PROOF OF INSURANCE (2017) CLOSEDQ 1988-201A ACORD CORPORATION. All rights reserved.
ACORD 26 (2014101) The ACORD name and logo are registered marks of AC O
T�hlo by CWR on August 04, 2016 at 12.05PM
POLICY NUMFIER: MGLO16U3314
COMMERCIAL GENERAL LIABILITY
CG 2010 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This Andorsement modifier: inrumnrn provided under the rollowing,
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Npme Of Additional Insured parsons)
or or anikatlon ,
Where rmiluirrml by written contract or agreeament,
The City Of El Segundo And Its Employer's
iiq. I'll attain rr;girlreA to
A. Section 11 — who Is An Insured is 21TIonded to
include as an additional insured the p9rson(a) or
organi2atifin(s) shown in itle Schedule, but only
with respect to liability for "bodily injury", "property
darriage" or "persorial and advortising injury"
caused, in whoin nr in part, by;
Your acts or oinissions; or
2. Thq nets or ornlssions cif those: acting on your
behnit;
in tho parformance of your ongoing, operations for
the additional insureds) of the Io ltion(s) desiq-
1123ted no'vc.
Locations Of CovertclS
yLratlon,
All operations of the named insured
350 Main Street, El Segundo, CA 90245
S. With respect to the inrurtince 2tforaed to thovie
additional insureds, the following additional exclu-
sions apply:
This insurance does not apply to "bodily Injury" or
'property darnago" occurring after:
1. All worst, including materials, parts or equip-
ment tumished in connection with ruch work,
oo hies project (other than service, maintenonco
or repairs) to be performed by or on behalf of
the additional Insured(s) at the location of the
covered operations has 4een completed; or
2. That portion Of '"yOUT Work" out of wniah the
Injury or damage arises has gaen put to its in-
tended use by any person or 0r00nl2!00*ri eth-
er than another contractor or subcontractor
ongaged in performing operations for a prin-
cipai as a p8rt of tho came project.
CC 20 10 07 04 Q 180 Properties. Inc., 2004 Pace h of 1
r❑
DATE (MMIDD/YYYY)
AC 1"0 CERTIFICATE OF LIABILITY INSURANCE 08/04/2016
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).
Auto Club Services LLC Services
PRODUCER ......,..�,...... N� � E14ti.�89 -016 24 2,.. EIf?�,
Services, PHONE
3333 Fairview Rd - -�
Costa Mesa, CA 92626Ia A ....... INSURE_R .
.. SAFFORDING CORA0 mm _ -MIT
�rAlc
LIC # OF97770 _
"RR A : THE HARFO RD 22357 al
_. .
INSURED PRECISION REEF SYSTEMS — .... -
DBA CHISTOPHER HEPPELL INSuRERC: ....- ...... ............ _ �_...
7712 GODDARD AVE IM1ISIJRER D
LOS ANGELES, CA 90045
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 MAY HAVE BEEN REDUCED BY PAID CLAIMS.
.�._..... __ _ �.��.. .. wu��z..
INR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER PO%IQY IFF POLICY E3tP ..._ LIMITS
W M8
rrCOMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5
1
CLAIMS-MADE a OCCUR mmM aNfi _..
W__._. ED EXP (pn� one arson S
PERSONAp & ADV CIN�9.7FT1Y.....�� .- 5 ................................ ...............................
GEN'L AGGREGATE LIMIT APPLIES PER' GENERAL AGGREGATE $
POLICY I - +' JPE a LOC PRODUCTS COMP /0P AGG 5
OTHER. M 1 _ .
AUTOMOr31LELIABILITY COMd3XNEP15I GLFILIhRNT S f1I1r1 r�QI�V.
6CMI..- ..,_.. ..... _.... tl V
ANY AUTO BODILY
ALL OWNED NON-OWNED 72UECHA9382 08/01/2016 08/01/ 2017 °1300I�TYURY(Per accident) �
INJURY P arson)
AUTOS NON-O
DAMAGE A HIREDAUTOS Q AUTOS .. '. . m...
i
S
UM13RELLA OCCUR
- EACIHOCCURRENCE ... 5.
EXCESS - .
L�!CLAIMS -MApE AGGREGATE -S
. _ ........ --- ------- ........
QED RETENTIONS ;
WORKERS COMPENSATION PER OTH-
ANDEMPLOYERS'LIABILITY YIN STpT,U[E, �'R
ANY PROPRIETORIPARTNERiEXECUTIVE — E IL EACH ACCIDENT S
OFFICERIMEM NIA BER EXCLUDED? `_ " t °" ""'"'- """"
(Mandatary in NH) E L. DISEASE - EA EMPLOYEE S
If yyes, dd rrgtna under T �'
pESGRNPl'IL N OF OPERATIONS below E L DISEASE - POLICY LIMIT S
DESCRIP71ON OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
10 DAY NOTICE OF CANCELLATION ONLY APPLIES TO NON — PAYMENT OF PREMIUM
1999 FORD EXPEDITON 1 FMRU1 7L2XLA36147 WITH COMP AND COLL BOTH $500 DED
CERTIFICATE HOLDER CANCELLATION
City of El Segundo
350 Main Street
El Segundo, CA 90245
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED
1 &I1rR",ill ►�.I
1988-2114 ACORD CORPORATION. AI rl s reserved.
ACORD 25 (2014101) The ACORD name and logo are registered m s oCORD
CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000),
IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES.
I affirm under penalty of perjury under the laws of California one of the following declarations:
(_J I have and will maintain a certificate of consent of self- insure for workers' compensation, issued by the Director
of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement
with the City of El Segundo.
Policy No.
(_)1 have and will maintain workers' compensation insurance as required by Labor Code § 3700 forthe performance
of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance
carrier and policy number are:
Carrier
Name of Agent
Policy Number Expiration Date
Phone #
(S/1 certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not
employ any person in any manner so as to become subject to the workers' compensation laws of California, and
agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must
immediately comply with tho ,pwa visjdr s of the agr ;; anent will autgniatically become void.
Signature of Applicant
Agreement for:' C
. .
Dated: °f
Reviewed b
Date