PROOF OF INSURANCE (2017) CLOSEDACCOR CERTIFICATE OF LIABILITY INSURANCE DATE 09/15/20D 16
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.
IMPORTANTt If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) 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 rl hts to the certificate holder in lieu of such endorsement s .
PRODUCER DEG Smith
Jacobs- Weber, Inc, P� 381 546 4209 (381} 293 -3074
P.O. Box 87 ( ) a jig
Yoakum, TX 77995 rs 5 Jacobs- webencom
_
INSURE 91 AFFORDING COVERAGE NAIC N
_W V11111 Arch Insurance Company 11150
_.�
INSURED Fire Service Specifications & Supply (OBA- FS3)
Frank Lane
18882 Beachmont Avenue INSURER c
Santa Ana, California 92705 INS Rio: - - -- ••••••- - - - - -•
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.
N P I Y E LIMITS
TYPE OF INSURANCE POLICY N M LIMITS
A COMMERCIAL GENERAL LIABILITY Y MFPK0856M 05/23/2016 5/23/2017 1 EACH OCCURRENCE s 1,000,000
FOl1 s
CLAIMS-MADE V OCCUR P _ .... 100,000 .._� -
MED EXP An one person) S 5,000
PERSONAL A AOV INJURY $
OEN't,AGGR;EGATELIMITAPPLIESPER: S 2,000,000
GENERAL AGGREGATE
POLICY 0 JPERC E LOC PRODUCTS - COMP/OP AGG !_2.000,000
t
THEk
A AUTOMOBILE LIABILITY Y MFPK06563000 05!23/2016 05/23/2017 RUIN0 SWGLE Lu I s 1,000,000
ANY AUTO BODILY INJURY (Per n) $
OWNED SCHEDULED BODILY INJURY (Per accident) S
AUTOS ONLY AUTOS
HIRED NON -OWNED R P DAMAGE S
AUTOS ONLY AUTOS ONLY RPor adarl4f „ITIT,,,�.
S
UMBRELLA LUIB OCCUR EACH OCCURRENCE $ -„
EXCESS LU1B CLAIMS- MADE AGGREGATE S
RETENT1914 S0 S
WORKERS COMPENSATION H
AND EMPLOYERS'' IA9ILITY YIN
ANY OFFRO�E R IET EXCLUDED? ARTNE EOU'T E E.L. EACH ACCIDENT _ S
NIA
(Mandatory In NH) E.L. OISEASE EA EMPLOYEE S __
tld a daacrt o Undier
0 RIPTI N OF OPERATIONS b0ow I I I E,L, DISEASE -POLICY LIMIT S
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, AddManal Remarks Schedule, may be attached If more apace Is required)
The City of El Segundo, its officers, officials, employees, agents and volunteers are listed as an additional Insured under the endorsement CG2010. Coverage Is
primary and non - contributory under the endorsement CG2001. A written notice of cancellation to the city Is Included under the endorsement ML0088.
I _�L" I
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of El Segundo, its officers, officials, employees, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
agents and volunteers ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
El Segundo, TX 90245 -3813 AUTHORIZED REPRESENTATIVE
I G�'[� Jam•
01986 -2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER:MFPK08583000
COMMERCIAL GENERAL LIABILITY
CG 2010 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
1i • II •
tie
•
This endorsement modifies insurance provided under the following;
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)
designated above.
However.
1. The insurance afforded to such additional
insured only applies to the extent permitted by
law; and
2. If coverage provided to the additional insured is
required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
B. With respect to the insurance afforded to these
additional insureds, the following additional
exclusions apply:
This insurance does not apply to "bodily injury" or
"property damage" occurring after:
1. All work, including materials, parts or
equipment 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
intended use by any person or organization
other than another contractor or subcontractor
engaged' in performing operations for a
principal as a part of the same project.
CG 2010 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 2
C. With respect to the insurance afforded to these
additional insureds, the following is added to
Section III — Limits Of Insurance:
If coverage provided to the additional insured is
required by a contract or agreement„ the most we
will pay on behalf of the additional insured is the
amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the
applicable Limits of Insurance shown in the
Declarations.
Page 2 of 2 ® Insurance Services Office, Inc., 2012 CG 2010 0413
COMMERCIAL GENERAL LIABILITY
CO 20 010413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
B Or
This endorsement modifies Insurance provided under the following:
CO 20 01104 13 ® insurance Services Offlce, Inc., 2012 Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
NOTICE OF CANCELLATION - CERTIFICATE HOLDERS
The person(s) or organization(s) listed or described in the Schedule below have requested that they
receive written notice of cancellation when this policy is cancelled by us. We will endeavor to mail or
deliver to the Person(s) or Organizations) listed or described in the Schedule a copy of the written notice
of cancellation that we sent to you. Such copies of the notice will be mailed as soon as practicable to the
address or addresses provided by your broker or agent.
This notification of cancellation of the policy is intended as a courtesy only. Our failure to provide such
notification to the person(s) or organization(s) shown in the Schedule will not extend any policy
cancellation date or Impact or negate any canceilation of the policy. This endorsement does not entitle
the person(s) or organization(s) listed or described in the Schedule below to any benefit, rights or
protection under this policy.
Any provision of this endorsement that is in conflict with a statute or rule is hereby amended to conform to
that statute or rule.
Schedule
Person(s) or Organizatlon(s) including mailing address:
350 Main Street
City of El Segundo El Segundo, CA 90245
All other terms and conditions of this policy remain unchanged,
Endorsement Number: 1
Policy Number: MFPK08563000
Named Insured: Fire Service Specifications & Supply
This endorsement is effective on the inception date of this Policy unless otherwise stated herein:
Endorsement Effective Date: September 15, 2018
00 ML0086 00 1110 Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
POLICY CHANGES
POLICY NUMBER
MFPK08563000
NAMED INSURED
Fire Service Specifications & Supply
COVERAGE PARTS AFFECTED
Commercial Lines Policy Coverage
Policy Change
POLICY CHANGES COMPANY
EFFECTIVE
09/15/2016 Arch Insurance Company
AUTHORIZED REPRESENTATIVE
McNeil & Company, Inc,
CHANGES
We have hereby ADDED form CG2010 (04/13), Additional Insured - Owners, Lessees or Contractors - Scheduled Person or
Organization and 00 ML0086 00 (11/10), Notice of Cancellation - Certificate Holders, on the above policy
to Include the following:
City of El Segundo
350 Main Street
El Segundo, CA 90245
*Please see attached
Premium Change
terms and conditions
dt 9/16/2016"`
IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983
Copyright, ISO Commercial Risk Services, Inc,, 1983
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:
(_) 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
(_) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the 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 Policy Number Expiration Date
Name of Agent Phone #
())6 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 revisions the agre nt will automatically become void.
Signature of Applicant �' �' Date
y
Agreement fork
Dated: Of
Reviewed by: " "/�