Loading...
PROOF OF INSURANCE (2017) CLOSED/—IN ,acoRU• CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 6/1/2017 1 5/27/2016 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 Lockton Insurance Brokers, LLC , 725 S. Figueroa Street, 35th Fl. A/c N , CA License #OF15767 is IC, No Ext : Los Angeles CA 90017 (213) 689 -0065 ....1)f f� l G INSURER A . Libertv Mutual Fire Insurance Comnanv 123015 INSURED Jody Swee) inl ,Inc:. INSURER B : Em lovers Insurance Com an of Wausau ,2 1047663 dtaa Nation wlc o n'voronrnental Services INSURER C : 1,ibertY insurance Corporation 4 and JNL Building Services 11914 Front St Starstone National Insurance Company 2 Norwalk CA 90650 INSUREI'TE d ....- ... ..... -- 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. R At}tat $UI1R EX R TYPE OF INSURANCE N y. POLICY NUMBER O D"I EFF PO pC LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y TB2 -Z91- 449522 -116 6/1/2016 6/1/2017 EACH OCCURRENCE 1. 000 000 CLAIMS -MADE OCCUR NOV AGL TO RENTED L.1 PRMI E r E/ $ 1,000,000 C JXJUMBRELLALIAIB X C El EXCESS LIAB C DED RETENTION $ N IN I ASC -Z91- 449522 -036 N I N I TH7 -Z91- 449522 -066 D AND EMPLOYERS' LIABILITY "N �IN Y 11 0 1 6003 6 ANY PROPRIETOR /PARTNER/EXECU I IVE u " " p a NIA OFFICER /MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below 8 ADV INJURY 1$ 1 GE.N'U AGGREGATE I.IMI'T API -'I IES PE:R:. POLICY PRO- LOC JECT 6/1/2016 OTHER B AUTOMOBILE LIABILITY '.BODILY INJURY (Per person) X ANY AUTO ALL OWNED BODILY INJURY (Per acei�.deril, SCHEDULED X HIREDAUTOS X NON-OWNED C JXJUMBRELLALIAIB X C El EXCESS LIAB C DED RETENTION $ N IN I ASC -Z91- 449522 -036 N I N I TH7 -Z91- 449522 -066 D AND EMPLOYERS' LIABILITY "N �IN Y 11 0 1 6003 6 ANY PROPRIETOR /PARTNER/EXECU I IVE u " " p a NIA OFFICER /MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below 8 ADV INJURY 1$ 1 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of 1 I scgundo its offic Mr/, "„ officials, clinploycesy a cnis and volunteers are Included as Additional Insured. lee Iba extent provided by the policy language or taclorsellicurl Issucd oil appiowd by the Insurance carrier. Coverage provided is pruumy and non- coal ributory. Waiver of Subrogation applies per attached or policy lalrgoage. CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1876365 AUTHORIZED REPRESENTATIVE City of El Segundo Attn: Floriza Rivera, PW Dept. 350 Main St. El Segundo CA 90245 ACORD 25(2014/01) ©1' 8 201 COD CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD 6/1/2016 6/1/2017 O1 C1iNdE SINGLE LIMIT ,a $ 1,000,000 '.BODILY INJURY (Per person) $ XXXX= BODILY INJURY (Per acei�.deril, $ XXXXXXX. Ie OErsTeYet�AMAGE $ XXXXXXX IComp & Coll Ded $ 1 000 6/1/2016 6/1/2017 EACH OCCURRENCE $ 5 ",000,000 AGGREGATE $ 5,000,000 $XXXXXXX 6/1/2016 6/1/2017 X ST AT X OTH !E,I EACH ACCIDENT I R 1.000.000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of 1 I scgundo its offic Mr/, "„ officials, clinploycesy a cnis and volunteers are Included as Additional Insured. lee Iba extent provided by the policy language or taclorsellicurl Issucd oil appiowd by the Insurance carrier. Coverage provided is pruumy and non- coal ributory. Waiver of Subrogation applies per attached or policy lalrgoage. CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1876365 AUTHORIZED REPRESENTATIVE City of El Segundo Attn: Floriza Rivera, PW Dept. 350 Main St. El Segundo CA 90245 ACORD 25(2014/01) ©1' 8 201 COD CORPORATION. All rights reserved 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 =iight ainst the verson or organization named in the Schedule. abis agleement a Iies onl,,,, to the extent that ou perform work under a written contract that requires Vou 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 * % of the California workers' compensation premium otherwise due on such remuneration. 01AW41 Person or Organization Job Description *The premium charge for this endorsement shall be 2% of the premium developed in the State of California, but not less than $500 policy minimum premium. WC 04 03 06 (Ed. 4-84) 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. Attachment Code: D448503 Certificate ID : 1876365 Policy Number: TB2 -Z91- 449522 -116 Item 10. Blanket Additional Insured Where Required By Written Contract Paragraph 2. of Section 11 - Who Is An Insured is amended to add the following: e. Additional Insured by Written Contract or Written Agreement The following are insureds under the policy when you have agreed in a written contract or written agreement to provide them coverage as additional insureds under your policy: (1) Lessors of Leased Equipment: The person(s) or organization(s) from whom you lease equipment, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your maintenance, operation or use of equipment leased to you by such person(s) or organization(s). (2) Managers or Lessors of Premises: Any manager or lessor of premises leased to you in which the written lease agreement obligates you to procure additional insured coverage. The coverage afforded to the additional insured is limited to liability in connection with the ownership, maintenance or use of the premises leased to you and caused, in whole or in part, by some negligent acts or omissions of you, your employees, your agents or your subcontractors. There is no coverage for the additional insured for liability arising out of the sole negligence of the additional insured or those acting on behalf of the additional insured, except as provided below. If the written agreement obligates you to procure additional insured coverage for the additional insured's sole negligence, then the coverage for the additional insured shall conform to the agreement, but only if the applicable law would allow you to indemnify the additional insured for liability arising out the additional insured's sole negligence. This insurance does not apply to: (a) Any "occurrence" which takes place after you cease to be a tenant in that premises or to lease that land; or (b) Any premises for which coverage is excluded by endorsement. (3) Mortgagees, Assignees or Receivers: Any person(s) or organization(s) with respect to their liability as mortgagee, assignee or receiver and arising out of the ownership, maintenance or use of your premises. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. (4) Any Person or Organization Other Than a Joint Venture: Any person or organization (other than a joint venture of which you are a member) for whom you are obligated by a written agreement to procure additional insured coverage, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: (a) In the performance of your ongoing operations; or (b) In connection with premises owned by you. This insurance does not apply to: 1. Any construction, renovation, demolition or installation operations performed by or on behalf of you, or those operating on your behalf; 2. Any person or organization whose profession, business or occupation is that of an architect, surveyor or engineer with respect to liability arising out of the preparation or approval of maps, drawings, opinions, reports, Attachment Code: D508870 Certificate ID : 1876365 surveys, change orders, designs, specification or the performance of any other professional services by such person or organization; or 3. Any person or organization more specifically covered in Paragraphs e.(1) through (4) above. The insurance afforded to any person or organization as an insured under this Paragraph 2.e.: (1) Applies only to coverage and minimum limits of insurance required by the written agreement or written contract, but in no event exceeds either the scope of coverage or the limits of insurance provided by this policy; (2) Does not apply to any person or organization for any "bodily injury", "property damage" or "personal and advertising injury" if any other additional insured endorsement attached to this policy applies to that person or organization with regard to the "bodily injury", "property damage" or "personal and advertising injury"; (3) Applies only if the "bodily injury" or "property damage" occurs, or offense giving rise to 'personal and advertising injury" is committed, subsequent to the execution of the written agreement; and (4) Applies only if the written agreement is in effect at the time the "bodily injury" or "property damage" occurs, or at the time the offense giving rise to the 'personal and advertising injury" is committed. Item 11. Blanket Additional Insured - Grantors Of Permits Paragraph 2. of Section II - Who Is An Insured is amended to add the following: Any state, municipality or political subdivision with respect to any operations performed by you or on your behalf, or in connection with premises you own, rent or control and to which this insurance applies, for which the state, municipality or political subdivision has issued a permit. However, this insurance does not apply to: 1. 'Bodily injury", 'property damage" or "personal and advertising injury" arising out of operations performed for the state, municipality or political subdivision; 2. Any "bodily injury" or "property damage" included within the "products- completed operations hazard ", except when required by written contract or agreement initiated prior to loss; or 3. "Bodily injury", 'property damage" or "personal and advertising injury", unless negligently caused, in whole or in part, by you or those acting on your behalf LC 04 44 04 12 Attachment Code: D508870 Certificate ID : 1876365