PROOF OF INSURANCE (2012) CLOSEDCERTIFICATE OF INSURANCE I1SSUE
103//2D011E
PRODUCER Cert# 66796 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
GEORGE L. BROWN INSURANCE AGENCY
1005 CALLE RECODO
SAN CLEMENTE, CA 92673
949.361.1400
FAX 949.361.2767
INSURED
BIG WEST CONSTRUCTION CORPORATION
2691 RICHTER AVE #123
IRVINE, CA 92606
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW,
COMPANIES AFFORDING COVERAGE
COMPANY
A NAVIGATORS SPECIALTY INSURANCE
COMPANY
B GENERAL INSURANCE COMPANY
COMPANY
C
COMPANY
D
COVERAGES
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
CO
POLICY EFFECTIVE POLICY EXPIRATION LIMITS
TYPE OF INSURANCE POLICY NUMBER
LTR
DATE (MM /DD/YY) DATE (MM /DD/YY)
GENERAL LIABILITY
GENERAL AGGREGATE
$ 2,000,000
X COMMERCIAL GENERAL LIABILITY 04NO022062
MAY 27 11 MAY 27 12 PRODUCTS- COMP /OP AGG.
$ 2,000,000
CLAIMS MADE X OCCUR
PERSONAL & ADV INJURY
$ 1,000,000
A
OWNER'S & CONTRACTOR'S PROT
EACH OCCURRENCE
$ 1,000,000
FIRE DAMAGE(Any One Fire)
$ 50,000
MED EXPENSE(Any One Person)
$ 5,000
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
$ 1,000,000
X ANY AUTO 24CC2935896
JUL 11 11 JUL 11 12
ALL OWNED AUTOS
BODILY INJURY
SCHEDULED AUTOS
(Per Person)
$
�( HIRED AUTOS
BODILY INJURY
$
X NON -OWNED AUTOS
(Per Accident)
PROPERTY DAMAGE
$
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
ANY AUTO
OTHER THAN AUTO ONLY:
EACH ACCIDENT
$
AGGREGATE
$
EXCESS LIABILITY
EACH OCCURRENCE
$
UMBRELLA FORM
AGGREGATE
$
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION AND
X STATUTORY LIMITS
EMPLOYERS' LIABILITY
EACH ACCIDENT
$
THE PROPRIETOR/ INCL
DISEASE - POLICY LIMIT
$
PARTNERS /EXECUTIVE
DISEASE -EACH EMPLOYEE
$
OFFICERS ARE EXCL
OTHER
REVISE CERTIFICATE #66697
DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLES /SPECIAL ITEMS
THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS, AND VOLUNTEERS ARE NAMED
ADDITIONAL INSUREDS INCLUDING PRIMARY WORDING PER FORM ANFESO43 (05/06) RE: ONGOING
OPERATIONS PERFORMED BY THE NAMED INSURED FOR THE CERTIFICATE HOLDER AS REQUIRED BY
WRITTEN CONTRACT
BLANKET ADDITIONAL INSUREDS-
OWNERS, HERS, LESSEES OR CONTRACTORS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization: ,
Any person or organization that the named insured is obligated by virtue of a written contract or agreement to
prvvidc 6'anucc --9, —1;-
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations-as.
applicable to this endorsement.)
A. Section If —Who Is-An Insured is amended to include as an insured the person or.
organization shown in the Schedule, but only to the extent that the person or organization shown
in the,Schedule is held, liable for your acts or omissions arising out of your ongoing operations
performed for that insured.
B; With respect,to the insurance afforded to these additional insureds, the following exclusion is
added:
2. Exclusions
This insurance does not apply to "bodily injury" or "property damage" occurring after:
(1) -All work; including materials, parts or equipment furnished irr 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 site 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.
C. The words "you" and "your" refer to the Named Insured shown in the Declarations.
D. "Your work" means work or operations performed by you or on your behalf, and materials; parts
or equipment furnished in connection with such work or operations.
PrimaryVor n
If required by written contract or agreement: Such insurance as is afforded by this policy shall
be primary insurance, and any insurance or self - insurance maintained by the above additional
insured(s) shall be excess of the insurance afforded to the named insured and shall not
contribute to it
Waiver f Subrogation
,if required by written contract or agreement: We waive any right of recovery we may have
against an entity that is an additional insured per the terms of this endorsement because of
payments we make for injury or damage arising out of "your work" done under a contract with
that person or organization.
ANF- ES 043 (5/2006)
IN REPLY REFER T0:
JANUARY 15, 2013
CITY OF EL SEGUNDO
DEPT OF BUILDING & SAFETY
350 MAIN ST
EL SEGUNDO CA 90245 -3813
CERTIFICATE OF WORKERS'
COMPENSATION INSURANCE
CANCELLATION NOTICE
RE: CERTIFICATE DATED FEBRUARY 24, 2012
THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER
NAMED BELOW HAS BEEN CANCELLED EFFECTIVE JUNE 1, 2012 AT
12 :01 A.M.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE
CONTACT THE EMPLOYER NAMED BELOW
EMPLOYER:
BIG WEST CONSTRUCTION CORPORATION
15331 NORMANDIE AVE
IRVINE, CA 92604
POLICY 238 - 0015095 -11
CUSTOMER SERVICE REPRESENTATIVE
CUSTOMER SERVICE CENTER
(877) 405 -4545
5860 Owens Drive • Pleasanton, CA 94588 -3900
Mailing Address: P.O. Box 8192 • Pleasanton, CA 94588 -9682
SCIF 19102