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PROOF OF INSURANCE (2017 - 2018) CLOSED AC I DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 3/212017 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 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 endorserrient(s). PRODUCER NAMECONTACT DAVID GLEASON N 9477 Greenback Lane N MAr" DA FAX Gleason Insurance Brokers LL PHOIN V6- G D E dal) 916 542 L A ONINSURANCEBROKE)RS.CO-A 948 855-543-4 Unit 523 INSPRER S AFFORDING COVERAGE NAIC# Folsom CA 95630 INSURERA:U-S. SPECIALTY INSURANCE COMPANY 29599 INSURED INSURER B:SECURITY NATIONAL INSURANCE AYUS&CO INC INS URERC:NATIONAL UNION FIRE INSURANCE 1511 N KENMORE AVE ILOS ANGELES CA 90027 RUR E..... COVERAGES CERTIFICATE NUMBER:003 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 'AID CLAIMS. ILTR COMMERCIAL GENERAL „Arms' /MM/DDY _rM...� EAC,,,,, S .. , EFF POLICY EXP p �� POLICY NUMBER IYYYY MJDD1YYYY'1 0 II a/�� 5AMA6E,ro PFN"TE"B L ( 00 bA.t§E§ xrtiprr nr.rJ............$ 1,000... CLAIMS-MADE � OCCUR U16AC91867-00 PRFHOOCUFR OCCURRENCE P $ 100,000 A 4/5/2016 4/512017 MED EXP(Any one person) $ 5,000 BIIPD„D R.S.ONA�..&ADV..IN�URY $ 1,000,000 ED$2000.00 PE ............ ....................................................................... GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 �-rr7��a,OLICY' JECT LOC .�PRODUCTS.�..COMP/OP.�AG�G.... s...2�'O�O�O'�O�O�O............................ VI OTHER: -_....................._....._........... ....,............... ... AUTOMOBILE LIABILITY 17-1 D C0 BINED:S.'.N.G.L.E...L.INti0.1 $ 1,000,000 000 ANY =Ga ac:ce{rarnt' B [Z-11 OWNED AUTO AUTOS SPP1526186 3/2/2017 3/212018 .."BODILYINJURY...(Per..accdeot)... ...................................................................... AUTOS ONLY AUTOS ONLY .�I. a Y DAMAGE .......................................................................... HIRED NON-OWNED ROPIL„���i 0�;nt1 L. UMBRELLA LIAB EACH OCCURRENCE $2,000,000 C EXCESS LIAB LAIMS,MADE EBU020689752 3/2/2017 31212018 AGGREGATE $2,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N L.STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) """"""""" E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) NON-STRUCTURAL REMODEL-TENANT IMPROVEMENTS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St. El Segundo, Ca 90245 AUTHORIZED REPRESENTATIVE u DAVID GLEASON p ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Produced using Forms Boss Web Software.www.FormsBoss.com(c)Impressive Publishing 800-208.1977 POLICY NUMBER: U16AC91867-00 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 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 Organization(s): Location(s) Of Covered Operations City of El Segundo Location(s) of Covered Operations: 350 Main St., El Segundo, Ca 90245 350 Main St., El Segundo, Ca 90245 Description of Operations: COMMERCIAL WORK -NON -STRUCTURAL REMODEL-KITCHEN AND BATHROOM IMPROVEMENTS .... .............. 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 additional exclu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage" or "personal and advertising injury" "property damage"occurring after: caused, in whole or in part, by: 1. Your acts or omissions; or 1. All work, including materials, parts or equip- ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project (other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) desig- covered operations has been completed; or nated above. 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 ❑ POLICY NUMBER: U16AC91867-00 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 t Name Of Additional Insured Person(s) Location And Description Of Completed Or Organization(s): O erations City of El Segundo 350 Main St., El Segundo, Ca 90245 350 Main St., El Segundo, Ca 90245 COMMERCIAL WORK- NON-STRUCTURAL REMODEL- KITCHEN AND BATHROOM IMPROVEMENTS 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 sched- ule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". CG 20 37 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 0 HCCNamed Insured:AYUS&CO INC Policy Number: U16AC91867-00 Insurer U.S.Specialty Ins Co—Admitted Carrier Endorsement Effective Date:02/15/2017 Change Endorsement Number:4 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY GENERAL CHANGE ENDORSEMENT The following endorsement modifies policy terms provided by the above listed policy number,. Form CG 20 10 07 04 -Additional Insured - Owners, Lessees or Contractors—Scheduled Pet-son or Organization is added to the policy with the following scheduled information: Name of Additional Insured Person(s) or Organization(s): City of"El Segundo 350 Main St., El Segundo, Ca 90245 Location(s) of Covered Operations: 350 Main St., El Segundo, Ca 90245 Description of0peratio ns: CONIME'RCIAL WORK -NON - STRUCTURAL REMODEL - KITCHEN AND BATI IROOM IM11ROVI:N4`NTS Form CG 20 37 07 04 -Additional Insured - Owners, Lessees or Contractors - Completed Operations is added to the policy with the following scheduled information: Name of Person or()rganization(s): City of El Segundo 350 Main St., Ed Segundo, Ca 90245 Location: 350 Main St., E1 Segundo, Ca 90245 Description of Completed Opperations: COMMERCIAL WORK -NON - STRUCTURAL REMODEL - KITCHEN AND B �`l-IROOM IMI ROVENIfiNTS ALL OTHER TERMS AND CONDITIONS OF HIS POLICY REMAIN UNCHANGED ve rcym,a,'�"irsa;rmwti I$cl'srzxn�at®rtati`c V HCS 060 08 11 12 Page 1 of 1 POLICY NUMBER: U16AC91867-00 COMMERCIAL GENERAL LIABILITY HCS 040 06 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND N ONCONVTRIBUTORY AND BLANKET WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. PRIMARY AND NON-CONTRIBUTORY TO B. WAIVER OF SUBGROGRATION—BLANKET OTHER INSURANCE Under SECTION IV — COMMERCIAL GENERAL With respect to any person or organization that is LIABILITY CONDITIONS, The Transfer Of an additional insured under this Coverage Part, Rights Of Recovery Against Others To Us the following is added to paragraph 4. of Condition is amended by the addition of the SECTION IV — COMMERCIAL GENERAL following: LIABILITY CONDITIONS: We waive any right of recovery we may have If you have agreed in writing in a contract or against any person or organization because of agreement that this insurance is primary and non- payments we make for injury or damage arising contributory relative to an additional insured's own out of: insurance, then this insurance is primary and we a. Your ongoing operations; or will not seek contribution from that other insurance. For the purpose of this endorsement, b. "Your work" included in the "products- the additional insured's own insurance means completed operations hazard". insurance on which the additional insured is a However, this waiver applies only when you have Named Insured. agreed in writing to waive such rights of recovery When this endorsement is attached to the policy it in a contract or agreement, and only if the contract supersedes all other insurance conditions within. or agreement: a. Is in effect or becomes effective during the term of this policy; and b. Was executed prior to loss. HCS 040 06 10 13 Page 1 of 1 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. POLICYHOLDER COPY SC • P.O. BOX 8192, PLEASANTON, CA 94588 r CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 02-15-2017 GROUP: POLICY NUMBER: 9167666-2016 CERTIFICATE ID: 2 CERTIFICATE EXPIRES: 04-08-2017 09-27-2016/04-08-2017 CITY OF EL SEGUNDO SC JOB:ALL CA OPERATIONS 350 MAIN ST EL SEGUNDO CA 90245-3813 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 10 days advance written notice to the employer. We will also give you 10 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 certilicate of insurance may be issued or to which it may pertain, the iinsurance 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 #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2017-02-15 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF EL SEGUNDO ENDORSEMENT #1600 - OSINAME,BABA PRIES SEC TRES - EXCLUDED. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2017-02-15 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO EMPLOYER AYUS & CD, INC DBA: AYUS & CO, INC SC PO BOX 361111 LOS ANGELES CA 90036 [ISS,CSI (REV.7-2014) PRINTED : 02-15-2017 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION 9167666-16 STATE NEW INSURANCE SC FUND 9-97-43-49 PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE FEBRUARY 15, 2017 AT 12 . 01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING APRIL 8, 2017 AT 12 . 01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME AYUS & CO, INC PO BOX 361111 LOS ANGELES, CA 90036 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, AYUS & CO. INC 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%. 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: FEBRUARY 17 , 2017 2570 AUTHORIZED REPRESEIV'I IVE PRESIDENT AND CEO SCIF FORM 10217 IREV.7-2014) OLD DP 217