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PROOF OF INSURANCE (2017) CLOSED AC CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 114 ✓ " I 12/20/2016 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 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 Kathy Macias—Ramirez NAME: „P ADDRESS: a,E%t)�, ym@ csins.com Millennium Corporate Solutions (626)275-3000 FAX (626)275-0130 License # OC13480 [. EO,. kth m D 550 N Brand Blvd #1100 INSURER(S)AFFORDING COVERAGE NAIC# Glendale CA 91203 y 37974 ... INSURER A S�`)~ Hawley Insurance Co ., INSURED Company INSURER Security Ins Com an 24082„, , INSURER,C ASU1 Indemnity Company 22314 Trueline INSURER D Everest National Ins Co 10120 1651 Market Street, Ste. B INSURER E: Corona CA 92880 INSURER F: COVERAGES CERTIFICATE NUMBER: 2016 - 2017 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 ILTR TYPE OF INSURANCE Ai pn'P''L''s'pJ'e)TI ”"""i MIDDY'EFF PWDDIY`yY ' INCn 1MVf1,l POLICY NUMBER IMM IYYYXI dMMd'DDtYYYY)i LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ..... A CLAIMS-MADE X N OCCUR ()AMKGE To AtN'M�O &:RENvMISES qE,a ocs,�w.mence) $ 50,000, $2,500 Ded — Per Occ X MGLO185435 7/25/2016 7/25/2017 MED EXP(Any one person) $ 5,000 I PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO. PRODUCTS X POLICY( JECT Loo TS-COMP/OPAGG $ 2,000 000 01HER Employee Benefits $ 1,000,000 I AUTOMOBILE LIABILITY COMBINED SINGLE,LIMIn $ , 1,000,000 (IEo gcgl,d"pk,,,,,, NON-OWNED BAS1756945605 7/25/2016 7/25/2017 ,BODILLY I person) $ V INJURY(Per B AUTOS X I AUTOS I)YURY(Peraccident) $ ANY AUTO BODILY ALL OWNED �SCHEDULED X HIRED AUTOS AUTOS t,F'?,t do 1)]AMAGE $ II Medical� .......5 X COMP-$1,000 X COLL-$1,000 payments $ 5,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 C EXCESS LIAR I CLAIMS-MADE AGGREGATE $ 1,900,000 DED X RETENTION$ -0- M0L0420761 7/25/2016 7/25/2017 $ WORKERS COMPENSATION PER �� OT'H- AND EMPLOYERS'LIABILITY y/N X „STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E L EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? D (Mandatory in NH) y 7600016618161 7/25/2016 7/25/2017 E L DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ 1'0 0 O 000 I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I, D 101,Additional Remarks Schedule,may be attached if more space Is required) RE: Covered CA Operations Performed By or On Behalf of the Named Insured. The City of El Segundo, its officers, officials, employees, agents, and volunteers are included as an additional insured, Primary/non-contributory, on the General Liability as respects to the insureds operations and only if required by written contract per the attached endorsement. Waiver of Subrogation applies to the Workers Compensation. Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. CERTIFICATE HOLDER CANCELLATION I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of E1 Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. E1 Segundo, CA 90245 AUTHORIZED REPRESENTATIVE (Margaret Gilmore/NB � -- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 igninnii Policy Number: MGL0185435 Mt. Hawley Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or O�rganl.ation(s): Location(s) Of Covered Operations: All persons or organizations where required by written contract. 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 in- not be broader than that which you are required clude as an additional insured the person(s)or organi- by the contract or agreement to provide for such zation(s)shown in the Schedule, but only with respect additional insured. to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or B. With respect to the insurance afforded to these in part, by: additional insureds, the following additional exclusions apply: 1. Your acts or omissions; or This insurance does not apply to "bodily injury" or 2. The acts or omissions of those acting on your "property damage"occurring after: behalf; 1. All work, including materials, parts or equipment in the performance of your ongoing operations for the furnished in connection with such work, on the additional insured(s) at the location(s) designated project (other than service, maintenance or re- above. pairs)to be performed by or on behalf of the addi- tional insured(s) at the location of the covered However: operations has been completed; or 1. The insurance afforded to such additional insured 2. That portion of"your work"out of which the injury only applies to the extent permitted by law; and or damage arises has been put to its intended use by any person or organization other than another 2. If coverage provided to the additional insured is contractor or subcontractor engaged in performing required by a contract or agreement, the in- operations for a principal as a part of the same surance afforded to such additional insured will project. CG 20 10 04 13 ®Insurance Services Office, Inc.,2012 Page 1 of 1 Insured Policy Number. MGLO185435 Mt Hawley Insurance Company 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 PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE , ' Name of Additional Insured Person(s) Location and Description of or Organization(s) Completed Operations All persons or organizations where required by written contract. 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. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to Section organization(s) shown in the Schedule, but only with III—Limits Of Insurance: respect to liability for "bodily injury" or "property dam- age"caused, in whole or in part, by"your work'at the If coverage provided to the additional insured is re- location designated and described in the Schedule of quired by a contract or agreement, the most we will this endorsement performed for that additional insured pay on behalf of the additional insured is the amount and included in the "products-completed operations of insurance: hazard". 1. Required by the contract or agreement;or However: 2. Available under the applicable Limits of Insurance 1. The insurance afforded to such additional insured shown in the Declarations; only applies to the extent permitted by law; and whichever is less. 2. If coverage provided to the additional insured is required by a contract or agreement, the insur- This endorsement shall not increase the applicable ance afforded to such additional insured will not Limits of Insurance shown in the Declarations. not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 37 04 13 ©Insurance Services Office, Inc., 2012 Page 1 of 1 Insured Policy Number: MGLO185435 Mt. Hawley Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDI'TI'ON This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition (2) You have agreed In writing in a contract or agree- and supersedes any provision to the contrary. ment that this Insurance would be primary and would not seek contribution from any other in- Primary And Noncontributory Insurance surance available to the additional insured. This insurance is primary to and will not seek con- tribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and CG 20 0104 13 ®Insurance Services Office, Inc.,2012 Page 1 of 1 Insured 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 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. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOM THE BLANKET WAIVER OF SUBROGATION NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH 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: 07/25/2016 Policy No. 7600016618161 Endorsement No. 001 Insured: Trueline Construction & Surfacing,Inc. Premium$INCL. Insurance Company: Everest National Insurance Company Countersigned By: -1998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved. From the WCIRB's California Workers'Compensation Insurance Forms Manual-1999.