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PROOF OF INSURANCE (2016) CLOSEDClient#: 32025 VASIL4 DATE (MMIDDIYYYY) ACORD,. CERTIFICATE OF LIABILITY INSURANCE 610312016 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 ADDITIONALWINSWURED,the policy(iWes) must be endorsed. WIfWSUBROGATION 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 endorseamnenl(s). PRODUCER NAME: Lon Winslow Allen Lawrence & Assoc., Inc. NQ Eie) 819 710-3422 �iN 8187 1 10 3423 License#0442083 E Am . - -- I ylt,S'S, !window( al Ionlawrencecom m..... w 7033 Owensmouth Avenue t � ,._...,._,........ mm - - Canoga Park, CA 91303 -2006 INSURERA: aN�sDaarRSJAEGaINr�vrR BAICA g �������RERA:................ Travelers Indemnity Co of CT 256 2 _....._ . w__.__ _ ., ... ...... ...... — INSURED ......._. ___..... ._.... Vasilj, Inc INSUM RU RSUI lndemnity Company INsuRa Ra State Compensation Insurance Fu...... 35076 15531 Arrow Highway Starr Indiamni & Liability Corm 38318 Irwindale, CA 91706 ImauRCRaa y INSURER E • Travelers Prop Casualty of Amer 25674 INSURER F! ,...__..._ .............. ...._...,...a..,..........,.�.. COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TAE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCeUIVENT WITH RESPECT TO WAICH THIS CERTIFICATE UAY 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 VAY HAVE BEEN REDUCED BY PAID CLAIMS- IN Sri ...... ......... _ .ADDL SUUR .. ,. POLICY EFF POLICY EXP ... '.,,Lrm1 TYPE OF INSURANCE ,,,,,,, ,W'S m WYD POLICY NUMBER _ ( DDPY ) IMMIDDIYYYY) LIMITS A GENERAL LI BILI Y DT22CO2505PO68TCT1 1210112015'121011201Bµ1 Aa� Ia CLJRfm NCIF. s1,000,000 }t '01101W HG sd 01 h'&Wd IIIiAHs nlY i Mu ml I „`ll uaI iaP ° -as r: b� 6300,000 ICL�IIAS- h%DI:: I NOCCUIR' LIED' LXIhpAny �ucr lrv�, a s5A00 l X BI /PD Ded:5,000 Pin R.sa`JNM an AMW llm, -O"y 61,000,000 _I udI IL,u. _ . a. ..w ��� a Rll a DTI s2 000 000 l ll .AJ..1 > >L . . a I m I R ,.. . w. Y w —_ —v m yJ±;IRK L uls:m�ur.aLrl 9 J mumca a mI ir J , �a �¢ ss c2 000 000 u .. AiA E A AUTOMOBILE BA2505P06815CNS 12!011201512!01 /2016 1,000,000 �x ANY AUIU '.... 119GJY:b III -W` Ipd�.JLJR`P QIG °mr Ixwv�,ew'y � _ _.M ....... . N I OVWgIr If) X C P4 FNA I D I tt:4GsI?lI_`+ IptiV.EB.11U$V Qlf' ;�a rdr.c�6;1ma IJ s s,aoTCr', Xro Igc.m& 0MI-0 r I` OP 1114' 1 V IYA N.,I.� +, 091HI -Il d'vVJItlG i X d9V.bIV'.)ht jlPrvr �G Cke_a Ii S Excess uA ocom )w mt i M1 MI I NHA239221 12I0112015�� BA9 1210112016, F.A I I c a CL)Rd IrNCf- $9,0004000 UMBRELLA u L a IZU a skin w 59 000,000 IJd•I•) I'iI mUU)'If ON �..wwW..�...e._ i .... ._.w,. S C AND LHMPIS,COMPENSATION YCH it W.lTY YIN 912070516 110112016 01 /011201 T aw I �m AN I I 61,000,000 Of Of I V1 NIA I rt Harr In N14) I I I rr� s4 I:.ILIUgff'a c D~P_ 51 000,000.....w 1- 0 III rs� v w iau L, � I I Nl I 51 000,000 vm� rLr�rrr'�� a_�sww�. ........_________ m..�www...wwww� ..wawa. .... ...»�- ��� ..._... ....e .....I ...�.......,. mJ k�Qdlfi �r)roptl F1�irv9sa.?�.e. D Contractors 1000065286151 1EI 65,000,000 Ea Occ Pollution Liab. 65,000,000 Aggregate Dad: 65,000 Per Occ DESCRIPTION OF OPERATIONS 1 LOCATIONS /VEHICLES (Altach ACORD 101, Additional Romarko Schodulu, i mom Spam is roquiod) " Workers Comp Information'* Proprietors /Partners /Executive Officers /Members Excluded: Iva Vasilj, CEO & Ivan Vasilj, VP The City of El Segundo, its officers, officials, employees, agents, and volunteers are included as (See Attached Descriptions) City Of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Clerk ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE @ 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) 1 Of 2 The ACORD name and logo are registered marks of ACORD #S3297201M318374 LEW t G i i r POLICY NUMBER: DT22CO2505P068TCT1 COMMERCIAL GENERAL LIABILITY ISSUE DATE: 06- 03 2016 MAIM • 46 0 1" • • This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART NAME OF PERSON(S) OR ORGANIZATION(S): City of El Segundo, its officers, officials, employees, agen,--s and volunz�eers 350 Main S,�reet El Segundo, CA 90245 1. WHO IS AN INSURED — (Section II) is amended to include the person or organization shown in the Schedule above, 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" on or for the project, or at the location, shown in the Schedule. The person or organization does not qualify as an addi- tional insured with respect to the independent acts or omissions of such person or organiza- tion. 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 a "written contract requiring insurance" for that additional insured, the insurance provided to the additional insured shall be limited to the limits of liability required by that "written con- tract requiring insurance ". This endorsement shall not increase the limits of insurance de- scribed 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 "properly damage" caused by "your work" and included in the "products- completed op- erations hazard" unless a "written contract requiring insurance" specifically requires you to provide such coverage for that additional insured, and then the insurance provided to the additional insured app!ies only to such "bodily injury" or "property damage" that oc- curs before the end of the period of time for which the "written contract requiring insur- ance" requires you to provide such coverage CG D2 47 08 05 0 2005 The St. Paul Travelers Companies, Inc. Page 1 of 2 COMMERCIAL GENERAL LIABILITY 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 a "written contract requiring insurance" for that ad- ditional insured specifically requires that this in- surance apply on a primary basis or a primary and non - contributory basis, this insurance is pri- mary to "other insurance" available to the addi- tional insured which covers that person or organi- zation 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 insurance', whether pri- mary, excess, contingent or on any other basis, that is available to the additional insured when that person or organization is an additional in- sured under such "other insurance ". 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: I. How, when and where the 'occurrence' or offense took place; ii. The names and addresses of any injured persons and witnesses; and Ili. 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 iii. 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 additionat 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. 5. 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 "bodi;y 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 47 08 05 Name of Person mrOrganization: The City of El Segundo, its officers, officials, employees, agents, and volunteers 350 Main Stzee-L El Segundo, C& 90245 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) damage arising out of your ongoing operations or "your work" done under contract with that person or organization and included in the "products- completed operations hazards." 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: DT22CC2505P068TCT1 ISSUE DATE: 06/03/2016 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED ENTITY - NOTICE OF CANCELLATION PROVIDED BY US This endorsement modifies insurance provided under the following: ALL COVERAGE PARTS INCLUDED IN THIS POLICY SCHEDULE CANCELLATION: Number of Days Notice of Cancell 30 PERSON OR ORGANIZATION: The City of 21 Segundo, its officers, officials, employees, agenzs and volunteers above. We will mail such notice to the address shown in the schedule above at least the number of days shown for cancellation in the schedule above before the effective date of cancellation IL T4 05 03 11 (0 2011 The Travelers Indemnity Company. Al rights reserved Page 1 of 1 t 1A1%T#trX&XM J NXnf ViVNIMT11 BUSINESS AUTO COVERAGE FORM VOTOR CA12,21ER COVETAGE FORV ADDITIONAL INSURED Designated Person or Organition: The City of El �a: �t:yr.:�a�, its officers, officials, employees, agents and Address: City of l Segundo 3S0 Main Street El Segundo, CA 90245 PROVISIONS 1. The following is added to Paragraph A.1., Who Is An Insured, of SECTION II — COVERED AUTOS LIABILITY COVERAGE: Any person or organization designated in the Ad- ditional Insured Schedule is an "insured ", but only with respect to liability for "bodily injury" or "prop- erty damage" caused, in whole or in part, by the acts or omissions of an "insured" under para- graphs A.1.a. or b. of SECTION I — COVERED AUTOS COVERAGES. 2. The following is added to Paragraph B., General Conditions, of the CONDITIONS Section: Notice of Cancellation to Additional Insured In the event of cancellation of this policy, written notice of cancellation will be mailed by us to that person or organization designated in the Addi- tional Insured Schedule. CA T3 01 02 15 020151Ihe Trave'ms lnderrnity Company. All rights reserved Page 1 of 1 Incly ides cooylglhted rrateria'. of Insurance Services Office, Inc, with ifs permission nis entorsemeni mou les insurance ♦ 1. r- i uffanTu- AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Forma ply unless modi- fied by the endorsement. SCHEDULE Narne(s) Of Person(s) Or Organization(s): The City of El Segundo, izs officers, officials, employees, agents and 350 Main S--reet El Segundo, CA 90245 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or or- ganization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization. CA 04 4410 13 0 Insurance Services Office, Inc., 2011 Page 1 of 1 7L',OLICY NUMBER: BA250SP06815CNS ISSUE DATE: 06/03 20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. '"—TMtTf I • arry ALL COVERAGE PARTS INCLUDED IN THIS POLICY SCHEDULE • 1� l PERSON OR ORGANIZATION: The City of El Segundo, its officers, officials, employees, agents and volunteers above. We will mail such notice to the address shown in the schedule above at least the number of days shown for cancellation in the schedule above before the effective date ♦ cancellation, IL T4TS 03 11 tD 21 11 The Travelers Indemnity Company. Al rights reserved. Page 1 • 1 This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM ADDITIONAL INSURED SCHEDULE Designated Person or Organization: The City of El Segundo, its officers, officials, employees, agents and volunteers Address: City of E1 Segundo 350 Main Street El Segundo, CA 90245 PROVISIONS 1. The following is added to Paragraph A.1., Who Is An Insured, of SECTION II -- COVERED AUTOS LIABILITY COVERAGE: Any person or organization designated in the Ad- ditional Insured Schedule is an "insured ", but only with respect to liability for "bodily injury" or "prop- erty damage" caused, in whole or in part, by the acts or omissions of an "insured" under para- graphs A.1.a. or b. of SECTION I — COVERED AUTOS COVERAGES. 2. The following is added to Paragraph B., General Conditions, of the CONDITIONS Section: Notice of Cancellation to Additional Insured In the event of cancellation of this policy, written notice of cancellation will be mailed by us to that person or organization designated in the Addi- tional Insured Schedule. CA T3 0102 15 © 2015 The Travelers Indemnity Company. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc. with its permission. ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS • :101 HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 1, 2016 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING JANUARY 1, 2017 AT 12.01 A.M. AT 1201 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME VASILJ, INC 15531 ARROW HWY IRWINDALE, CA 91706 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. THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 2.00% OF THE TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION BLANKET WAIVER OF FOR WHOM THE NAMED INSURED SUBROGATION HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER REP 09 9120705 -16 RENEWAL SC 4- 10 -64 -97 PAGE 1 OF 1 NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: JANUARY 5, 2016 AU I HORI PRESIDENT AND CEO SCSF FORM 10217 MEV_7-20144 2572 OLD OF 217