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PROOF OF INSURANCE (2017) CLOSEDL A Y N E- 2 ........................ O P.... I �. :.....S. F DATE (MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 07/28116 _ .. _........ ............... THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER ..... ..... 925 - 977 -9220 CONTACT SAME, Walnut hew Way A 94597 925 - 977 -9224 Easterly Sure & Ins.Svcs.lnc PHONE 1 r nc u, fmxtl• V 4a.ICd Nra9 E MAIL Kevin P. Easterly ADDRESS: 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR �. A�iIL. sOI�R .... ......9 POL IC Y -EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE 1LJ.S j mm POLICY NUMBERm�mmmmmmm „ 9 „�MM /IIRR YYI �MMIDDIYYYYI GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000' 0 MAXOr °TIDACN[TC %a .. ............................... X X 00528484 04/14/16 04114/17 pllf ISf°SM,M.mocc�,in%9 $ A X COMCLAIMS- ... 50,000 ..._. .. [.. MADEERXLIABILITY 1 OCCUR MED EXP,(Any one person) $ 12000 . PERSONAL & ADV INJURY $ ..... 1,000,000 ......... ................... ... ........ ....... GENERAL AGGREGATE $ 2,000,00 0 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP /OP AGG $ 2,000,000 ,_ ... ..,.. . ........ YT $ Ir LOC .. .... .,..,..,..,,�, AUTOMOBILE LIABILITY Ea aceid.... M I eb 8 NGLE LIMI.7"........ G ... � .... .............................. ..... . ANY AUTO BODILY INJURY (Per person) $ �. ALL OWNED ........e.. SCHEDULED BODILY INJURY ...... ............................... JURY (Per accident) $ ,........ ......... OS AUTOS AUTOS NON OWNED PROPERTY DAMAGE HIREDAUTOS AUTOS (Per.�c4Jn1) • ..... ... $ UMBRELLALIAB X OCCUR EACH OCCURRENCE $ 4,000,000 A X EXCESS IAB CLAIMS -MADE XL660370004 04114/16 04/14/17 AGGREGATE $ 4,000,000 DED.- ....... .a„aa w„ ...._ ... ....... .....�.. ,,.,.._.... ._. ? ........_.......... _...... ...... .._,�,., COMPENSATION I .I.... I X GFR; AND EMPLOYERS' IABNTION$ L l ! f Y/ N X 9088031 02/01 /16 02/01/17 E.L.. EACH ACCIDENT $ B PROPRIETOR/PARTNER/EXECUTIVE EACH CID 1,000,000 OFFICE ER EXCLUD? N / A If es, descnbe under DESCRIPrTIION OF OPERATIONS below.....❑ mmmmmmmIT ........ m E L DISEASE POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Add ................� D 101, Additional Remarks Schedule, if more space is required) PROJECT: WATER DIVISION CARPET REMOVAL AND REPLACEMENT. JOB NO. 13 -21. CITY OF EL SEGUNDO, ITS OFFICIALS AND EMPLOYEES ARE NAMED AS ADDITIONAL INSURED PER THE ATTACHED ENDORSEMENT FORMS CG2010 0704 AND CG2037 0704. THIS INSURANCE IS PRIMARY AND NON — CONTRIBUTORY. WAIVERS OF SUBROGATION APPLY. *10 DAYS NOTICE OF CANCELLATION FOR NON — PAYMENT OF PREMIUM _.__ ...... _. ------- .. —...W W W .. CERTIFICATE HOLDER CANCELLATION W W ....... W W_ . . ELSEGUN 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. 350 MAIN ST EL SEGUNDO, CA 90245 AUTHORIZED REPRESENTATIVE ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 00052848 -4 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following :: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organizations : Locations Of Covered Operations Blanket where required by written contract Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury ", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) desig- nated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a princi- pal as a part of the same project. CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ POLICY NUMBER: 00052848 -4 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location And Description Of Completed Opera - Or Organization(s): tions Blanket where required by written contract _ ........... Information required to com lete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organiza- tion(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location desig- nated and described in the schedule of this endorse- ment performed for that additional insured and included in the "products- completed operations hazard ". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON CONTRIBUTORY ENDORSEMENT This endorsement modifies insurance provided under the following: ALL COVERAGE PARTS Any coverage provided to an Additional Insured under this policy shall be excess over any other valid and collectible insurance available to such Additional Insured whether primary, excess, contingent or on any other basis unless a written contract or written agreement specifically requires that this insurance apply on a primary and noncontributory basis. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED, AP5031 US 04 -10 Page 1 of 1 POLICY NUMBER: 00052848 -4 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF' SIG TS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Where required by written contract or written agreement Information required to complete this Schedule. if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products - completed operations hazard ". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 0 Insurance Services Office, Inc., 2008 Page 1 of 1 0 CERTIFICATE OF LIABILITY INSURANCE DATE MWJDDIWM 03/01/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERI S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the plollcy(les;) 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 lien of such endorsoment)s PRODUCER a ued.' R{ mDn Waafi REMON WASFI PHONE 310- 3221132 ° 310 -640 1057 E�Ia. t ire! StateMmi 432 MAIN ST a4alremOnYlaEf,k0w3a stawtefarltlCom EL SEGUNDO, CA 90245 w IHSUsiAFCaeaNOCOV�ruoE� NAIC� w INSURER A :State Farm General Insurance Company 25181 ........ ............ _mmw_ .....................e .. . INSURED CC LAYNE & SONS 14SUMRB: 213 RICHMOND ST. INSURERC: EL SEGUNDO, CA90245 — 3719 NS ®f Bp{URER E ; L__1 B'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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. ­_ U m _.... / uwr ..... _- . ....w.....�.., .......� ... .. ......ww..ww ....... ., uw►r�ce..�,,,,,�..� TYPE OF INSURANCE wwo LIMrTB A COMMERCIAL GENERAL LIABILITY Y EACH OCCURRENCE S „ a. E' S CLAIMS-MADE Pial.��r MED EXP � ons persons PERSONAL B ADV INJURY S GENIL AGGREGATE LIMIT APPLIES PER: GENERAL AOGRECiATE f POLICY JET FI LOC PRODUCTS COMPIOPAGG S _..... m .- ... AUTOMOBILELaeILm 4461661- C26 -75C 03/26/2016 03/28/2017 = 1,000,000 ANY AUTO 211 9366- C26 -75Y 0312612018 03128/201 BODILY INJURY (Per person) $ 1 000 000 7 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per eedderd) S 1,000.000 470 7367- C26 -75B 03126/2016 03/2612017 HIRED AUTOS NON-OWNED AUTOS OFiAWAF S 1,000,000 322 6646- C26 -75F 03126/2016 03/2612017 s UMBRELLA LIM OCCUR EACH OCCURRENCE 6 EXCES8 LIAa CLAIMS- MADE AGGREGATE $ D O RETENTION S WORKERS COMPENBATWON ' AND EMPLOYERS' LIABILITY YIN ANY PROPRIE 40RIPARTNERIEXECVTNE NIA ACE/ AEMf REXCLU 'D'I _E L EACH ACCIDENT S . (Mendalowy In NN) E L DISEASE - EA EMPLOYE S .. _ .. aly ie do doe QESIrIP'raON� OP'I RA7`IONS E L. DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarke Schedule, may be attached X more space le required) ADDITIONAL INSURED: THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS AND VOLUNTEERS AS ADDITIONAL INSURED. CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 MAIN STREET I`, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EL SEGUNDO, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. I AUTHORMO REPRESENTATIVE ®1988.2014 ACORD CORPORATION. All rights reserved. ACORD 28 (2014101) The ACORD name and logo am registered marks of ACORD 1001486 132849,9 02 -04 -2014 DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 03/01/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) 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 endorsemen s . PRODUCER cgrjACTRemjo n Wasfi REMON WASFI PH 'M 310 -322 1132 1 Sgt 310-640-1057 432 MAIN ST f remon NsufRE0 a tatef r n,com EL SEGUNDO, CA 90245 1 ...� ...................�... �,.._ ! ...µ._. RAGE ....,.,..�..mNAIC n INSURERA:State Farm General Insurance Company 25161 ...mm.... .� . . . ........ ............................... ... -_ .�wwww ....._.._ ..... INSURED CC LAYNE & SONS INSURERB, 213 RICHMOND ST. INSURERC:...__� _.., w .....w_._...�._. .._...��_......... ....... �.......��....._ .. INSURER . D. � ......................... , ......�..,.................... .u,....,' °'.___......._. ._,....,...... ............ ............................... EL SEGUNDO, CA90245 - 3719 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. . ....�,........ .i�._....� .. ...............��.............. ".S .� .. -..,. ..��.� �_� � ._ .... ........ --- ........ P'M�LI�y���F�� ��'Li�4`W��S4+. .: LTR INSO TYPE OF INSURANCE PD1.I NUMBER A LIMITS A COMMERCIAL GENERAL LIABILITY Y EACH OCCURRENCE $ �.... CLAIMS IVI X °a OCCUR .CAN"lICE "'GO PiEr�l°E �. -MADE MEO EXP (An one person S PERSONAL & ADV INJURY S ........_......�. -...._ .........._. ... .....,..,a.�,,.�...._. GEtlV`LAGGRE'QAT9E.LIMIT APPLIES PER.............. GENERALAC,GREDATE E F POLICY .... JT LOC PRODUCTS COMP /OPAGG S r'ti111R _.. $ AUTOMOBILE LIABILITY. mm 284 5408- C26 -75H COMSMED SINGLE LpI ,.....,m.� ...,...... 03!26/2016 03!26/2017 :1i_ S 1 000 000 ANY AUTO BODILY INJURY (Per person) $ ALLOWNED SCHEDULED AUTOS -OWNED dent) BODILY INJURY Perm NON PRIWIRTYi7AMAd� E HIRED AUTOS AUTOS .,1a.�lli .. „.�..... ....... ..., a UMBRELLAUAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS- MADE. AGGREGATE $ DED RETENTION S S WORKERS COMPENSATION... PE. AND EMPLOYERS' LIABILITY YIN °°” _$W; " " ""°°°.......,. '" ... "" .... .." ANY BNEH EXCLUDED? NIA F dER,U kt E L DISEASECIEA EMPLOY S S GPat r D GkRIP'Tt P 0'PERATIDN k ,. „. F s.., o�.ro ..... ... m.� ................ E L DISEASE POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached K more space Is required) ADDITIONAL INSURED: CHEVRON USE INC., AND ITS SUBSIDIARIES AND AFFILIATES NAMED AS ADDITIONAL INSURED. CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 MAIN STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EL SEGUNDO, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ®1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014101) The ACORD name and logo are registered marks of ACORD 1001486 132849.9 02 -04 -2014 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION 9088031 -16 RENEWAL NA 0- 23 -53 -02 PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE FEBRUARY 10, 2016 AT 12.01 A.M. AND EXPIRING FEBRUARY 1, 2017 AT 12.01. A. M. ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME C C LAYNE & SONS INC 213 RICHMOND ST EL SEGUNDO, CA 90245 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWI "IIiSTAIDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF EL SEGUNDO WHICI °I M'IG:1Frr Al�'ASE BY REASON OF Atrl PA YMEIll- i,ll1DER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, C C LA't'"NE & SONS INC IT IS FUFl.I"IIER AGREED THAT TIDE INSURIED !.',ffAL.L MAINTAIN PAYROLL RECORDS A(.'I'IJ RATE LY :" I..I..,I "E`0A °I°ING THE REMIJNER o -I;OIu OF EMPLOYEES Willf -E ENGAGED IN WORK FOR '111Ew "" ABOVE EMPLOYER. r IS FURTHER AGREED "IIIA'4 PREMIUM ON Tl'lE EARNINGS OF SUCH EMPLOYEES SMALL BE INCREASED BY 03%. 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: AI�11 "�(1114"I~:L'b I�EPR'I:SN I• N "IVL. SCIF FORM 16217 I EV,7- 20141 FEBRUARY 11, 2016 PRESIDENT AND CEO 2570 r