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PROOF OF INSURANCE (2017) CLOSED TG CONSTRU .JLOPE Atl�'ti�RO �� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 01/03/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFI CATE 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 have ADDITIONAL INS URED 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 CONTACT NAMF� PHONE FAX The Wooditch Company Ins.Svcs.,Inc. (A/C,No,Ext):(949)287-5677 JAAC,No): 1 Park Plaza,Suite 400 A rDRE$$y Irvine,CA 92614 pp INSURER(S)AFFORDING COVERAGE I NAIC# INSURER A: o Insurance Co.Co. 29742 INSURED INSURER B ntegon National n TG Construction,Inc. INSURER c:Travelers Prop Casu Co of Amer 1125,674,,, 139 Nevada St. INSURER D:Security National Insurance Co 19879 El Segundo,CA 90245 INSURER E:Arch Specialty„Insurance Company 21199 INSURER F: COVERAGES CERTIFICATE NUMBER: ..........REV.I.S.I.O.N..NmUM,@.ER......�..........................................................._- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTVVITHSTANDING 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 D CONDITIONS O SUCH POLICIES LIMITS SHOWN HAVE BEEN REDUCED P P S S F ICY EEXPIN POLICY NUMBER 1t�QY`Yat .LIM.mmITm.S D E o - A X COMMERCIAL GENERAL 1'006006 I EACH C :CIIRRFN"E I CLAIMS-MADE ryry X OCCUR A 05/01/2016 06/01/2017 DAMGEx�rr�ErdTEEI 100,000' X X PRFMI$r$(r.00 c�wrre�nr pj $ MED EXP,(Any one person) $ PERSONAL.R AnV INJURY $ 1,000,000' CroEN1 AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000! OTHER ( PRO- E Ft, „ ............. ............... .....................,..... $ .2 $ ,000,000 V JECT u LOG PRC.?nL�ICTS-COMPrOP AGO B AUTOMOBILE LIABILITY CCJ�1��'SIi,IEt7 MANGLE LIMIT (Cn,.Ckr.CILitYtl* „ X ANY AUTO X X '12001410 06/01/2016 0610112017 9PnLY INJURY(Per person) OWNED "I SCHEDULED AUTOS OIJLY lIl AUTOS Lr BODL.Y INJURY(Per acadenl) AUTOS ONLY Ai�1iTS )1i YI (Pe PROPERTY DAMAGE $ C X UMBRELLA LIAB X OCCUR EACH OCCIJRRENCE $ 4'000'000 EXCESS LIAB CLAIMS-MADE ZUP-51M33479-16-NF 0610112016 06/01/2017 4,000,000 AGGREGATE $ AND EMPLOYERS'LIABILITY .......Y f N ........_..........-. � $ IIN CJ P X � RETENTION$ 10,000 _ ..... ......... PER OTH- D WORKERS COMPENSATION ANY PROPRIETOR/PARTNER/EXECUTIVE IpI X SWC1113880 06/01/2016 06/0112017 1,000,000 9°ICI";wV MEMBER EXCLUDED 4 ,,,,,, NIA XI EACH ACCIDENT RR„ „�,,,,,, �GtrMC a ory In NH) EL DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ E Professional Liab. PDCPP0019500 1212912016 12/2912017 Aggregate/Per Claim 1,000,000 DESCRIPTION.. ............ OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks S'c Pgada'Ye,may be attached if more space is required) E:Engineering Plan Check'Svcs,City of El Segundo. gIaipwvlauaiwv/wcwv The City of El Segundo,its officials,officers,agents and employees are included as Additional Insureds as respects General and Auto Liability per attached endorsements. This Insurance shall apply as Primary and Non-Contributory per attached endorsement. Waiver of Subrogation for Workers'Compensation,General Liability,and Auto Liability:See Attached Endorsements. *Excess Liability follows form. ., ___________........._............................................................................................... !CERTIFICATE HOL,DER CANCE'LLAT'ION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN tY 9 ACCORDANCE WITH THE POLICY PROVISIONS. Attn:Floriza Rivera,PW Dept. 350 Main St. El Segundo,CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID:TG CONSTRU JLOPEZ LOC#: 1 A�RJ ' ADDITIONAL REMARKS SCHEDULE Page 1 of 1 ...AGENCY...............,,,,, .............................. _....... .. ................................. NAMED INSURED TG Construction,Inc. 139 Nevada St. POLICY NUMBER El Segundo,CA 90245 SEE PAGE 1 CARRIER NAIC SEE PAGE 1 SEE P 1E EFFECTIVE DATE ..........._�..... �W .........,, :SEE PAGE 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORP 26 FORM TITLE: Certificate of Liability Insurance Cancellation *Except for 10 days notice of cancellation for non payment of premium. *Should this policy be cancelled before the expiration date,The Wooditch Company will mail 30(thirty)days written notice to those Certificate Holders which require such action per contract or agreement.* ACORD 1.01m(2008/01) ©2008 ACORD CORPORATION......All rights........................................................... reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: AES1038411 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operations All persons or organizations where required by written contract with the Named Insured Information required to complete this Schedule, if not shown above, will be shown in the Declarations. 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" or"property dam- age caused, in whole or in part, by "your work" at � the location designated and described in the sche- dule of this endorsement performed for that addi- tional insured and included in the "products- completed operations hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ POLICY NUMBER: AES1038411 COMMERCIAL GENERAL LIABILITY CG 20 33 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - O'W'NERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured any person or or- additional insureds, the following additional exclu- ganization for whom you are performing operations sions apply: when you and such person or organization have This insurance does not apply to: agreed in writing in a contract or agreement that such person or organization be added as an addi- 1. "Bodily injury", "property damage" or "personal tional insured on your policy. Such person or or- and advertising injury" arising out of the render- ganization is an additional insured only with re- ing of, or the failure to render, any professional spect to liability for "bodily injury", "property architectural, engineering or surveying servic- damage" or "personal and advertising injury" es, including: caused, in whole or in part, by: a. The preparing, approving, or failing to pre- 1. Your acts or omissions; or pare or approve, maps, shop drawings, opi- 2. The acts or omissions of those acting on your nions, reports, surveys, field orders, change behalf; orders or drawings and specifications; or in the performance of your ongoing operations for b. Supervisory, inspection, architectural or t engineering activities. he additional insured. A person's or organization's status as an additional 2. "Bodily injury" or "property damage" occurring insured under this endorsement ends when your after: operations for that additional insured are com- a. All work, including materials, parts or pleted. equipment furnished in connection with such work, on the project (other than ser- vice, maintenance or repairs) to be per- formed by or on behalf of the additional in- sured(s) at the location of the covered operations has been completed; or b. 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 subcontrac- tor engaged in performing operations for a principal as a part of the same project. CG 20 33 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ POLICY NUMBER: AES1038411 COMMERCIAL GENERAL LIABILITY NX GL 009 08 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON-CONTRIBUTING INSURANCE (THIRD-PARTY) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Third Party: All persons or organizations where required by written contract with the Named Insured ........................... . _. (Absence of a specifically named Third Party above means that the provisions of this endorsement apply as required by written contractual agreement with any Third Party for whom you are performing work.) Paragraph 4. of SECTION IV: COMMERCIAL GENERAL LIABILITY CONDITIONS is replaced by the following: 4. Other Insurance: With respect to the Third Party shown above, this insurance is primary and non-contributing. Any and all other valid and collectable insurance available to such Third Party in respect of work performed by you under written contractual agreements with said Third Party for loss covered by this policy, shall in no instance be considered as primary, co-insurance, or contributing insurance. Rather, any such other insurance shall be considered excess over and above the insurance provided by this policy. NX GL 009 08 09 Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission POLICY NUMBER: AES1038411 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: All persons or organizations where required by written contract with the Named Insured Information required to complete this Schedule, if not shown above, will be shown in the Declarations„ The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions: 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 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 ❑ POLICY NUMBER: 12001410 COMMERCIAL AUTO CA 20 48 02 99 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s)who are "insureds" under the Who Is An Insured Provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. _................._ Endorsement Effective: Countersigned By: 06/01/2016 Named Insured: TG Construction Inc (Authorized Representative) SCHEDULE Name of Person(s) or Organization(s): ANY PERSON OR ORGANIZATION WHERE REQUIRED BY WRITTEN CONTRACT (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section II of the Coverage Form. CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 POLICY NUMBER:. COMMERCIAL AUTO 12001410 CA 04 44 03 10 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modi- fied by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: TG Construction, Inc. Endorsement Effective Date: 06/01/2016 SCHEDULE Name(s) Of Person(s) Or Organization(s) Any person or organization with whom the insured has agreed to waiver rights of recovery, provided such agreement is made in writing and prior to the loss Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization. CA 04 44 03 10 © Insurance Services Office, Inc., 2009 Page 1 of 1 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 2.00%of the California workers'compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Any person or organization as required by written contract Notes: I, This endorsement may be used to waive the company's right of subrogation against named third parties who may be responsible for an injury. 2. The sentence in( )is optional with the company. It limits the endorsement to apply only to specific jobs of the insured,and only to the extent that the insured is required to obtain this waiver. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 6/1/2016 Policy No. SWC1113880 Endorsement No. Insured TG Construction,Inc. Insurance Company Security National Insurance Company Countersigned By