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PROOF OF INSURANCE (2018) CLOSED BRUBE-1 I aPtMm 6 CERTIFICATE OF LIABILITY INSURANCE IDDIYYYY) I GATE 03/0712017 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 cortlficate 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 certNicate holder in lieu of such endorsement(s). PRODUCER 866-376.2510 UkPCT Andrew Hyland Rack 10 Insurance Services PHONE 866-376-2510 066-are.aai t P.O.Box 15500 ,,,,ip No Exl%: _ _ $AJC„No)i: San Diego,CA$2175 a...a�.y.,_.z...._. Andrew HVland A, e,ahylend6rock101naurance.com °IRER(3��1Ff01 ,RQING,,CO„V,,,,ERf1¢E NAICN INSURER A:Uoyd's of London Synd 1991 INSURED P.O.eox Construction Co. R B:Everest National Insurance Co. 1I Iws,UFE 120 RN��R. Moreno Valley,CA 92556 p. c INSURER D: wusuAER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION Nk1MiBER: 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 3OLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS S TYPE OFINSURANCE L..-51J..Yy B POLIC........U,,.,,,,,,,,,,. ADDERS POUOYEFF DICDI-YYY-U LIMITS I AR X w.. . ....... IN ............ . VA YN MBER fplA!yD®1YYYY):, COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ 1,000,00o CLAIMS-MADE .X... OCCUR X X CISOTWOMS117 03!01/2017 01101/2018 .,'71tMA,X�, Xp al rsu„p1 Q 3,000 --- PERSONAL 6 ADV INJURY $ 1,000,000 GENt LIIr'1I�L.,1A1EJEMITAPPLIESP 4��14?IJJCTR-COMP/OP,AQQ,,,,I X POLICY ER, GENERALAGGREGA7E $ 2'000'000 ICY'D P�7 � LOC P 2,000,000 AUTOMOBILE E $ LIABILITY COMl3NN(:'A1RiiNr)y.E LIMIT $ ANYAUTO ...Ii ..LR.,Y.L RWL?Yd,mon)......$ AU70SONLY ALTOSDULED BODILY INJURY(PereradeM) $ AUTOS ONLY NON-O ONLY C J1aYrat1 diAACSE. $ ....11e EXCESSUABAB OCCUR LAIMS-MADE „� ...�....00CIJRRENCE $ AG(I'H �B8 RELATE $ .�..._, DED q I flETE NTION$ ---- ...- ._. X PTR i ., �;-R..H ..._$ ������., , WORKER COMPENSATION 17604013959161 11/2112016 11/21/2017 AAN� PROP IETOR LI RTNEIY ' 1,000,000 (Mandatory in NH?PARTNENEXECUTIVE X F t n SFASE ACCIDENT Fl EWMEMBER EXCLUDED. Y Nf A i,000,000� EA EMPI-OVEF $ 11 yes,describe under 1,000,000 PFRCRIPTION OF 0PFRATIONS below E L DISEASE-POLICY LIMIT $ PI g Included as I SOtonal l N51 VEHICLES(ars,ag 1 st,Ad dill Remarks Schedule,maybe ailadted fl more spa OF OPERATIONS))LOCATIONS is required) Rar:Cu of Et Segundo CI1 0l'EI Sa undo Ira oniclidlau o49flcer a dr+aa and orrt o s,areInclud augured under CornmorAw GL olc Eea'ail4ao endoraernnrtt(CG 20 jo to oi)�Gtpb)oci is cwrhten conaract� alwean Naame Insured and Addl onal heloed.GIL coversq�a Is pprimary 11,non- am kYC co laraga, CER AE HOLDER ON. C CITYOEL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of El Segundo ACCORDANCE WITHD THE EPO POLICY PROVISIONSE WILL BE DELIVERED IN Attn: PW Dept 350 Main St AUTHORIZED REPRESENTATIVE El Segundo,CA 90245 rI ACORD 25(2016103) 01988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Ft1MR:B6991SCO2015S01 I COMMERCIAL GENERAL LIABILITY POLICY NUMBER:cISDTWO02 651 17 CG 20 1010 01 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 Person or Organization: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section 11 - Who Is An Insured is amended to (1) All work, including materials, parts or include as an insured the person or organization equipment furnished in connection with such shown in the Schedule, but only with respect to work, on the project (other than service, liability arising out of your ongoing operations maintenance or repairs)to be performed by or performed for that insured. on behalf of the additional insured(s) at the B. With respect to the insurance afforded to these site of the. covered operations has been additional insureds, the following exclusion is completed; added: or 2. Exclusions (2) That portion of "your work" out of which the This insurance daes riot apply to "bodily in- injury or damage arises"has been put to its jury"or"property,damage" occurring after: intended use by any person or organization other than another contractor or subcontractor engaged in performing. operations for a principal as a part of the same project. CC 2010 10 01 Copyright ISO Properties,Inc.,2000 Page I of 1 ❑ V• UMR: B6991SCO2015S01 POLICY NUMBER EFFECTIVE DATE AND TIME INSURED C1SI)TWO02651 17 ; 03/01/2017 Douglas Bruce DBA: Brubec Construction Co. THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTING INSURANCE (Third Party's Sole Negligence) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART OWNERS AND PROTECTIVE LIABILI7Y COVERAGE FORM The following Is added to the Owner Insurance conditions of SECTION IV-CONDITIONS;: Other Insurance, Third Party It is agreed that in the event of a claim or "suit" arising out of the Named Insured's sole negligence, this insurance shall be primary and any other insurance maintained by the additional insured named as the Third Party below shall be excess and non-contributory. The Third Party to whom this endorsement applies is: Absense of a specifically named Third Party above means that the provlsJons of this endorsement apply "as required by written contractual agreement with any Third Party for whom ybu are performing work." All other terms, conditions and exclusions under this policy are applicable to this Endorsement and remain unchanged. DGL 1070 0716 Includes copyright material from Insurance Services Office, Inc. Page 1 of 1 UMR; B6991SCO2016SOI COMMERCIAL GENERAL LIABILITY POLICY NUMBER: C'UMTw002651 1-1 CG 24 04 110 93 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVER' AGAINST. OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: (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 0410 93 Copyright, Insurance Services Office,Inc., 1992 Page 1 of 1 D PROOF OF INSURANCE VEHICLES ON POLICY YEAR MAKE VEHID.# Interinsurance Exchange of the Automobile Club 2OD4 FORD 1FTSW3DL04EC92626 NAIL#:1559$ :013 FORD 1Mg6K7F84DGC866?3 a i Named Insured Policy Number: CAA 0628490/0 � BRUCE.DOUGLAS AND BRUCE,REBECCA = 9 DRIVERS ON POLICY ? BRUCE,DOUGLAS H Effective Date: 02.08.16 Explration Date: 02 08-17 BRUCE,REBECCA F Thk policy piovides at least the minimum arnounte of Gebitily insurance ioquitedi by the CA VEH CODE SECTION 16066 rar the spedried Vehicles,and nadred insuredn,WM may provide covw"a let other persorm acid other vehlctes as provided by lhn io."nurance policy, :. 800.40CIA222 W04 Yaw :imU Member Cuie CODE 429004 8808096707 CARD DpirmnoN DATE MAR 29 17 DOUGLAS H BRUCE "a�ai'��;.:.'!°.. t..a„"...'., ."•_. s............�... ......�<,f:;......_ ..._....,,_..,...ire �/ PROOF OF INSURANCE VE J� HICLES ON POLICY PROOF OF INSURANCE YEAR 161AKE VEH I.D.X Interinsurance Exchange of the Automobile Club 2013 FORD 1FM5K7F84DGC86823 NAIC fl:15598 Named Insured Policy Number. CAA 0628 49 01 0 BRUCE,DOUGLAS AND BRUCE.REBECCA a DRIVERS ON POLICY BRUCE,DOUGLAS H BRtJCE,.RE'BEC'CA F Effective Date: 02-08.17 Expiration Date: 02-08-18 11his policy provides at Moat the min1murn Wnounls of ttebilt1y insuranceroaqgviredby The CAVW CODE'SECTION'16DSrw orthu specillad valb Was OW nand Insureds and ma,y Iatovidn coverage for olhef persons and othervehieles as provided by the Iasuiance policy. VEHICLES ON POLICY PROOF OF INSURANCE YEAR MAKE VEH I.D.it 2004 FORD 1FrSW30L04EC 92826 Interinsurance Exchange of the Automobile Club 2013 FORD 1FWK7F84DGCBU23 NAIL#:15598 Named Insured Polley Number: CAA 062a49010 m BRUCE,DOUGLAS AND BRUCE,REBECCA DRIVERS ON POLICY BRUCE,DOUGLAS H Effective Date: 02-08-17 Expiration Date: 02-08.18 R BRUCE,REBECCA F Tril's poky plovlries at least the rminlrn m amoitiils of 11abil'4y insurance required by the CA VEH CODE SECTION'16058 ror the ap"Ined votdcloo,and ri«amod'insareds and may,prmlda cxavata,ge rdr olhar rici'som and othorvehlolos as prawided by the Insurance policy. Place the Proof of Insurance in each vehicle insured under your policy. In addition, we suggest that each listed driver carry a card. 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 5 % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION CITY OF EL SEGUNDO NORK INVOLVES INSTALLING RESTROOM 350 MATN STREET PARTTTTONS CTTY OF FT, SEGUNDO 350 EL SEGUNDO, CA 90245 MAIN ST. ,EL SEGUNDO, CA 90245 This endorsement changes the policy to which it fs 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 01-04--17 Policy No. 7600013959161 Endorsement No. 001 Insured BRUCE, DOUG (AN INDIVIDUAL) Premium $ INCL. Insurance Company EVEREST NATIONAL INSURANCE COMPANY Countersigned By -1988 by the Workers'compensation Insurance Rating Sumau of Callforrda. All rights reserved. iFrom the WCIRft California Workers'Compensation Insurance Forms Manual-.4999. INSURED COPY '9 DATE(MM/DDIYYYY) � CERTIFICATE OF LIABILITY INSURANCE 06/28/2016 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 policy(ies) 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 I certificate holder in lieu of such endorsement(s). PRODUCER CONTACT' MCGRIFF,SEIBELS&WILLIAMS OF GEORGIA,INC. NAME: PHONE .. ........ ..._---FAX .....,... 5605 Glenridge Drive-Suite 300 tA/C No, x :404 497-7500 (A/C.Not; Atlanta,GA 30342 EMAIL ADDRESS: INSURERS) AFFORDING COVERAGE NAIC# INSURER A,Zurich American Insurance Company 16535 INSURED ance Company 40142 Veritiv Operating Company INSURER B:American Zyr!oh„..L.S.4f....................... 1000 Abernathy Rd NE INSURER C: Building 400,Suite 1700 Atlanta,GA 30328 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:PEFV5BC2 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. - TR TYPE OF .. ,.,���.,. Wvp POLICY NUMBER IMWDDIYYYYI �(MMIDD INSR INSURANCE ADD B .. iid0dY�E F 0OUd'Y'EXP L LIMITS 1YYYY I A X COMMERCIAL GENERAL LIABILITY GLO3878675-02 07/01/2016 07/01/2017 EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE I- OCCUR T.FA?ugk�,II E'!P'L' 'I'��:'I+l'rturF.....................'...' 1,000,000 _ F'R((�t'MSES F.aocri.Irnerrcel $..,,,, MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 2,000,000 '''G���EN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY F-1,,PROi El LOC PRODUCTS-COMP/OPAGG $ 000 ECG 4,000, OTHER $ A AUTOMOBILE LIABILITY BAP 3878576-02 07/01/2016 07/01/2017 COMBINED SINGLE t.0l` tF.a,•acci,d„ent) $ 5 000„000......................0 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED .... ............................................ AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON accident)PROaccidenk_..—_ ...................................... Per P� AGE: $ CLAIMS- AGGREGATE $ , EXCESS L.IAB.A.B............ ...O.C.....M.S..MADE EACH OCCURRENCE $......... DED N RETENTION$ $ B WORKERS COMPENSATION WC 3878573-02 AOS) 07/01/2016 07/01/2017 X S PER A?JTE,,,,,,,,,, O(H ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WC 3878574-02MA,WI) EACH ACCIDENT ,,. R.. ..$,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 1,000,000 j OFFICER/MEMBER EXCLUDED? N N/A i (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ 1,000,000 $ $ $ $ $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Re Evidence Only CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Veritiv Operating Company ACCORDANCE WITH THE POLICY PROVISIONS. 1000 Abernathy Rd NE Building 400,Suite 1700 AUTHORIZED REPRESENTATIVE Atlanta,GA 30328 ° Page 1 of 1 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD