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PROOF OF INSURANCE (2017) CLOSEDDATE(MM /DnfYYYY) CERTIFICATE OF LIABILTY INSURANCE 10/1B,2D,8 I 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(les) must have ADDNTIONAL INSURED provisions or 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($), PRODUCER CONTACT .Aon Risk Services Central, Inc.. NAPr1E.. Chicago IL Office (p,IC. No. Ext): (866) 283 - 7122 .................._ ... N ...800- 363 -0105 200 East Randolph E -MAIL Chicago IL 60601 USA ADDRESS: INSURED Shelter Clean Services Inc. 11065 Penrose Street Sun Valley CA 91352 USA INSURER(S) AFFORDING COVERAGE ....... ......... ......... ...._. .._..._ . ........ _ ................ ... INSURER A: QBE Insurance Corporation NAIC # ......_....... 39217 INSURER B: Praetorian Insurance Company 37257 INSURER C: NSO INSURER D: POLICY NUMBER INSURER E: _... ...... ............................. .._....................._..,,.,.,...................................................._._.............. ......................_.....__. INSURER F: IMMIDDNYYY CnVFRAnFS CERTIFICATF NIIMRFRt s7nnfi41709nq REVISION NIIMRFR- Tf jIS 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. Limits shown are as requested L7R TYPE OF INSURANCE NSO SUBR WMVD POLICY NUMBER PO MM1DDrd'Y y I IMMIDDNYYY LIMITS X COMMERCIAL GENERAL LIABILITY CGA EACHOCCURRENCE $1,000,000 CLAIMS -MADE X I OCCUR .4 PREM SES Ea oocurrancal $S00,000 MED EXP (Any one person) X Contractual Liability PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3 , 000, 000 POLICY 4 o JECT E] LOC PRODUCTS - COMP /OP AGG $3,000,000 OTHER: A AUTOMOBILE LIABILITY 'CBA0913299 02/28/2010 02/28/2017 COMBINED SINGLE LIMIT $1,000,000 A CBA0926211 02/28/2016 02/28/2017 a ccidentl X ANY AUTO BODILY INJURY( Per person) OWNED SCHEDULED BODILY INJURY (Per accident) AUTOS ONLY AUTOS PROPERTY DAMAGE HIREDAUTOS NON -OWNED (Per accident ONLY AUTOS ONLY X ComplColl Doll $5 ,G UMBRELLA LIAR EACH OCCURRENCE HOCCUR EXCESS LIAR CLAIMS -MADE AGGREGATE DED RETENTION B WORKERS COMPENSATION AND CWC0913300 02/28/2016 02/29/2017 PER OTH- X EMPLOYERS' LIABILITY STATUTE .'.._.._. Y d N A05 Except NY ANY PROPRIETOR I PARTNER I EXECUTIVE E,L, EACH ACCIDENT $1,000,000 N OFFICER/MEMBER EXCLUDED? N/A '...... (Mandatory in NH) E.L. DISEASE -EA EMPLOYEE $1,000,000 '... If yes, dot,cdbo under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 1D1, Additional Remarks Schedule, may be attached if more space is required) RE: City of E1 Segundo. City of El Segundo, its officials, officers, agents and employees are included as Additional Insured in accordance with the policy provisions of the General Liability policy. A waiver of Subrogation is granted in favor of Certificate Holder in accordance with the policy provisions of the workers' compensation policy. rx-1- I `m c dl d O 2 0 0 v 0 r N O Z d N V t' d V allllllrlal CERTIFICATE HOLDER CANCELLATION t.11 0 City of E1 Segundo Attn: PIN Dept. 350 Main street El Segundo CA 90245 USA ACORD 25 (2016/03) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE M11, FA ©1988 -2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: CGA0913299 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, 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: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is 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. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: CGA0913299 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL I SURED - O"'W'"NERS, LESSEES O CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Section II — Who Is An Insured is amended to in- at the location designated and described in the clude as an additional insured the person(s) or or- schedule of this endorsement performed for that ad- ganization(s) shown in the Schedule, but only with ditional insured and included in the "products -com- respect to liability for "bodily injury" or "property pleted operations hazard ". damage" caused, in whole or in part, by "your work" 41' A 1111J/ _ CG 20 37 07 04 Copyright, ISO Properties, Inc., 2004 Page 1 of 1 UNIFORM POLICY NUMBER: CGA0913299 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED - OWNERS, S, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: 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 include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury ", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) desig- nated above. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment furnished in 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 location 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 in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 11 POLICY NUMBER: CGA0913299 COMMERCIAL GENERAL LIABILITY CG 24 04 10 93 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: ANY PERSON OR ORGANIZATION THAT REQUIRES YOU TO WAIVE YOUR RIGHTS OF RECOVERY, IN A WRITTEN CONTRACT OR AGREEMENT WITH THE NAMED INSURED THAT IS EXECUTED PRIOR TO THE ACCIDENT OR LOSS (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 (Section IV — COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products- completed" operations hazard ". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 10 93 Copyright, Insurance Services Office, Inc., 1992 Page I of 1 INSURED COPY WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04 -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 perform 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 2% of the California workers' compensation premium otherwise due on such remuneration. Person or Organization Schedule Job Description Any person or organization for which you have agreed to waive your rights of recovery in a written contract, provided such contract was executed prior to date of loss. L/ This endorsement changes the policy to which it is attached and is effective on the dale issued unless otherwise stated. (The Information below Is required only when this endorsement Is issued subsequent to preparation of the policy.) Endorsement Effective 02/28/2016 Policy No. CWC0 913 3 0 0 Endorsement No. 000 Insured TRIANGLE SERVICES INC Insurance Company PRAETORIAN INSURANCE COMPANY Countersigned By CWC0913300 20160228 000