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PROOF OF INSURANCE (2017) CLOSED�1 DATE (M CIVIWOR -01 TREMBLY DDIYYYY) 9/2U CERTIFICATE OF LIABILITY INSURANCE 2016 AFRO y FI NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NO S THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFER T 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 heRlons of the polder is an policies D ADDITIONAL INSURED, , endorsement. A statement on this ....._ I HOLDER. _ certificate - p y(' ) e endorsed. If SUBROGATION IS WAIVED, subject to the terms n require certificate does not confer rights to the certificate holder in lieu of such endorseratelttms� PRODUCER PHON,. � �- C. Foy 8 Associates Insurance Services Inc. 0 (8 703 8057 PAX- Peter 703 -0935 c Ney {818 6200 Canoga AVG. E MAIL Suite 325 AoDRr~SS __��.� _,,,, Woodland Hills, CA 91367 NSURERJS) AFhOf t:$NC COVERAGE NAIC a _... INSURER C�I��� Insurance C �� „n - 39,993 INSURED INSIRrR B: Navigators Insurance C+Drtl�tr' ..� ...,.,aaa_.. ” Civil Works Corporation 10009 Artesia Blvd INSURE R D ; Bellflower, CA 90706 INSURER ,Em _ INSURER F CERTIFICATE NUMBER: D BELOW HAVE BEEN IS REVISION NUMBERS COVERAGES CERTIFY THAT INDICATED. NOTWITHSTANDING � MB _ THIS IS TOMAYNIT STANDI OR NMA REQUIREMENT, MENT, TI RM ORC CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH ... SUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD CERTIFICATE HIS THE Pi OL ICI DESCRIBED HEREIN IS SUBJECT TO ALL T_ HG TERMS, 1 @ , EXCLUSIONS AND CON DITIONS O F SUCH POLICIES. SHOWN HAVE BEEN RE DUCED BY P AID CLAIMS . F LIMITS TYPE OF INSURANCE POLICY NUMB:R YY YYY uNSO tl A CO .. ' � M�"" GENERAL ITY P RCH R RPEeNcCurE �e X100 000 CLAIMS- MADE OCCUR X 103GL00 1289 2 0 02/17/2016 0211712017 $ 10,00 MED ny $ PERSONAL & AD V INJURY S 1,000,00 _... - E GNERAL AG GREGATE $ � WYY 2Ty.000 " pTELIMITAPPLIESPE R. �POLICY JCT $O PRODUCTS OPIOP AGG 2,000, 0 rHER, eductible2,500 . .m ...�. ......_...... _ . w _..... r 61G SINGLE O �._ AUTOMOBILE LIABILITY Ea awdeol BODILY INJURY (Per person) S ANYAUTO ...............�--- __...."., ......_... ALL OWNED SCHEDULED BODILY INJURY (Per accident) '.... $ AUTOS AUTOS • - -- NON -OWNED PR0.JFFd "- A AO'E S HIREDAUTOS AUTOS .1LP' a dana S B Excess aeAe,.....K X ELAIMS -MaDE LL SEI6EXC8054451C ^ ^ 0211712016 02/1712017 AGGREGATE $ 4.000,000 $ 4, DEO RETENTIONS ... �.. .-- ....." .... — ..�. ..� �__ � $. ��. wOR7r4ERS'C'OMePENSA7NCyN ^ "FE ERA _. AND EMPLOYERS' LIABILITY YIN ..n. "� ANY PROPRIETOWPARTNERPE'XrOUi IVE', [- ...�.I N / A E L EACH ACCIDENT S €;bFFICEWMEMBER EXCI. IDt. D "g I (Mandatory In NHI E „L DISEASE EA EMPLOYEE S ...... ” 0 ns, de cnbe nde&".+P'E'R.A.q NP:'fhpS k eIa nr EL DISEASE POLICY LIMIT S Remarks Schedule, may be attached if more ...... _ .. .... ..... .........__.._ „ IONS 1 LOCATIONS! VEHICLES (ACORD 101, Additional Re space is required) Project Name: Richmond ON OF OPERAT and Street Bollard Installation Project Address: Richmond Street, El Segundo, CA 90245 Certificate holder is named as an additional insured as respects to the Commercial General Liability as their interest may appear subject to all policy terms, conditions, and exclusions. .FRTIFICAT HOLDER ...” ...... � .......�- .�.�.�_ _ .._ t^ - DER CANCELLATION 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 Street Attn: City Clerk AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 1 ..6.._ _ .........� _ .. _.m... ".. . ...... a ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 103 GL 0012892-00 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. A, SECTION II — WHO IS AN INSURED is amended to include as an insured any person or organiza- tion for whom you are performing operations when YOU and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an addi- tional insured on your policy. Such person or organization is an additional insured only with respect to liability caused, in whole or in part, by your ongoing operations performed for that 'insured. A per- son's or organization's status as an insured under this endorsement ends when your operations for that insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: 2. Exclusions This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising directly orindi- rectly out of the rendering of, or the failure to render, any professional architectural, engi- neering or surveying services, including: (1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opin- ions, reports, surveys, field orders, change orders or drawings and specifications; and (2) Supervisory, inspection, architectural or engineering activities. b. "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 be- half of the additional insured(s) at the site of the covered operations has been com- pleted; 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 subcontrac- tor engaged in performing operations for a principal as a part of the same project. C. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance is amended and the following added: For any person or organization you have agreed in writing in a contract or agreement to add as an additional insured, the insurance afforded by this Coverage Part for that additional insured is primary insurance and we will not seek contribution from any other insurance available to that additional insured. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANQED, U255-0310 Contains material Q ISO Properties, Inc., 2000 Page 1 of 1 with its permission, 103 GL 0012892 -00 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED — AUTOMATIC STATUS OPERATIONS WHEN REQUIRED I ' N AGREEMENT - PRIMARY INSURANCE - COMPLETED LIMITED TYPES OF CONSTRUCTION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. SECTION it — WHO IS AN INSURED is amended and the following added: Any person or organization for whom you are performing operations, and when a written contract or agreement requires that such person or organization be added as an additional insured, coverage is extended to this additional insured, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" performed for that additional insured and in- cluded in the "products- completed operations hazard", This additional insured coverage only extends to work the insured is performing on buildings, struc- tures or other improvements to real property constructed, maintained or sold, inclusive of all infra- structure improvements, to be occupied for residential or business use excluding "condominium pro- jects", "condominium conversion projects", "custom homes", "residential tract housing", "single family homes built on spec" or "town house projects", With respect to the insurance afforded to these additional insureds, this insurance does not ,apply to "bodily injury ", "property damage" or "personal and advertising injury" arising directly or indirectly out of the rendering of,, or the failure to render„ any professional architectural, engineering or surveying services, including: (1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, re- ports, surveys, field orders, change orders or drawings and specifications; and (2) Supervisory, inspection, architectural or engineering activities. S, SECTION IV – COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance is amended and the following added: For any person or organization you have agreed in writing in a contract or agreement to add as an additional insured, the insurance afforded by this Coverage Part for that additional insured is primary insurance and we will not seeK contribution from any other insurance available to that additional in- sured. C. For the purpose of this endorsement only, the following is added to DEFINITIONS: "Common Interest Development" means any of the following: (1) A condominium project; (2) A stock cooperative. "Condominium" is defined as any of the following: (1) An estate in real property where there is an undivided interest in common in a portion of real property, coupled with a separate interest in space called a unit., the boundaries of which are described on a recorded final map, parcel map, or condo- minium plan. The areas within the boundaries may be filled with air, earth or water, or any combina- tion thereof, and need not be attached to land except by easements for access and support; (2) A type of ownership in real property where all of the owners own the property, common areas and buildings together, with the exception of the interior of the unit to which they have title; (3) Real es- tate, portions of which are designated for separate ownership and the remainder of which is desig- nated for common ownership, solely by the owners of those designated portions; (4) A single real 0575 -0310 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 2 with its permission. 103 GL 0012892 -00 property parcel with all the unit owners having a right in common to use the common elements with a separate ownership confined to the individual units that are serially designated. "Condominium Conversion Projects ", which are defined as any existing multi unit dwelling structure, including "Apartment Structures ", that prior to, during, or after the policy period, is converted to be sold as "Condominium(s)", "Cooperative(s) ", "Common Interest Development(s)" or any sort of com- bination or derivative thereof, all as those terms are defined elsewhere in this Endorsement. "Condominium Projects", which are defined as consisting of multiple individual "Condominiums ", as defined elsewhere in this Endorsement, on a single parcel of real property. "Cooperative" means any of the fallowing; (1) A type of multiple ownership of real property in which the residents of a multi unit housing complex own shares in the cooperative corporation that owns the property, giving each resident the right to occupy a specific apartment or unit; (2) dwelling units in a multi - dwelling complex in which each owner has an interest in the entire complex and a lease of his /herlits own apartment. "Custom Homes ", which are defined as houses of a unique plan or blueprint built to an owner's specifications and sold before construction begins. "Residential Tract Housing" which is defined as single family, duplex, triplex or fourplex residential housing, not part of a "Condominium Project" or "Townhouse Project" (as defined elsewhere in this Endorsement), that is built by residential developers for sale to individuals during or after completion of construction. "Tract Housing " is further defined as consisting of 10 or more units in a single con- tiguous location. "Single Family Homes Built on Spot ", which are defined as homes of a unique plan or blueprint, built by themselves, and not in conjunction with other homes of like design and blueprint, by a general contractor, for sale after completion of construction. "Townhouse Projects", which are defined as multi unit housing consisting of houses in a row, of usu- ally the same or similar design, with common side walls or with a very narrow space between adja- cent side walls, including individual Townhouses.. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. 0575 -0310 Includes copyrighted material of Insurance Services Office, Inc., Page 2 of 2 with its permission. DATE iMMIDDIYYYY) `.. CERTIFICATE OF LIABILITY INSURANCE GA TE(MW2016 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 pollcy(les) must he endorsed. If SUBROGATION I'S WAIVED,, subject t0 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 "AMK ��aia,,EAOi IIFS Hi 5624.a _ Troy Kelly(2965362) POONr 562 -434 0301 FAx 39 -5071 5353 E 2nd St Ste 207 srlr rt �. Iwtlrla Beach m ®,... CA 90803. "5383 .. ........... iNSmU,RERA Truck Insurance Exchran e 21709 INSURED ....... ''.. INSURER B : Farmers Insurance Exchange 21652 Civil Works Corp c Mid f;r rllury 4ns�urance Conll aa) INSURER . 21687 10009 Artesia Blvd INSURER o " ...� Bellflower CA 90706 INSURENE "® -- _ ........... �.._ INSURER F: I COVERAGES CERTIFICATE NUMBER, REVISION NUMBER. FHES 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, RN'SIC AoGL�S' �'`oL.9C'Y &NN# 4uE'P.i.. ®,.. N' LiR TYPE OF INSURANCE i PCI.I(:YNLPMBER MMI ' YYY , MM rYM" DMlis GENERAL LIABILITY EACH GCCURRENCE $ — COMMERCIAL GENERAL LIABILITY ! DAMAGE TO IYEhi O I+d" §6.?I?.Se.5brr1.... CLAIMS-MAUE „� OCCUR .. MEb EXP Ah one Watson $ -� PERSONAL 8 ADV INJURY $ � GENERALAGGREGATE $ C.rFNp A01;Er11GArr LIMIT APPLIES PER: L E PROCUCT5 COMPIOPAG G S "s Pt�p,ICY I P LOC $ " r AUTOMOBILE LIABILITY C )MN IN 0U SINGLE LIMIT-.. 2,000 000 1 ANY AUTO BODILY INJURY (Per person) S ,.., ALL OWNED ..,,.,., SCHEDULED 0 AUTOS Y Y 604957187 ..... an ,.........d.. - .,...,, a„ # 11 /27/2015 11/27/2016 BODILY $ X_,. HIIREGSAIJ'f0�° AUT03 p.,. Pi1INJURY(Pereccidanl) LRTY DA G 1 ..... I $ UMBRELLA LIAR ,.. OCCUR i EACW OCCURRENCE $ EXCESS LIAR CLAIMS MApE. AGGREGATE ; _ RETFNTION.S $ WORKERS COMPENSATION WC STA: nJ [ OTH- IANDEMPLOYERS'LIABILiTY YdN ANY PROPRIETORIPARTNEWEXE5CUTIVE - .�..Ts;,15�,YiUMTS1, .J _ .... `. EACIi ACC/ DENT,. $ OFF'ICERfMEMSER EXCLUDE[,?_ NIA . I a ) #P7dr�'M E L EA EMPL6YT $ Mid °umG,'a�u ..., . _ .,...,......,,, . IIN C ribe r:k' AT #�C7rJ; q .,,,.. ^` E.I_, DISEASE POLICY LIMIT. _$ DESCRIPTION OF OPERATIONS I LOCATIONS I VENICLE8 (Anaah ACORD 101, Additional Remarks Schadula, N more ® is requked) 10009 Artesia Blvd, Beiiflower, CA 90706 Project Name: Richmond St., El Segundo, CA 90248 Certificate Holder is named as Additional Insured on the referenced policy, with Waiver of Subrogation SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main St ACCORDANCE WITH THE POLICY PROVISIONS, El Segundo CA 90245 ACORD 25 (2010105) 986.2b`!O RD CORPORATION. All rights reserved. The ACORD name and logo are reg ere rlrs of AC D THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. �&' � F A R M E R S E0002 Effective Date: 9/22/2016 Policy Number: 604357187 Named Insured: CIVIL WORKS CORPORATION DESIGNATED INSURED Name of person(s) or organization: CITY OF EL SEGUNDO Job: RICHMOND ST BOLLARD INSTALLATION, RICHMOND ST, EL SEGUNDO, CA This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM The following language is added- Primary/Non-Contributory Provision. If the additional insured designated herein has an Other Insurance provision malting its policy excess, and You (CIVIL WORKS CORPORATION) agreed in a written contract or written agreement to provide the Additional Insured coverage on a Primary/Non - Contributory basis under the provision of the Addi- tional Insured endorsement (CA20480299) attached hereto, then this policy shall be Primary/Non- Contributory to any insurance issued directly to the Additional Insured, provided such written contract or written agreement were executed prior to the issuance of the Additional Insured endorsement. Page 1 of 'I COMMERCIAL AUTO PRIMARY PROVISION E0002 POLICY NUMBER: 604357187 COMMERCIAL. AUTO CA 20 48 02 99 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modifies insurance provided under the following; BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provi- sion of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective: 912212 ©16 Named Insured: CIVIL WORKS CORPORATION Name of Person(s) or Organization(s): CITY OF EL SEGUNDO Countersigned SCHEDULE (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section ill of the Coverage Form, Page 1 of 1 Copyright, Insurance Services Office, Inc., 1998 CA 20 4802 99 THIS ENDORSEMENT CHANGES THE POL€CY. PLEASE READ IT CAREFULLY. FARMERS INSURANCE CHANGESIN TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE. COVERAGE FORM TRUCKERS COVERAGE FORM E3 : 53 tst Edition With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Endorsement Effective: Countersigned By. 09/22/16 Named Insured: CIVIL WORKS CORPORATION Y (Atithorired R Name Of Person(s) Or Organization(s): CITY OF EL SEGUNDO (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The Transfer Of Rights Of Recovery Against Others To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule. We will retain the additional premium shown above, regardless of any early termination of this endorsement or the policy. This endorsement is part of your policy. It supersedes and controls anything to the contrary. It is otherwise subject to all the terms of the policy. 710KI MY kY7Y3fVA 644 PA1511101 Pqc 101 9034,1).! ACAORO CERTIFICATE OF LIABILITY INSURANCE DATE (M M/DD/VYYY) 09/22/2016 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 c,nr#Iflrate holder in lieu of such endorserrtent(s). PRODUCER r rvff4-0+14:_.,....,m......��. ,.. ...... ...... Bouchard Insurance for WBS P PHONE 566 3- 3,600, ext. ..623 P.O.Box 6090 E E 14AIL Clearwater, FL 33758 -6090 A AcTDrcrss _ ............ -" ... .. __ .,..__,_. ........_ �...,.......,., ��..., ,.W, I INSURER A Anner9Can tarr rich Ins,uraancl .... ....... ......n..n . INSUR,Rt1 COVERAGES CERTIFICATE NUMBER:15FL079921396 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, .. — Po CE B AID CLAIMS. EXCLUSIONS OF SUCH POLICIES LIMITS SHOWN o v NuMa RVE BEEN REDUCED BY PM „ LIMITS ILTRXCLUSIO ADtif ,U& POLICY EXP MIDDKYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ _ ,... - -.. CLAIMS -MADE E'] OCCUR t?tlkEMtSEa' a,a urve oea. $ .. ,..._ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ ..._, -,. a..., . w.. .._ ..._..........._,.._ r„ r;, MAI";�"PEGATE.. LIMIT APPLIES PER: GENERAL AGGREGATE $ -wy ....... • „ „M wmCTS COMP /OPAGG $ ... „.. PRO- I LOC PRODU..... m.....-._ ............ ........__�___,_._..- m......... POLICY � � JECT a $ AUTOS _.^ OTHER, $ AUOBILE LIABILITY n V. L BODILY INJURY (Per person) $ AUTO ALL OWNED SCHEDULEDOF ER'PY DAMAG' $, BODILY INJURY (Per accident) -. AUTOS .. NO OWNED r _...._.,m.� $ ..�... w...� t HIREDAUTOS AUTOS A LIAB OCCUR EACH OCCURRENCE _ IAB MADE CLAIMS RETENTION$ WORKERS COMPENSATION PER fib AND EMPLOYERS' LIABILITY YIN ANY PROP 'RIETOWP'AR,T"NEROEX�E:.CUTr VE N / A X WC 00 -95- 750-00 09/0112016 1213112016 N...E L EACH ACCIDENT .. _$ . mm 1�DDD,000 A OFFICL- RMEMBER EXCLUDED? E L DISEASE- „... (Mandatory In NH) SE EA EMPLOYEE $ 1,DD0 DUO dfyea. dWSahre randmr E.L. DISEASE- POLICY LIMIT $ 1,000,000 DES CRI PT ION OP OPERAT IONNS hLd ovr Location Coverage Period: 09/01/2016 12/31/2016 Client# 054510 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more apace is required) Civil Works Corporation Richmond St Bollard Installation Coverage Is pfovtded for 10009 Artesia Blvd only those co-employees BeNlt%ower, CA 90706 of. but not subcontractors to: Endorsements: Waiver of Subrogation CERTI'F'ICATE HOLDER CANCELLATION 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 Ele Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE „ J 71 68.2014 ACORN CORPORATION. All rights reserved. ACORD 2512014/011 The ACORD name and logo are registered marks of ACORD WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4 -84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT — CALIFORNIA 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 per - form work: under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be $0 of the California workers' compensation premium otherwise due on such remuneration. Person or Organization IN FAVOR OF: City of El Segundo 350 Main Street Ele Segundo, CA 90245 SCHEDULE Job Description Richmond St Bollard Installation f� This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: 09/01/2016 Policy No: WC 00 -95- 750 -00 Endorsement No: Insured: Workforce Business Services CA, LLC Labor Contractor, for co- employees of: Civil Works Corporation Insurance Company: American Zurich Insurance Company Countersigned by WC 04 03 06 Copyright 1983 National Council on Compensation Insurance