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PROOF OF INSURANCE (2016) CLOSEDAssociation of California Water Agencies / Joint Powers Insurance Authority P.O. Box 619082, Roseville, CA 95661 -9082 CERTIFICATE OF COVERAGE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE COVERAGE DOCUMENT THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE COVERAGE DOCUMENTS LISTED HEREIN. MEMBER West Basin Municipal Water District 17140 S. Avalon Blvd., Ste. 210 Carson, CA 90746 -1296 COVERAGE INFORMATION This is to certify that coverage documents listed herein have been issued to the Member Agency herein for the Coverage period indicated. Not withstanding any requirement, term or condition of any contract or other document with respect to which the certificate may be issued or may pertain, the coverage afforded by the coverage documents listed herein is subject to all the terms, conditions and exclusions of such coverage documents,. Type of Coverage Certificate # _ _Effective Date Ex iration Date Limits General Liability MOLC- 100115 10/1/2015 10/1/2016 Aggregate $1,000,000 0 Commercial General Liability G I I I Per Occurrence $1,000,000 D Contractual Liability El Products /Completed Operations El Occurrence Auto Liability • Owned Autos • Hired Autos 0 Non -Owned Autos Auto Physical Damage Scheduled Autos Hired Autos Property Special Form Mobile Equipment Boiler and Machinery Crime Workers' Compensation Coverage A - Workers' Comp. Coverage B - Employer's Liability DESCRIPTION Regarding: License Agreement No. W2641 MOLC- 100115 1 10/1/2015 1 10/1/2016 1I Per Occurrence $1,000,000 Additional Covered Party(ies), as required by written contract: City of El Segundo, its officials, and employees, per attached Addendum. CERTIFICATE HOLDER City of El Segundo Attn: City Clerk 350 Main Street El Segundo, CA 90245 CANCELLATION Should any of the coverage documents herein be cancelled before the expiration date thereof, ACWA /JPIA will endeavor-to provide 30 days written notice to the certificate holder named herein, AUTHORIZED REPRESENTATIVE DATE 6/29/2016 FaVA-W-1-011VT to the Memorandum of Liability ili overage for the ASSOCIATION OF CALIFORNIA WATER AGENCIES JOINT POWERS INSURANCE AUTHORITY MEMBER: West Basin Municipal Water District COVERAGE PERIOD: 10/1/2015 -10/1/2016 ADDENDUM DATE: 6/29/2016 ADDENDUM NUMBER: 27 Change in the following Sections: Section III. WHO IS COVERED is amended to include the following entity(ies) as an Additional Covered Party(ies): City of El Segundo, its officials, and employees, as required by written contract. Additional Covered Party(ies) is covered only if the liability is caused in whole or in part by the acts or omissions of the Member Agency and excludes coverage for the sole negligence of the Additional Covered Party(ies), and subject to a $1,000,000 per occurrence and annual aggregate limit of liability. Section VI. CONDITION'S (G). OTHER COVERAGES is amended to read: The coverage afforded in this Memorandum of Liability is primary to and will not seek contribution from any other insurance available to an Additional Covered Party(ies) under the Memorandum of Liability provided that: (1) The Additional Covered Party(ies) is(are) a Named Insured under such other insurance, and (2) is required in a written contract or agreement. The following is added to Section VI. CONDITIONS I WITHDRAWAL /CANCELLATION: If the Authority elects to cancel this coverage before the stated expiration date, the Authority will provide the Additional Covered Party(ies) at least thirty (30) days prior written notice, as required by a written contract or agreement. Regarding: License Agreement No. W2641 Signed By: �` . ,� , "' 0 _ _.._ �.. Date: 6/29/2016 (Authorized Represent ,f) POLICYHOLDER COPY SC P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 08 -17 -2016 GROUP: POLICY NUMBER: 9071645 -2016 CERTIFICATE ID: 8 CERTIFICATE EXPIRES: 05 -10 -2017 05 -10- 2016/05 -10 -2017 CITY OF EL SEGUNDO SC 350 MAIN ST 05 -10 -2016 EL SEGUNDO CA 90245 -3813 SC This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 60 days advance written notice to the employer. We will also give you 60 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE, ENDORSEMENT /#2055 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 05 -10 -2016 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT ##2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2016 -08 -17 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO EMPLOYER WEST BASIN MUNICIPAL WATER DISTRICT SC 17140 AVALON BLVD STE 210 CARSON CA 90746 [P13,SC1 IREV.7 -20141 PRINTED : 08 -17 -2016 WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation: 1. Please be advised that a waiver of subrogation requires that a 3% surcharge will be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certificate holder who requested the waiver. (Note: if you have no employee payroll on that job, then there is no charge.) 2. To apply the 3% surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work on job /s for the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. Example: Payroll for job: Sample Rate: Regular Premium equals: Surcharge: Additional Waiver charge: Total premium equals $5,000.00 13.30% $ 665.00 3.00% $ 19.95 $ 684.95 (665.00 + 19.95) ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION REP 03 9071645 -16 RENEWAL SC 0- 27 -13 -64 PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE AUGUST 17, 2016 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING MAY 10, 2017 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME WEST BASIN MUNICIPAL WATER DISTR 17140 AVALON BLVD STE 210 CARSON, CA 90746 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF EL SEGUNDO WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, WEST BASIN MUNICIPAL WATER DISTR IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03%. A--- NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AIJT iORIZEl7 REF'RESEI' r IVE. SCIF FORM 10217 (REV.7 -2014) AUGUST 19, 2016 PRESIDENT AND CEO 2570 OLD DP 217