PROOF OF INSURANCE (2017) CLOSED Policy Number: 605067657 Date Entered; 14
DATE(MMIDDIYYYY)
�.� CERTIFICATE OF LIABILITY INSURANCE 12r8r2016
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 have ADDITIONAL 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(s).
PRODUCER CONT'AC'T Nm
Jason Ortega Insurance Agency, Inc. NAME'
PHONE (949)429-3620 ,.,.,.,., _... ............FAX
3553 Camino Mira -MAIL (949)661-2066
3553
Suite G
San Clemente, CA 92673 INSURERS)AFFORDING COVERAGE NAIC N
INSURER A;FAR1-ZR8 INSURANCE E'XCHA'NGE
INSURED GSE SOLUTIONS LLC INSURERS:TRUCK INSURANCE EXCHANGE
C/O GREGORY STEVENS INSURER C:
3622 PONTIAC DR. INSURER D:
CARLSBAD, CA 92010-2133 INSURER E::
INSURER F
COVERAGES C'ERTIFICA'TE.NUMBER'. 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,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR Abbl.SUER POLICY EFF POLICY EXP
INSURANCE . 1. „M.m... ........ OLIGYMNUMBER . I ......._. . . . ... ,.__.m._...�....r._...._.............. .. LIMITS w JNIR.
_pa COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE f 1,000,000
CLAIMS-MADE OCCUR 01/09/2016 01/09/2017 PREMISES TO(Ea oc4urr ocp a 75 000
605067657 � r
MED EXP(Any one person) f 5,000
PERSONAL 6 ADV INJURY f 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE f 2,000,000
POLICY JEC LOC PRODUCTS-COMP/OP AGO a 1,000,000
OTHER .. ..--.......................--.,
f
... _............................._.
AUOMO_-LE-LIABIL-.IT..Y-
aPo �174I ' II�IT""...,.,.,:,iµ1,000,000
A ANY AUTO 605067657 01/09/2016 01/09/2017 BODILY INJURY(Par person) f
OWNED SCHEDULED BODILY INJURY(Per soddent) f
AUTOB ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE f
AUTOS ONLY AUTOS ONLY (Per accld000
f
�. . .OCCUR.....................,........,,,.,,.,,,,,,„................................,,,........._._....... ,,..._-................----__...,...--............-_........._._�.�.._..__._._�... EACH OCCURRENCE r_,.„....w-,..,,,......-,w..,.,.,..,...,...,...,
UMBRELLA LIAR 0 e
EXCESS LIAB CLAIMS-MADE AGGREGATE 'f
D E D RETENTION f......... ..Y;.N.-mmm................ ..........................._ a
WORKERS COMPENSATION ........mm................_........,.,.m..-.._ PER ..y,..^......,.....,......,...
AND EMPLOYERS'LIABILITY STATUTE ER
ANY PRO PRIETORIPARTNER/EXECUTNE ❑ NIA E.L.EACH ACCIDENT e
OFFICERIMEMBER EXCLUDED' '
(Mandatory In NH) E.L.DISEASE a EA EMPLOYEE e
If yyes,dosoribe under
OEBCRIP'TION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT f
H mmE60.._..(PROFE98IONAL................_.. _._...r............. SD..9 ......_..........._...._......n.......__................................m_......_.._................_
2242 02/01/2016 02/01/2017 LIMIT $1,000,000
LIABILITY )
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES ACORD 101,Additional Remarks Schedule,may be attached If more space ___ -..wwww _wwwwww....... .. ..........�_, .,�..,�...�...,
( Y P Is required)
CERTIFICATE HOLDER CANCELLATION
City of El Segundo
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
E1 Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
it
JASON ORTEGA
®1986.2016 ACO,RD'CORPORATION, All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
Producedusing Fortes Bose Plus software,www.FormeBose,cwmlmpreeelvsPubllshing 800.208.1977
POLICY NUMBER: 60506-76-57 BUSINESSOWNERS
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED PERSON
OR ORGANIZATION
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS POLICY
SCHEDULE"
Name Of Person Or Organization:
CITY OF 8L SEG=O
Information required to complete this Schedule, If not shown on this endorsement, will be shown In the
Declarations.
The following is added to Paragraph C. Who Is An
Insured in the Businessowners Liability Coverage
Form:
4. Any person or organization shown In the Sched-
ule Is also an Insured, but only with respect to
liability arising out of your ongoing operations
or premises owned by or rented to you.
BP 04 48 01 97 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 ❑
0 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY E3306
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY 1d Edition
AGAINST OTHERS TO US
0117 6 -74-57
Effective Date Policy Number
This endorsement modifies Insurance provided under the following:
BUSINESSOWNERS COMMON POLICY CONDITIONS,-BP 00 09
SCHEDULE
Nana of Person or Organization:
CITY OF EL SEGUNDO
(If no entry appears above, information required to complete this Endorsement must be shown In the Declarations as applicable to
this endorsement.)
The provisions of the Businessowners Common Policy Conditions are modified by this endorsement as follows:
Condition K. Transfer OI Rights Of Reaovory Apind Others To
Us in the Businessowners Common Policy Condltlons Is amended
by the addition of the following:
3. We waive any right of recovery we may have against the
person or organization shown In the Schedule above because
of payments we m e for Injury or damage
ang 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, organtz^atlon shown In the Schedule
above.
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.
IM-M 16T EDITION W I"Mudoo cepy"ght mftrial ImNem serAm office,Ina,IM 13W01 PAGE 1 OF 1
CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000),
IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES.
I affirm under penalty of perjury under the laws of California one of the following declarations:
(_) I have and will maintain a certificate of consent of self-insure for workers'compensation, issued by the Director
of Industrial Relations as provided for by Labor Code§3700 for the performance of the work set forth the agreement
with the City of El Segundo.
Policy No.
C_)I have and will maintain workers'compensation insurance as required by Labor Code§3700 for the performance
of the work for which the agreement with the City of El Segundo is executed. My workers'compensation insurance
carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone#
1 certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not
employ any person in any manner so as to become subject to the workers' compensation laws of California, and
agree that, if I should become ubject to Wthe ' compensation provisions of Labor Code § 3700 1 must
immediately comply with those isions oent will aut omatically become void.
Signature of Applicant Date
�...._� r
Agreement for G
w
Dated: — I
Reviewed by' a
1