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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
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7033 Owensmouth Avenue t � ,._...,._,........ mm - -
Canoga Park, CA 91303 -2006 INSURERA: aN�sDaarRSJAEGaINr�vrR BAICA
g �������RERA:................ Travelers Indemnity Co of CT 256 2
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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
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AN I I 61,000,000
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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