplies or
appliances;
c. First aid: or
d. "Good Samaritan services." As used In
this Provision E., "Good Samaritan ser-
vices" are those medical services ren-
dered or provided In an emergency and
for which no remuneration is demanded
or received.
2. Paragraph 2.a.(1)(d) of WHO IS AN IN-
SURED (Section II) does not apply to any
registered nurse, licensed practical nurse,
emergency medical technician or paramedic
employed by you, but only while performing
the services described in paragraph 1. above
and while acting within the scope of their em-
ployment by you. Any 'employees" rendering
"Good Samaritan services" will be deemed to
be acting within the scope of their employ-
ment by you.
3. The following exclusion is added to paragraph
2. Exclusions of COVERAGE A. — BODILY
INJURY AND PROPERTY DAMAGE LIABIL-
ITY (Section I — Coverages):
(This Insurance does not apply to:) "Bodily in-
jury" or "property damage" arising out of the
willful violation of a penal statute or ordinance
relating to the sale of pharmaceuticals com-
mitted by or with the knowledge or consent of
the insured.
4. For the purposes of determining the applica-
ble limits of insurance, any act or omission
COMMERCIAL GENERAL LIABILITY
together with all related acts or omissions in
the furnishing of the services described in
paragraph 1. above to any one person will be
deemed one "occurrence ",
6. This Provision E. does not apply if you are in
the business or occupation of providing any of
the services described in paragraph 1. above.
6. The insurance provided by this Provision E.
shall be excess over any valid and collectible
"other insurance" available to the insured,
whether primary, excess, contingent or on
any other basis, except for insurance that you
bought specifically to apply in excess of the
Limits of Insurance shown on the Declara-
tions of this Coverage Part
F. EXTENSION OF COVERAGE — BODILY IN-
JURY
The definition of "bodily Injury" (DEFINITIONS —
Section V) is deleted and replaced by the follow -
Ing:
"Bodily Injury" means bodily injury, mental an-
guish, mental injury, shock, fright, disability, hu-
miliation, sickness or disease sustained by a per-
son, including death resulting from any of these at
any time.
G. CONTRACTUAL LIABILITY— RAILROADS
1. Paragraph c. of the definition of insured con-
tract" (DEFINITIONS — Section V) is deleted
and replaced by the following:
c. Any easement or license agreement;
2. Paragraph f.(1) of the definition of "insured
contract" (DEFINITIONS — Section V) is de-
leted.
H. ADDITIONAL INSURED — STATE OR POLITI-
CAL SUBDMSIONS — PERMITS
WHO IS AN INSURED (Section II) is amended to
Include as an insured any state or political subdi-
vision, subject to the following provisions:
1. This insurance applies only when required to
be provided by you by an ordinance, law or
building code and only with respect to opera-
tions performed by you or on your behalf for
which the state or political subdivision has is-
sued a permit.
2. This insurance does not apply to:
a. "Bodily injury, "' "property damage," "per-
sonal injury" or "advertising injury" arising
out of operations performed for the state
or political subdivision; or
CG D316 07 04 Copyright, The Travelers Indemnity Company, 2004 Page 3 of 6
COMMERCIAL GENERAL UABIUTY
b. "Bodily injury" or "property damage" in-
cluded In the "products-completed opera-
tions hazard ".
I. OTHER INSURANCE CONDITION
A. COMMERCIAL GENERAL, LIABILITY CON-
DITIONS (Section IV), paragraph 4. (Other
Insurance) is deleted and replaced by the fol-
lowing:
4. Other Insurance
If valid and collectible "other insurance" is
available to the insured for a loss we
cover under Coverages A or B of this
Coverage Part, our obligations are limited
as follows:
a. primary Insurance
This insurance is primary except
when b. below applies. If this insur-
ance is primary, our obligations are
not affected unless any of the "other
Insurance "' Is also primary. Then, we
will share with all that "other insur-
ance" by the method described in c.
below.
b. Excess Insurance
This insurance Is excess over any of
the "other insurance", whether pri-
mary, excess, contingent or on any
other basis:
(1) That is Fire, Extended Coverage,
Builders Risk, Installation Risk,
or similar coverage for "your
work":
(2) That is Fire insurance for prem-
ises rented to you or temporarily
occupied by you with permission
of the owner;
(3) That is insurance purchased by
you to cover your liability as a
tenant for "property damage" to
premises rented to you or tempo-
rarily occupied by you with per-
mission of the owner, or
(4) If the loss arises out of the main-
tenance or use of aircraft,
"autos", or watercraft to the ex-
tent not subject to Exclusion g. of
Section I — Coverage A — Bodily
Injury And Property Damage Li-
ability; or
insured under any other policy,
including any umbrella or excess
policy.
When this insurance is excess, we
will have no duty under Coverages A
or B to defend the insured against
any "suit" If any provider of "other in-
surance" has a duty to defend the in-
sured against that "suit". If no pro-
vider of "other insurance" defends,
we will undertake to do so, but we will
be entitled to the insured's rights
against all those providers of "other
Insurance ".
When this insurance Is excess over
"other insurance ", we will pay only
our share of the amount of the loss, if
any, that exceeds the sum of:
(1) The total amount that all such
"other insurance" would pay for
the loss in the absence of this in-
surance; and
(2) The total of all deductible and
self - insured amounts under that
"other Insurance ".
We will share the remaining loss, if
any. with any "other insurance" that is
not described in this Excess Insur-
ance provision.
c. Method Of Sharing
If all of the "other insurance" permits
contribution by equal shares, we will
follow this method also. Under this
approach each provider of insurance
contributes equal amounts until it has
paid its applicable limit of insurance
or none of the loss remains, which-
ever comes first.
If any of the "other insurance" does
not permit contribution by equal
shares, we will contribute by limits.
Under this method, the share of each
provider of insurance is based on the
ratio of its applicable limit of insur.
ance to the total applicable limits of
insurance of all providers of insur-
ance.
B. The following definition is added to DEFINITIONS
(Section V):
"Other insurance ":
(5) That is available to the insured a. Means insurance, or the funding of losses,
when the insured is an additional that is provided by, through or on behalf of:
Page 4 of 6 Copyright, The Travelers Indemnity Company, 2004 CG D3 16 07
(1) Another insurance company;
(2) Us or any of our affiliated Insurance com-
panies, except when the Non cumulation
of Each Occurrence Limit section of
Paragraph 5 of LIMITS OF INSURANCE
(Section 111) or the Non cumufation of Per-
sonal and Advertising Injury limit sections
of Paragraph 4 of LIMITS OF INSUR-
ANCE (Section 111) applies;
(3) Any risk retention group;
(4) Any self- insurance method or program,
other than any funded by you and over
which this Coverage Part applies; or
(5) Any similar risk transfer or risk manage-
ment method.
b. Does not include umbrella insurance, or ex=
cess insurance, that you bought specifically to
apply in excess of the Limits of Insurance
shown on the Declarations of this Coverage
Part.
J. INCREASED SUPPLEMENTARY PAYMENTS
Paragraphs 1.b, and 1.d. of SUPPLEMENTARY
PAYMENTS — COVERAGES A AND B (Section
— Coverages) are amended as follows:
1. In paragraph 1.b., the amount we will pay for
the cost of bail bonds is increased to $2500.
2. In paragraph 1.d., the amount we will pay for
loss of earnings is increased to $500 d day.
K. KNOWLEDGE AND NOTICE OF OCCUR-
RENCE OR OFFENSE
1. The following is added to COMMERCIAL
GENERAL LIABILITY CONDITIONS (Section
IV), paragraph 2. (Duties In The Event of Oc-
currence, Offense, Claim or Suit):
Notice of an "occurrence" or of an offense
which may result in a claim must be given as
soon as practicable after knowledge of the
"occurrence" or offense has been reported to
you, one of your "executive officers" (if you
are a corporation), one of your partners who
is an individual (if you are a partnership), one
of your managers (if you are a limited liability
company), or an "employee" (such as an in-
surance, loss control or risk manager or ad-
ministrator) designated by you to give such
notice.
Knowledge by any other "employee" of an
"occurrence" or offense does not imply that
you also have such knowledge.
COMMERCIAL GENERAL LIABILITY
2. Notice of an "occurrence" or of an offense
which may result in a claim wilt be deemed to
be given as soon as practicable to us if It Is
given In good faith as soon as practicable to
your workers' compensation insurer. This ap-
plies only if you subsequently give notice of
the "occurrence" or offense to us as soon as
practicable after you, one of your "executive
officers" (if you are a corporation), one of your
partners who is an Individual (If you are a
partnership), one of your managers (if you are
a limited liability company), or an "employee"
(such as an insurance, loss control or risk
manager or administrator) designated by you
to give such notice discovers that the 'occur-
rence" or offense may involve this policy.
3. This Provision K. does not apply as respects
the spec number of days within which you
are required to notify us in writing of the
abrupt commencement of a discharge, re-
lease or escape of "pollutants" that causes
"bodily Injury" or "property damage" which
may otherwise be covered under this policy.
L. UNINTENTIONAL OMISSION
The following is added to COMMERCIAL GEN-
ERAL LIABILITY CONDITIONS (Section IV),
paragraph 6. (Representations).
The unintentional omission of, or unintentional
error in, any information provided by you which
we relied upon in issuing this policy shall not
prejudice your rights under this insurance. How-
ever, this Provision L. does not affect our right to
collect additional premium or to exercise our right
of cancellation or nonrenewal in accordance with
applicable state insurance laws, codes or regula-
tions.
M. PERSONAL INJURY — ASSUMED BY CON-
TRACT
1. The following is added to Exclusion e. (1) of
Paragraph 2., Exclusions of Coverage B.
Personal Injury, Advertising Injury, and
Web Site Injury Liability of the Web XTEND
Liability endorsement:
Solely for the purposes of liability assumed in
an "insured contract", reasonable attorney
fees and necessary litigation expenses in-
curred by or for a party other than an insured
are deemed to be damages because of "per-
sonal injury" provided:
(a) Liability to such party for, or for the cost
of, that pWs defense has also been as-
CG D316 07 04 Copyright, The Travelers Indemnity Company, 2004 Page 5 of 6
COMMERCIAL GENERAL LIABILITY
sumed in the same "insured contract ";
and
(b) Such attorney fees and litigation ex-
penses are for defense of that party
against a civil or alternative dispute reso-
lution proceeding in which damages to
which this insurance applies are alleged.
2. Paragraph 2.d. of SUPPLEMENTARY PAY-
MENTS — COVERAGES A AND B (Section
-- Coverages) is deleted and replaced by the
following:
d. The allegations In the "suit" and the in-
formation we know about the "occur-
rence" or offense are such that no conflict
appears to exist between the interests of
the Insured and the interests of the in-
demnitee:
3. The third sentence of Paragraph 2 of SUP-
PLEMENTARY PAYMENTS — COVERAGES
A AND B (Section I — Coverages) Is deleted
and replaced by the following:
Notwithstanding the provisions of Paragraph
2.b.(2) of Section I -- Coverage A -- Bodily In-
jury And Property Damage Liability, or the
provisions of Paragraph 2.e.(i) of Section I
Coverage B — Personal Injury, Advertising In-
jury And Web Site Injury Liability, such pay-
ments will not be deemed to be damages for
"bodily injury" and "property damage ", or
damages for "personal injury", and will not re-
duce the limits of insurance.
4. This provision M. does not apply if coverage
for "personal injury" liability is excluded by
endorsement.
N. BLANKET ADDITIONAL INSURED — LESSOR
OF LEASED EQUIPMENT
WHO IS AN INSURED (Section lt) is amended to
Include as an Insured any person or organization
(referred to below as "additional Insured ") with
whom you have agreed In a written contract, exe-
cuted before the "bodily injury" or "property dam-
age" occurs or the "personal injury" or "advertis-
ing Injury" offense is committed, to name as an
additional insured, but only with respect to their lk
ability for "bodily injury", "property damage ", "per-
sonal Injury" or "advertising injury" caused, in
whole or In part, by your acts or omisslons in the
maintenance, operation or use of equipment
leased to you by such additional insured, subject
to the following provisions:
1. Limits of Insurance. The limits of insurance
afforded to the additional Insured shall be the
limits which you agreed to provide in the writ-
ten contract, or the limits shown on the Decla-
rations, whichever are less.
2. The Insurance afforded to the additional In.
sured does not apply to any "bodily injury" or
"property damage` that occurs, or "personal
injury" or "advertising injury" caused by an of-
fense which is committed, after the equipment
lease expires.
3. The insurance afforded to the additional in-
sured Is excess over any valid and collectible
"other insurance" available to such additional
insured, unless you have agreed in the writ-
ten contract that this insurance must be pri-
mary to, or non - contributory with, such "other
insurance ".
Page 6 of 6 Copyright, The Travelers Indemnity Company, 2004 CG D3 16 07 04
POLICY NUMBER: U '1'.22.OU•72 {-q!'5.38.1iC'I' -1G
COMMERCIAL GENERAL LIABILITY
ISSUE DATE: 03/01/2016
THIS ENDORSEMENT CHANGES: THE POLICY. PLEASE READ IT CAREFULLY.
g1gamgacti -
This endorsement>modifies.insurance provided under the following:
COMMERCIAL GENERAL,LIABILITY COVEt AGF, PART
SCHEDULE
Designated Project(s);
Designated Project
General Aggr"ete(e):
JOB: ON CALL WATER SYSTEM MAINTENANGE AND REPAIR SERVICE, PROJECT NO PW 16 -21,
A, For all sums which the insured becomes legally
obligated to pay as damages caused by "occur-
rencee under COVERAGE A. (SECTION Q, and
for all medical expenses caused by accidents un-
der COVERAGE C '.(SECTION :li), which can be
attributed only to operations at a. single esig-
nated ",project" shown In the Schedule above:
1. A separate Designated Project General Ag-
gregate Llmit;appiies to each designated "Pro-
ject.", and that limit is equal to the amount of
the General Aggregate limit slh=n in the
Declarations, unless : se..parate. Designated
Project General Aggregate(s) are. sched-
uled, above. .
2. The Designated Project General Aggregate
Limit.is the most we will pay forthe sum of all
damages under COVERAGE A., except
damages because of "bodily injury." or "prop-
erty damage" included in the "products-
completed operations hazard ", and for medi-
cal expenses under. COVERAGE C, regard-
less of the number of:
a. Insureds;
b. :Claims made or "suits" brought; or
c. Persons or organizations making claims
or bringing "suits ".
I Any payments made under COVERAGE A.
for damages or under COVERAGE C. for
medical expenses shall reduce the Deslg-
hated Project General Aggregate Limit for
that designated "pmjoct'. Such: payments
shall not reduce -the General Aggregate Limit
shown in the Declarations nor shall they re-
duce any other Designated Project General
Aggregate. Limit for any other designated
"project "shown In the Schedule above.
4. The limits shorn in the .Declarations for Each
Occurrence, Damage. To :Premises Rented
To You and Medical Expense continue to
apply. However, instead 'of.:being subject to
the General Aggregate Urn shown, in the
Declarations, such limits will be subject to the
applicable Design, tod project General, Aq-
gregate Limit.
B. For all sums which the insured becomes Legally
obligated to pay as damages caused by "occur -
rences" sender COVERAGE~ A. (SECTION 1). and
for all medical expenses caused by accidents un-
der COVERAGE C. (SECTION 1), which• cannot
be attributed only to operations at a single desig-
:.noted " proJect" shown in the Schedule above:
-CG D2 11 01 04 - Copyright, The Travelers Indemnity :Company, 2004 Page:1 of 2
COMMERCIAL GENERAL LIABILITY
1. Any payments made under COVERAGE A.
for damages or under COVERAGE C. for
medical expenses shall reduce the amount
available under the General Aggregate Limit
or the Products - Completed Operations Ag-
gregate Limit, whichever is applicable; and
2. Such payments shall not reduce any Desig-
nated Project General Aggregate Limit. E.
C. Fart 2. of SECTION 111 — LIMITS OF INSURANCE
is deleted and replaced by the following:
2. The General Aggregate Limit is the most we
will pay for the sum of:
a. Damages under Coverage B; and
b. Damages from "000urrences" under
COVERAGE A (SECTION 1) and for all
medical expenses caused by accidents
under COVERAGE C (SECTION 1) which
cannot be attributed only to operations at
a single designated "project" shown In the
SCHEDULE above.
D. 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 Aggre-
gate Limit nor the Designated Project General
Aggregate Limit
For the purposes of this endorsement the beflnl-
tions Section is amended by the addition of the
following definition:
"Project" means an area away from premises
owned by or rented to you at which you are per-
forming operations pursuant to a contract or
agreement. For the purposes of determining the
applicable aggregate limit of insurance, each
"project" that includes premises involving the
same or connecting lots, or premises whose con-
nection is interrupted only by a street, roadway,
waterway or right -of -way of a railroad shall be
considered a single "project ".
F. The provisions of SECTION III — LIMITS OF
INSURANCE not otherwise modified by this en-
dorsement shall continue to apply as stipulated.
Page 2 of 2 Copyright, The Travelers Indemnity Company, 2004 CG 02 11 01 04
Insured; Doreck Construction, Inc.; Stephen Doreck Equipment Rentals, Inc. COMMERCIAL AUTO
Polioyit: DT- 810 - 81)457897- TIL -16
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
AUTO COVERAGE PLUS ENDORSEMENT
L SEGUNDO. ITS OFFICERS.
• CITY OF E OFFICIALS,
EMPLOYEES, AGENTS AND VOLUNTEERS
This endorsement modifies Mwmnce 35D MAIN STREET, EL SEGUNDO, CA 90245 -3813
provided Under file following: JOB: ON CALL WATER SYSTEM MAINTENANCE
BUSINESS AUTO COVERAGE FORM AND REPAIR SERVICE, PROJECT NO PW 16 -21.
With respect to Coverage provided by tNS endorMe-
ment, the provislons of the Coverage Form apply
unless modified by the endorsement
A- PERSONAL EFFECTS COVERAGE
SECTION 111 — PHYSICAL DAMAGE COVER-
AGE, A. Coverage. 4, Owyerage Extensions is
amended by adding to following;
Personal Weeds Coverage
We will pay up to $400 for "loss" to wearing ap-
parel and other personal effete which are:
(1) owned by an insured'; and
(2) in or on your covered 'auto',
in the event of a total theft "loss" of your covered
'auto'.
No deductiblas apply to Personal Effects Cover-
age.
B. AUTO LOAN LEASE GAP COVERAGE
SECTION NJ — PHYSICAL DAMAGE COVER-
AGE, A Coverage, 4. Coverage Extensions Is
amended by adding the following
Auto Loan Lease Gap Coverage for Private
Passenger Type Vehicles
In the event of a total loss" to a covered "auto" of
:the private passenger type shown in the Schedule
or Declarations for which Physical Damage Cov-
erage Is provided, we will pay any unpaid amount
due on the lease or loan for such covered "auto"
less the following:
(1) The amount paid under the Physical Damage
Coverage Section of the policy for that "auto ";
and
(d) Costs for extended warranties, credit Life
Insurance, Health, Accident or Disability
Insurance purchased with the loan or
lease; and
(a) CaIrlY batances from previous bens
or leases.
C. COVERAGE EXTENSION — AUDIO, VISUAL
AND DATA ELECTRONIC EQUIPMENT NOT
DESIGNED SOLELY FOR THE PRODUCTION
OP SOUND
SECTION Ifs — PHYSICAL DAMAGE COVER-
AGE, B. Exclusions, exception paragraph a. to
exclusions Cot 4.d is deleted and replaced with
the following:
a. Equipment and accessories used with such
equipment, except tapes, records or discs,
providod'such equipment is pernnanently In-
stalled in the covered "auto" at the time of the
`loss' or Is removable from a housing unit
which Is permanently installed In the covered
"auto" at the time of the "loss ". and such
equipment Is designed to be solely operated
by use of the power from the "auto a electri-
cal system, In or upon the covered "auto'; or
D. WAIVER OF DEDUCTIBLE —GLASS
SECTION IN — PHYSICAL DAMAGE COVER-
AGE, D. Deductible is amended by adding the
following:
No deductible for a covered 'auto" will apply to
glass damage if the glass is repaired rather than
replaced.
E. HIRED AUTO PHYSICAL DAMAGE COVER-
AGE
(2) Any. SECTION Iii — PHYSICAL DAMAGE COVER.
(a) Overdue IeaseAoan payments at the time AGE, A- Coverage, 4. Coverage Extensions Is
of the "loss"; amended by adding the following:
(b) Financial penalties Imposed under a Hired Auto Physical Damage Coverage Exton.
lease for excessive use, abnormal weer Sion
and tear or high mileage; If hired "autos " are covered ' autos" for Liability
(c) Security deposits not returned by the les- Coverage and this policy also provides Physical
sor, Damage Coverage for an owned "auto", then the
CA T4 20 07 06 Includes the copyrighted material of Insurance Services ottlav, Inc, with Its permission. Page 1 of 2
Indudes the copyrighted material of The St Paul Travelers Compenise, Inc.
COMMERCIAL AUTO
Physical Damage Coverage Is eidwWad to
"autos' that you hire, rent or borrow subject to the
following;
(1) The most we will pay for Okm" in any one
'accident" to a hired, rented or borrowed
'auto " is the lesser of:
(a) $50,000; G'
(b) The actual cash value of the dam-
aged or stolen property as of the time
of the *We; or
(c) The cost of repairing or replacing the
damaged or stolen property with
tatter property of like kind and quality.
(2) An adjustment for depredation and
physicsd condition will be made In dater
miring actual cash value In the event of a
total 'loss".
(3) if a repair or replacement results In better
than Ike idnd or quality, we will not pay
for the amount of betterment
(4) A deductible equal to the highest Physical
Damage deductible applicable to any
owned covered "auto ".
(5) This Coverage Extension does not apply
to:
(a) Any "auto! that is hired. rented or bor-
rowed with a driver, or
(b) Any "auto" that Is hired, rented or bor-
rowed from your "employee ".
F. BLANKET WAIVER OF SUBROGATION
SECTION IV — BUSINESS AUTO CONDITIONS,
A. loss Conditions, 5. Transfer Of Rights Of
Recovery Against Others To Us Is deleted and
replaced by the following:
5. Transfair Of Rights Of Recovery Against
Others To Us
We waive any right of recovery we may have
against any person or organization to the ex-
tent required of you by a written contract exe-
cuted prior to any 'sodden!' or "IOC", pro-
vided that the "accident" or Im" *Ases out of
the operations contemplated by such con-
tract. The waiver soles o* to the person or
organization designated In such contract.
131ANKEY ADDITIONAL INSURED
SECTION li — LIABIL1'llY COVERAGE, part A. 1,
Who Is An Insured. paragraph c. Is amended by
adding the following:
Any person or oqpnMon that you are required
to include as an additional insured on this Cover-
age Form in a written contract or agreernent that
is signed and executed by you before the 'bodily
injury or ' property damage" occurs and ti-tat is in
effect during the policy period Is an 'insured- for
Liability Coverage, but only for damages to which
this Insurance applies and only to the arlent that
person or organization qualMs as an "insured'
under the Who Is An Insured provision contained
In sedlon II.
L:i�'1�•l��:i : �+ : tTF
SECTION p LIABILITY COVERAGE. A. Cov-
erage, I. Who is An Insured Is amended by add-
ing the Mowing-
An "employee" of yours is an "insured" while op-
erating an'aute hired or rented under a contract
or agreement in that "employee's" name, with
your perrrdssion, while performing duties related
to the conduct of your business.
I. COVERAGE te'7tTENSION — TRAILERS
SECTION I — COVERED AUTOS, C. Certain
Trailers, Mobft Equipment and Temporary
Substitute Aultos. paragraph 1. is deleted and
replaced by the following:
1. - Trallers- with a load capacity of 3,000
pounds or less designed primarily for travel
on public roads.
Page 2 of 2 Includes the copyrighted material or Irmronce Seevices Olaoe. tim wilts he permission. CA T4 20 07 41116
Includes the copyrighted materiel of The St. Paut Travelers Companies, Inc.
" r r M
it
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
ENDORSEMENT WC 99 03 76 (00) —
POLICY NUMBER: I >r.1- Lies- 7,noNSSx -16
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS.
ENDORSEMENT - CALIFORNIA
(BLANKET WAIVER)
We have the right to recover:our payments from anyone liable for an injury t<overed by this policy. We will not
enforce ourright against the person or organization named in the Schedule.
You must maintain payroll records accurately segregating the remuneration of your employees .while engaged in
the work described in the Schedule.
The additional premiurn for this endorsement shall be
mium otherwise due on such remuneration.
Schedule
Person or Organization
CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS,
EMPLOYEES, AGENTS AND VOLUNTEERS
350 MAIN STREET, EL SEGUNDO, CA 90245 -3813
DATE OF ISSUE: 03/01/2016 ST ASSIGN:
% of the California workers' compensation pre-
Job Description
JOB: ON CALL WATER SYSTEM MAINTENANCE
AND REPAIR SERVICE, PROJECT NO PW 16 -21.
Form W"9 Request for Taxpayer Give Form to the
(Rev. December 2011) identification Number and Certification requester' Do not
Department of the Treasury ury Send t0 the IRS.
Internal Revenue Service
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Ca
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Name (as shown on your Iirr „orvre IsK roturn)
Stephen Doreck Equipment Rentals, Inc.
entity name, if different from above
Check appropriate box for federal tax classification:
❑ Individual /sole proprietor ❑✓ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate
❑ Limited liability company. Enter the tax classification ( C =C corporation, S =S corporation, P= artnershi P) ► ❑ Exempt payee
❑ Other ('soo instructions) ►
Address (number, street, and apt. or suite no.) Requester's name and address (optional)
9075 Telegraph Road
City, state, and ZIP code
Pico Rivera, CA 90660
List account number(s)mhere ( optional)
ter Identification Number I
Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name” line
I Social security number
to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
iT
F1
- -r
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3.
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose
number to enter.
Employer identification number
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding, and
3. 1 am a U.S. citizen or other U.S. person (defined below).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 4 t -�
_..__......_.�........... 6 q�
Date Sign Signature of ....... �
Here U.S. person ►
General lnstruction ") 11,`
Section references are to the Internal Revenue Code unless otherwise
noted.
Purpose of Form
A person who is required to file an information return with the IRS must
obtain your correct taxpayer identification number (TIN) to report, for
example, income paid to you, real estate transactions, mortgage interest
you paid, acquisition or abandonment of secured property, cancellation
of debt, or contributions you made to an IRA.
Use Form W -9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN to the person requesting it (the
requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are waiting for a
number to be issued),
Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exempt
payee. If applicable, you are also certifying that as a U.S. person, your
allocable share of an artnershi income from a U S trade or business
Note. If a requester gives you a form other than Form W -9 to request
your TIN, you must use the requester's form if it is substantially similar
to this Form W -9.
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
• An individual who is a U.S. citizen or U.S. resident alien,
• A partnership, corporation, company, or association created or
organized in the United States or under the laws of the United States,
• An estate (other than a foreign estate), or
• A domestic trust (as defined in Regulations section 301.7701 -7).
Special rules for partnerships. Partnerships that conduct a trade or
business in the United States are generally required to pay a withholding
tax on any foreign partners' share of income from such business.
Further, in certain cases where a Form W -9 has not been received, a
partnership is required to presume that a partner is a foreign person,
and pay the withholding tax. Therefore, if you are a U.S. person that is a
partner in a partnership conducting a trade or business in the United
States, provide Form W -9 to the partnership to establish your U.S.
status and avoid withholding on your share of partnership income.
Yp P
is not subject to the withholding tax on foreign partners' share of
effectively connected income.
Cat. No. 10231X Form W -9 (Rev. 12 -2011)
Form W-9 (Rev. 12-2011)
The person who gives Form W-9 to the partnership for purposes of
establishing its U.S. status and avoiding withholding on its allocable
share of net income from the partnership conducting a trade or business
in the United States is in the following cases:
• The U.S. owner of a disregarded entity and not the entity,
• The U.S. grantor or other owner of a grantor trust and not the trust,
and
• The U.S. trust (other than a grantor trust) and not the beneficiaries of
the trust.
Foreign person. If you are a foreign person, do not use Form W-9.
Instead, use the appropriate Form W-8 (see Publication 515,
Withholding of Tax on Nonresident Aliens and Foreign Entities).
Nonresident alien who becomes a resident alien. Generally, only a
nonresident alien individual may use the terms of a tax treaty to reduce
or eliminate U.S. tax on certain types of income. However, most tax
treaties contain a provision known as a "saving clause." Exceptions
specified in the saving clause may permit an exemption from tax to
continue for certain types of income even after the payee has otherwise
become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an exception
contained in the saving clause of a tax treaty to claim an exemption
from U.S. tax on certain types of income, you must attach a statement
to Form W-9 that specifies the following five items:
1. The treaty country. Generally, this must be the same treaty under
which you claimed exemption from tax as a nonresident alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that contains the
saving clause and its exceptions.
4. The type and amount of income that qualifies for the exemption
from tax.
5. Sufficient facts to justify the exemption from tax under the terms of
the treaty article.
Example. Article 20 of the U.S.-China income tax treaty allows an
exemption from tax for scholarship income received by a Chinese
student temporarily present in the United States. Under U.S. law, this
student will become a resident alien for tax purposes if his or her stay in
the United States exceeds 5 calendar years. However, paragraph 2 of
the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows
the provisions of Article 20 to continue to apply even after the Chinese
student becomes a resident alien of the United States. A Chinese
student who qualifies for this exception (under paragraph 2 of the first
protocol) and is relying on this exception to claim an exemption from tax
on his or her scholarship or fellowship income would attach to Form
W-9 a statement that includes the information described above to
support that exemption.
If you are a nonresident alien or a foreign entity not subject to backup
withholding, give the requester the appropriate completed Form W-8.
What is backup withholding? Persons making certain payments to you
must under certain conditions withhold and pay to the IRS a percentage
of such payments. This is called "backup withholding." Payments that
may be subject to backup withholding include interest, tax-exempt
interest, dividends, broker and barter exchange transactions, rents,
royalties, nonemployee pay, and certain payments from fishing boat
operators. Real estate transactions are not subject to backup
withholding.
You will not be subject to backup withholding on payments you
receive if you give the requester your correct TIN, make the proper
certifications, and report all your taxable interest and dividends on your
tax return.
Payments you receive will be subject to backup
withholding if:
1. You do not furnish your TIN to the requester,
2. You do not certify your TIN when required (see the Part 11
instructions on page 3 for details),
3. The IRS tells the requester that you furnished an incorrect TIN,
4. The IRS tells you that you are subject to backup withholding
because you did not report all your interest and dividends on your tax
return (for reportable interest and dividends only), or
5. You do not certify to the requester that you are not subject to
backup withholding under 4 above (for reportable interest and dividend
accounts opened after 1983 only).
Page 2
Certain payees and payments are exempt from backup withholding.
See the instructions below and the separate Instructions for the
Requester of Form W-9.
Also see Special rules for partnerships on page 1.
n7mmem ME=
You must provide updated information to any person to whom you
claimed to be an exempt payee if you are no longer an exempt payee
and anticipate receiving reportable payments in the future from this
person. For example, you may need to provide updated information if
you are a C corporation that elects to be an S corporation, or if you no
longer are tax exempt. In addition, you must furnish a new Form W-9 if
the name or TIN changes for the account, for example, if the grantor of a
grantor trust dies.
Name
If you are an individual, you must generally enter the name shown on
your income tax return. However, if you have changed your last name,
for instance, due to marriage without informing the Social Security
Administration of the name change, enter your first name, the last name
shown on your social security card, and your new last name.
If the account is in joint names, list first, and then circle, the name of
the person or entity whose number you entered in Part I of the form.
Sole proprietor. Enter your individual name as shown on your income
tax return on the "Name" line. You may enter your business, trade, or
"doing business as (DBA)" name on the "Business name/disregarded
entity name" line.
Partnership, C Corporation, or S Corporation. Enter the entity's name
on the "Name" line and any business, trade, or "doing business as
(DBA) name" on the "Business name/disregarded entity name" line.
Disregarded entity. Enter the owner's name on the "Name" line. The
name of the entity entered on the "Name" line should never be a
disregarded entity. The name on the "Name" line must be the name
shown on the income tax return on which the income will be reported.
For example, if a foreign LLC that is treated as a disregarded entity for
U.S. federal tax purposes has a domestic owner, the domestic owner's
name is required to be provided on the "Name" line. If the direct owner
of the entity is also a disregarded entity, enter the first owner that is not
disregarded for federal tax purposes. Enter the disregarded entity's
name on the "Business name/disregarded entity name" line. If the owner
of the disregarded entity is a foreign person, you must complete an
appropriate Form W-8.
Note. Check the appropriate box for the federal tax classification of the
person whose name is entered on the "Name" line (Individual/sole
proprietor, Partnership, C Corporation, S Corporation, Trust/estate).
Limited Liability Company (LLC). If the person identified on the
"Name" line is an LLC, check the "Limited liability company" box only
and enter the appropriate code for the tax classification in the space
provided. If you are an LLC that is treated as a partnership for federal
tax purposes, enter "P" for partnership. If you are an LLC that has filed a
Form 8832 or a Form 2553 to be taxed as a corporation, enter "C" for
C corporation or "S" for S corporation. If you are an LLC that is
disregarded as an entity separate from its owner under Regulation
section 301.7701-3 (except for employment and excise tax), do not
check the LLC box unless the owner of the LLC (required to be
identified on the "Name" line) is another LLC that is not disregarded for
federal tax purposes. If the LLC is disregarded as an entity separate
from its owner, enter the appropriate tax classification of the owner
identified on the "Name" line.
Form W -9 (Rev. 12 -2011)
Other entities. Enter your business name as shown on required federal
tax documents on the "Name" line. This name should match the name
shown on the charter or other legal document creating the entity. You
may enter any business, trade, or DBA name on the "Business name/
disregarded entity name" line.
r
If you are exempt from backup withholding, enter your name as
described above and check the appropriate box for your status, then
check the "Exempt payee" box in the line following the "Business name/
disregarded entity name," sign and date the form.
Generally, individuals (including sole proprietors) are not exempt from
backup withholding. Corporations are exempt from backup withholding
for certain payments, such as interest and dividends.
Note. If you are exempt from backup withholding, you should still
complete this form to avoid possible erroneous backup withholding.
The following payees are exempt from backup withholding:
1. An organization exempt from tax under section 501(a), any IRA, or a
custodial account under section 403(b)(7) if the account satisfies the
requirements of section 401(f)(2),
2. The United States or any of its agencies or instrumentalities,
3. A state, the District of Columbia, a possession of the United States,
or any of their political subdivisions or instrumentalities,
4. A foreign government or any of its political subdivisions, agencies,
or instrumentalities, or
5. An international organization or any of its agencies or
instrumentalities.
Other payees that may be exempt from backup withholding include:
6. A corporation,
7. A foreign central bank of issue,
8. A dealer in securities or commodities required to register in the
United States, the District of Columbia, or a possession of the United
States,
9. A futures commission merchant registered with the Commodity
Futures Trading Commission,
10. A real estate investment trust,
11. An entity registered at all times during the tax year under the
Investment Company Act of 1940,
12. A common trust fund operated by a bank under section 584(a),
13. A financial institution,
14. A middleman known in the investment community as a nominee or
custodian, or
15. A trust exempt from tax under section 664 or described in section
4947.
The following chart shows types of payments that may be exempt
from backup withholding. The chart applies to the exempt payees listed
above, 1 through 15.
IF the payment is for ... THEN the payment is exempt
for...
Interest and dividend payments All exempt payees except
for 9
Broker transactions - Exempt payees 1 through 5 and 7
through 13. Also, C corporations.
Barter exchange transactions and Exempt payees 1 through 5
patronage dividends
Payments over $600 required t.... e Generally, exempt - payees
ob
y q e Gene payees
reported and direct sales over 1 through 7 2
$5,000,
'See Form 1099 -MISC, Miscellaneous Income, and its instructions.
2 However, the following payments made to a corporation and reportable on Form
1099 -MISC are not exempt from backup withholding: medical and health care
payments, attorneys' fees, gross proceeds paid to an attorney, and payments for
services paid by a federal executive agency.
" s • s u
i
Enter your TIN in the appropriate box. If you are a resident alien and
you do not have and are not eligible to get an SSN, your TIN is your IRS
individual taxpayer identification number (ITIN). Enter it in the social
security number box. If you do not have an ITIN, see How to get a TIN
below.
If you are a sole proprietor and you have an EIN, you may enter either
your SSN or EIN. However, the IRS prefers that you use your SSN.
If you are a single- member LLC that is disregarded as an entity
separate from its owner (see Limited Liability Company (LLC) on page 2),
enter the owner's SSN (or EIN, if the owner has one). Do not enter the
disregarded entity's EIN. If the LLC is classified as a corporation or
partnership, enter the entity's EIN.
Note. See the chart on page 4 for further clarification of name and TIN
combinations.
How to get a TIN. If you do not have a TIN, apply for one immediately.
To apply for an SSN, get Form SS -5, Application for a Social Security
Card, from your local Social Security Administration office or get this
form online at www.ssa.gov. You may also get this form by calling
1- 800 - 772 -1213. Use Form W -7, Application for IRS Individual Taxpayer
Identification Number, to apply for an ITIN, or Form SS -4, Application for
Employer Identification Number, to apply for an EIN. You can apply for
an EIN online by accessing the IRS website at www.irs.gov /businesses
and clicking on Employer Identification Number (EIN) under Starting a
Business. You can get Forms W -7 and SS -4 from the IRS by visiting
IRS.gov or by calling 1 -800- TAX -FORM (1- 800 - 829 - 3676).
If you are asked to complete Form W -9 but do not have a TIN, write
"Applied For" in the space for the TIN, sign and date the form, and give
it to the requester. For interest and dividend payments, and certain
payments made with respect to readily tradable instruments, generally
you will have 60 days to get a TIN and give it to the requester before you
are subject to backup withholding on payments. The 60 -day rule does
not apply to other types of payments. You will be subject to backup
withholding on all such payments until you provide your TIN to the
requester.
Note. Entering "Applied For" means that you have already applied for a
TIN or that you intend to apply for one soon.
Caution: A disregarded domestic entity that has a foreign owner must
use the appropriate Form W -8.
M
4. Other payments. You must give your correct TIN, but you do not
have to sign the certification unless you have been notified that you
have previously given an incorrect TIN. "Other payments" include
payments made in the course of the requester's trade or business for
rents, royalties, goods (other than bills for merchandise), medical and
health care services (including payments to corporations), payments to
a nonemployee for services, payments to certain fishing boat crew
members and fishermen, and gross proceeds paid to attorneys
(including payments to corporations).
5. Mortgage interest paid by you, acquisition or abandonment of
secured property, cancellation of debt, qualified tuition program
payments (under section 529), IRA, Coverdell ESA, Archer MSA or
HSA contributions or distributions, and pension distributions. You
must give your correct TIN, but you do not have to sign the certification
What Name and Number To
Give the Requester
For this type of account:
. . .....................................
Give name and WIN of:
1. Individual
The individual
2. Two or more individuals (joint
The actual owner of the account or,
account)
if combined funds, the first
individual on the account
3. Custodian account of a minor
The minor 2
(Uniform Gift to Minors Act)
4. a. The usual revocable savings
The grantor-trustee
trust (grantor is also trustee)
b. So-called trust account that is
The actual owner'
not a legal or valid trust under
state law
5. Sole proprietorship or disregarded
The owner'
entity owned by an individual
6. Grantor trust filing under Optional
The grantor'
Form 1099 Filing Method 1 (see
Regulation section 1.671-4(b)(2)(j)(A))
For this type of account:
Give name and EIN of:
7. Disregarded entity not owned by an
The owner
individual
8. A valid trust, estate, or pension trust
Legal entity 4
9. Corporation or LLC electing
The corporation
corporate status on Form 8832 or
Form 2553
10. Association, club, religious,
The organization
charitable, educational, or other
tax-exempt organization
11, Partnership or multi-member LILC
The partnership
12. A broker or registered nominee
The broker or nominee
13. Account with the Department of
The public entity
Agriculture in the name of a public
entity (such as a state or local
government, school district, or
prison) that receives agricultural
program payments
14. Grantor trust filing under the Form
The trust
1041 Filing Method or the Optional
Form 1099 Filing Method 2 (see
Regulation section 1.671-4(b)(2)(i)(13))
List first and circle the name of the person whose number you furnish If only one person on a
joint account has an SSN, that person's number must be furnished,
2 Circle the minor's name and furnish the minor's SSN.
3 You must show your individual name and you may also enter your business or "DBA" name on
the "Business name/disregarded entity" name line You may use either your SSN or EIN (if you
have one), but the IRS encourages you to use your SSN,
4 List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the
personal representative or trustee unless the legal entity itself is not designated in the account
title.) Also see Special rules forpartnerships on page 1
*Note. Grantor also must provide a Form W-9 to trustee of trust,
To reduce your risk:
• Protect your SSN,
• Ensure your employer is protecting your SSN, and
• Be careful when choosing a tax preparer.
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with
the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation
of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS,
reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District
of Columbia, and U.S. possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies
to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to
file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a
TIN to the payer, Certain penalties may also apply for providing false or fraudulent information.