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PROOF OF INSURANCE (2017) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/VYYY) 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 have ADDITIONAL INSURED provisions or 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 g Partners enter (EPIC) CONTACT 9000 MacArthuBlvd. PH Floor OH ..Xta, ..sas 263 oso6 ... ...fAX Irvine, CA 92612 ; ? ,jkq,.N�)...... (949),263-090 MAIL City O E( Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Department Of Public Works ACCORDANCE WITH THE POLICY PROVISIONS. 156 Illinois Street El Segundo CA 902453813 AUTHORIZED REPRESENTATIVE Ton D Asaro ©1988 -2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 28865618 1 16 -17 GL /UMB AI MAIN MASTER I Ginny Hattan 1 3/4/2016 3:41:21 PM (PST) I Page 1 of 3 INSURER(S) AFFORDING COVERAGE ___ NAIC #_______ www.edgewoodins.com ......._.. _..._ ,__ ----- - - - - - -- ---------- ---- -- — -- -- INSURERA_ „Rockhlll Insurance Company 28053 INSURED INSURER B Robert's Liquid Disposal 14018 Carmenita Rd. INSURERc ...................... ..................... -_ ..... Santa Fe Springs CA 90670 INSURER o INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 28865618 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......., S LTR TYPE OF INSURANCE INSO ✓ WVQ POLICY NUMBER MWDDIIYYYY MM DINYYYY LIMITS A yA' COMMERCIAL GENERAL LIABILITY ENVP01272301 3/5/2016 3/5/2017 EACH OCCURRENCE ''. $ 1,000,000 CLAIMS -MADE OCCUR P(2Etv1(SES Fa occi.(�rence) $ 50,000 MED EXP (Any one person) $ 5,000 PERSONAL &ADVINJURY $ 1,000,000' _ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 ✓ ..— POLICY JEC"r LOC PRODUCTS COMP /OP AGG $ 2 +000+000. ... O'rFIER' $ AUTOMOBILE —,. LIABILITY COMBINED oD SINGLE LIMIT I E a $ ..... ...... . ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS ONLY ........................ AUTOS HIRED NON -OWNED PROPERTY DAMAGE AUTOS ONLY ,.,.,. AUTOS ONLY („Per acri,danl. $ A UMBRELLA LIAB OCCUR ENVP01272501 3/5/2016 3/5/2017 EACH OCCURRENCE 0 $ 4 000 0 O ✓ EXCESS LIAB CLAIMS -MADE AGGREGATE $ 4,000,000 DID ✓ RETENTION$10 OOO WORKERS COMPENSATION STARTUTE GRH_ AND EMPLOYERS' LIABILITY YIN ,— ' ANYPROPRIETOR/PARTNER/EXECUTIVE E.LEACH ACCIDENT $ OFFICER /MEMBER EXCLUDED? NIA -” E.L. DISEASE - EA EMPLOYEE $ (Mandatory In NH) If yes, describe under _ DESCRIPTION OF OPERATIONS. below ''. E.L. DISEASE -POLICY LIMIT $ A Pollution Liability ENVP01272401 3/5/2016 3/5/2017 $5,000,000 per rccurrence /Aggregate Limit Transportation Pollution Liability $5,000,000 per Occurrence /Aggregate Limit DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder is named as additional insured as respects the general liability, but only if required by written contract with the named insured, prior to an occurrence, per form CG 2010 07/04. Subject to all policy terms and conditions. CERTIFICATE HOLDER CANCELLATION City O E( Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Department Of Public Works ACCORDANCE WITH THE POLICY PROVISIONS. 156 Illinois Street El Segundo CA 902453813 AUTHORIZED REPRESENTATIVE Ton D Asaro ©1988 -2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 28865618 1 16 -17 GL /UMB AI MAIN MASTER I Ginny Hattan 1 3/4/2016 3:41:21 PM (PST) I Page 1 of 3 AGENCY CUSTOMER ID: LOC #: AC"RV � ADDITIONAL REMARKS SCHEDULE AGENCY NAMED INSURED Edgewood Partners Insurance Center EPIC k ocrt's Liquid Dispposal ............................... .. 1401F. Carmenita Rd. POLICY NUMBER Santa Fe Springs CA 90670 CARRIER I NAIC CODE EFFECTIVE DATE: Page of ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ADDENDUM 28865618 1 16 -17 GL /OMB AI MAIN MASTER I Ginny Hattan 1 3/4/2016 3:41:21 PM (PST) I Page 2 of 3 Robert's Liquid Disposal 3/4/2016 POLICY NUMBER: ENVP01272301 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 Organization s City of El Segundo Department of Public Works 150 Illinois Street El Segundo CA 902453813 Location(s) Of Covered Operations Information re uired to com lete 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. rtWI M 1 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. 28865618 1 16 -17 GL /UMB Al MAIN MASTER I Ginny Hattan 1 3/4/2016 3:41:21 PM (PST) I Page 3 of 3 Page 1 of 1 ❑ DATE (MMIDD /YYYY) '�"'�"`R CERTIFICATE OF LIABILITY INSURANCE 08/01/2016 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(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 NAME: Judy Beth Bettger Insurance Agency, Inc. PHONE 562 496 1000 FAX N�) 5 2 809 955x9 taje 3r 20220 State Road E-MAIL ADDRESS, JtjrJy.@bett'ibeitger.com .... Cerritos, CA. 90703 INSURER(S) AFFORDING COVERAGE NAIC # INSURED RQbert.. _ .... ... .. ............. .... _..,.................. INSURER A :State Farm Mutual Automobile Insurance Company 25178 & Peggy Her'ricks — INSURER e ; __- ...: _ _ __ ___ DBA Roberts Li q uid Dis p osal INSURERC 14018 Carmenita Rd INSURER D ... .. m .. , ...... ........... ...... ...... Santa Fe Springs, CA 90670 -4919 INSURER E INSURER F t. 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. ..�....... ...,,_...,_ .,._....._._...,_...,._.._..... - -- — nt -- -ML � 0 _. .. OLICY EFF POLICY EXP .... .... LIMITS.. .... YNSR TYPE OF INSURANCE POLICY NUMBER MM /DDIYYYY MM /DD/YYYY '.. t.TR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ..... _._..., _ C1AA� "'1"ia"I'0'rL� ....... CLAIMS -MADE � .- OCCUR PR£.hCSE',S (Eararcraprenre) MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY � PRO ❑ LOC PRODUCTS COMP /OP AGG $ �,....... JECT .... OTHER, jEaaccdenfJ.IN LE LIMIT ........... ... .............................00 AUTOMOBILE LIABILITY $ 2,000,000 ............ ANY AUTO m,.y.... 403-0161- D21-75Y 04/21/2016 10/21/2016 BODILY .INJURY(Perperson).....$.... ....... .. X,,,,, AUTO OWNED SCHEDULED BODILY INJURY (Per accident) $ NON -OWNED P73- 6862- A06 -75Q 07/06/2016 01/06/2017 pROpgf HIREDAUTOS Pera d AUTOS . �T'Y DAWkbf $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE ..AGGREGATE .................................$.................................. ............................... DED — ....RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN . STATUTE ERH ANY PROPRIETOR /PARTNER /EXECUTIVE N/A 1 E.L.. EACH ACCIDENT $ OFFICEWMt'MBEREXCLUDED? ._.1 --- --- - -- ...(Mandatory kn NH) E L.. DISEASE - EA EMPLOYEE $ 0 es describe under m..,._....._ ,...._,.._. - -- -- . .. ............_ _.... -._ t� SCRIi "1 "IION OF' OPER;AI "VON$ boNow EL DISEASE- POLICY LIMIT $ DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION' City Of El Segundo /Public Works Dept. 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 25 (2014/01) The ACORD name and logo are registered marks of ACORD 1001486 132849.9 02 -04 -2014 POLICYHOLDER COPY SC P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 08 -01 -2016 CITY OF EL SEGUNDO, PUBLIC WORKS DEPT SC 350 MAIN ST EL SEGUNDO CA 90245 -3813 GROUP: POLICY NUMBER: 1446891 -2015 CERTIFICATE ID: 245 CERTIFICATE EXPIRES: 12 -31 -2016 12 -31- 2015/12 -31 -2016 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer,. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this cer'tHicate: of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative President and CEO UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' COMPENSATION LAW. EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS:, $1,000,000 PER OCCURRENCE. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 12 -31 -1998 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2016 -08 -01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO, PUBLIC WORKS DEPT EMPLOYER HERRICKS, ROBERT LEE (II) AND HERRICKS, PEGGY LEE DBA: ROBERT'S LIQUID DISPOSAL 14018 CARMENITA RD SANTA FE SPRINGS CA 90670 [ERG,CS] IREV.7-2014) PRINTED : 08 -01 -2016 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION REP 02 1446891 -15 RENEWAL SC 1- 37 -56 -44 PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE AUGUST 1, 2016 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING DECEMBER 31, 2016 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME ROBERT'S LIQUID DISPOSAL 14018 CARMENITA RD SANTA FE SPRINGS, CA 90670 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF EL SEGUNDO, PUBLIC WORKS DEPT WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, ROBERT'S LIQUID DISPOSAL IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL 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: AIJ'1'I�ORd�l:9 REPRESENT IVE' SCIF FORM 10217 IREV.7 -2014) AUGUST 3, 2016 AL - J/"- - , , PRESIDENT AND CEO 2570 OLD DP 217 WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation: 1. Please be advised that a waiver of subrogation requires that a 3% surcharge will be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certificate holder who requested the waiver. (Note: if you have no employee payroll on that job, then there is no charge.) 2. To apply the 3% surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work on job /s for the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. Example: Payroll for job: $5,000.00 Sample Rate: 13.30% Regular Premium equals: $ 665.00 Surcharge: 3.00% Additional Waiver charge: $ 19.95 Total premium equals $ 684.95 (665.00 + 19.95)