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PROOF OF INSURANCE (2017) CLOSED
" 0 ", DATE(MMMDIYYM CERTIFICATE OF LIABILITY INSURANCE 811212016 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 PRODUCER "'U""' i Irene Garcia m. TIB Transportation Ins Brokers PHONE 6t6.246 250 425 West Broa�iwYa , Suite 400 dAll..1WB Ex11 _ 1,Ne1..... Glendale CA 0120 DDIE6s.. .... ...... _ pn1 1 arola I Iras�frerroCe _ ;26077 INSURED INLAN -1 Inland Empire Slates Ltd, 9567 Eighth Street Rancho Cucamonga CA 517304504 s 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. TYPE OFINSURANCE t.... k POL A[ X ( COMMERCIALGENERALLIABIUTY Y I Y i GL1561OM14 c,.. CLAIMS-MADE OCCUR GEN`L, AGGREGATE LIMIT APPLIES PER: POLICY J EC E::l LOC OTHER AUTOMOBILE LIABILITY Y I Y W BA157040#14 ANY AUTO T03 EU X kIJ � g 1 A� p� pyUp EO N NL 111-4 X i HIREDAUTOS f X, 9 I4CD AUTOS UMBRELLA LIAR I I OCCUR q m� EXCESS LIAB yky r_i aiue uene� 'ICERS COMP ERSAMON EMPLOYERS' LIABILITY PROPR10ORMAR "6'NERPEXE,C'U�TNt YIN F ca"IP'a,EMSER exc'.,UU'E01 �N NIA I CaTP T-1 813112016 18/31/2017 8/3112016 1 8/31 /2017 LIMITS I'Sr�FJt"�r,telawdeml S BODILY (PerOccidenu 9 IS EACH OCCURRENCE S AGRREGAE rS E L. DISEASE , EA E 4 S CH ACC EL 01 SE AS E. POlCYUMIT[S DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be anachad If more space Is required) THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS AND VOLUNTEERS ARE ADDED AS ADDITIONAL INSURED BUT ONLY TO THE EXTENT THAT THE CERTIFICATE HOLDER IS HELD LIABLE FOR THE CONDUCT OF THE NAMED INSURED. "WAIVER OF SUBROGATION APPLIES "'THIS POLICY IS PRIMARY AND NON- CONTRIBUTORY" POLICY NUMBER: GL156100#14 COMMERCIAL GENERAL LIABILITY CG 2010 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, L SSES OR CONTRACTORS - SCHEDULED PERSON OR ORGA NIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Locations Of Covered Operations City of El Segundo Parks & Recreation 350 Main Street Room 5 El Segundo, CA 90245 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 B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage" or "personal and advertising injury" "property damage" occurring after: caused, in whole or in part. by: 1. All work, including materials, parts or 1. Your acts or omissions; or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work" out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization Insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of the same project. 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. CG 20 10 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 2 GU 207 (AIII (Ed. SIO This endorsement, effective on 08/31/16 at 12:01 A.M. standard time,forms a part of Policy No.BA157040#14 LANCER INSURANCE-COMPANY ■ 1 9 (Name of insurance compang It is hereby understood and agreed that the following is added as Additional insured only with respects to operation • the named insu�-e• Name: City of El Segundo Parks & Recreation 350 Main Street Room 5 El Segundo, CA 90245 ISSUE DATE: 08/31,/16 Page 1 0 f 1 (Ed®6 -7 ) CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 9/28/2016 999tow TE IS ISSUED AS A MATTER OF INFORMATION ONLY AND C ONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS OES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED VE OR PRODUCER, AND THE CERTIFICATE HOLDER the certificate holder is an ADDITIONAL INSURED, the policy 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 —rFS f� nta hntrlrrr in lieu of such endorsementg .. _.... ,...., -. PRODUCER - �C4idC� Qdrr. - �.-"�" ... FAX IB Transportation Ins Brokers PHrrNr �I 818 246 2800 �..� �c «.Nr�« 818-246-4690 � 425 West Broadway, Suite 400 r -MAIL om Glendale CA 91204 oatlles an axatikalrnsLFrance c ..._ NAIC # INS�UR . t'i, �R_ INSCSR s AFOR G....E e jl c ndem qo Of America.. ....�._m .-.�.- �. �. 2.2.�..179 _ ..�.. .��. INSURED ,,,,.,..... ....__........._._.........,�., . �........, ........_... ....A..._� � . _ .. INLAN -1 . .am ,. —..n_ ....— ...�.. ..w._...n.,_...m._ —._.. _ m. - ..... ...._._ i�r�uRrmaa�:m.� - ....�. Inland Empire Stages Ltd. -_w------- .___ ... — ...._ ..... 9567 Eighth Street D ..._.._.w_.. Rancho Cucamonga CA 91730 -4504 INSURER E: CER'rlFICA1 "E NUMBER: 546294272 i EVtlSI 1&� I�iLIMDER:,_ COVERAGES THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POtl.,ICY PERIOD WHICH THIS THIS IS TO CERTIFY ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO INDICATED. NOTWITHSTANDING BED THE INSURANCE AFFORDED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE ISSUED LRIBE PAID CLAIMS. CONDITIONS OF SUCH POLICIES. CITE LIMITS SHOWN MAY HAVE BEEN REDUCED BY ANDYCON ER ONS � ....._ v EXCLUSIONS . �. Y LIMITS INS TYPE OF INSURANCE POLICY NU'I:PIFJER MMCDIGVYYYY MMIfoDkY'Y'YY COMMERCIAL GENERAL LIABILITY EACHOC(,URRENCE ('wAMA OCCUR ,.... � Ea ncCS�ieresr,P,r �� REm�1IS i �.. mm� CLAIMS -MADE MED_iSr IA. y�onef PERSONAL .-- .��.�... &ADVINJU,RY .., '..w,.— ,....�........A.._...m ...m_ '. e..m, _ ....._� ,.........._,�m_�...� AGGREGATE $ GENERAL A 'E LIMIT APPLIES PER: ('; L;N L AGGREGATE PcILRCY' E � JECT 1:1 LOC COMp3P AC 6 S' _-. _.. -.� OTHER: ��' AUTOMOBILE LIABILITY LF BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per a DIL INJURY(Pe accident) 5 .� AUTOS NON-0WNED ..,. Peg Oex.aKIeI'Yt HIRED AUTOS AUTOS UMBRELLA LAB OCCUR AEGA'Llk+"RFNCE. EXCESS LAB CLAIMS -MADE '_ ^^^G L ...... . . _ .�.,..m... _. Dfi S7 RLTETI N 5 Y 10/1 /2016 10/112017 WORKERS COMPENSATION 15669015 J E 4 NTIi ST FE _ t � _ EMPLOYERS' LIABILITY A AND EMP YIN � 51 uI•I'rl 000 E L. EA .g ACCIDENT 1 p — ANYP ROIDRRETOF UPAR'rNIRtExF:C.UTIVE "" C"I'FFiCEfkffl Nkr 8E-',R EXC'LhtVfiEfp"^ N I A .... ..'� .... DISEASE EA EMRII &YYE S1 000 OOG (Mandatory in NH) i � . C q UISEA E A.f Y I,MI "r SU 000,001 DtSCR PTON (.)F 0P:RAIION- 0W DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Officer Exclusion Applies - Curtit3 Basey, Nicole Basey, Steve Mahan ,. CERTIFICATE HOLDER _ CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo Park & Recreational THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main St Room 5 ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo CA 90245 AU #ORAZED REPRESENTATIVE ©1988 -2014 ACORD CORPORATION. All rights reserved, ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 0313 (Ed. 04-84) p WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule State Person or Organization Job Description California City Of El Segundo All Operations Park & Recreational Attn: City Clerk 350 Main St Room 5 El Segundo, Ca 90245 The additional premium charge for this endorsement shall be $26 per job for those listed above. This endorsement changes the policy to which II Is attuohad and Is etrocilvv on the date Issued uniess otherwise stated. Republic Indemnity Company of America Countersigned by: WC 00 0313 Insured Copy (Ed. 04-84) - ,IIIM h