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PROOF OF INSURANCE (2018) CLOSED
At wrC 0 IY I DATE(MMIDDYYY) A " CERTIFICATE OF LIABILITY INSURANCE 02116/2017 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 certificate holder in lieu of such endorsement(s). `PRODUCER CONTACT Marsh USA,Inc. NAME: PAX Two Alliance Center (AJCC N%F f,►. (A/C,,No): 3560 Lenox Road,Suite 2400 E-MAIL Atlanta,GA 30326 ADDRESS Attn:Atlanta.CertRequest @marsh.com I Fax:212-948-4321 INSURER(S)AFFORDING COVERAGE NAIL a 457102-RI-GAUWX-16-17 INSURER A.Westchester Su rplus Lines Insurance Co 10172 INSURED Charter Oak Fire Insurance Company 25615 Robertson Industries 2414 W.12th Street'Inc. INSURER C:National Union Fire Insurance Co.of Pittsburgh,PA 19445 Suite 5 INSURER D:Phoenix Insurance Company 25623 Tempe,AZ 85281 INSURER E:Liberty Insurance Underwriters Inc. 19917 INSURER F:Travelers Property Casually Company Of America n25674 COVERAGES CERTIFICATE NUMBER: ATL-004042748-07 REVISION NUMBER:3 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 IN D Y POLICY POLICY NUMBER (MMIDDIYYYYI IMMIDDIYYYY 1 P LIMITS A X COMMERCIAL GENERAL LIABILITY G2821800A 001 02/01/2017 08/01/2018 EACH OCCURRENCE $ 2,000,000 DAMAGE TO CLAIMS-MADE I X I OCCUR PREMISES Ea occurrence), $ 100,000 X SIR$10,000 Per Occ. MED EXP(Any one person) $ EXCLUDED PERSONAL&ADV INJURY $ 2,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY X PRO- ............. LOC POLICY AGGREGATE P AGG $ 0,000,000 p JECT � OTHE'F"�' F AUTOMOBILE LIABILITY 1'J-CAP-9D89706-5-16 08/01/2016 08/01/2017 $ 1, 00 nl (EaamdaD)1NGI'LELWbd0.0I' ..,......1.000.0......... X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED ti NON-OWNED PROPERTY DAMAGE $SCHEDULED AUTOS AUTOS accident) $ HIRED AUTOS f AUTOS (Per aczz dam) (Per Comp/Coll Ded:$1,000 $ X UMBRELLA LIAB C X N OCCUR EACH OCCURRENCE BE036027482 08/01/2016 08/01/2017 $ 25,000,000 " EXCESS LIAB ( I CLAIMS-MADE AGGREGATE $ 25,000,000 DED ( X RETENTION$10,000 $ D WORKERS COMPENSATION TC2NUB-9D900314-16(AOS) 06/0112016 08/01/2017 X I PER OT'H- B N I A TRO-UB-9D90032-6-16 AZ,OR,WI 08/01/2016 08/0112017 $ 1,000,000 (Mandatory n NH)LIABILITY E L EAUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ( ) E, E, ,ACCIDENT YIN OFFICER/MEMBER EXCLUDED EACH LAN`'. a.E.EA EMPLOYEE $ 1,000,000 yes,descdbe under DESCRIPTION OF OPERATIONS below E Ltib'ISEASE,'.POLICY r-tMl't $ 1,000,000 E Excess Umbrella 100005445606 08/01/2016 08/01/2017 Each Occurrence 25,000,000 Aggregate 25,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) RE:George E.Gordon Clubhouse Playground Resurfacing Project—Project No,PW 14-10 Upon award of the referenced project.City of El Segundo,CA,its officers and employees are listed as additional insured for General Liability in regards to services performed by the Insured during the referenced p project,on a primary and non-contributory basis per endorsements CG 2010 and CG 2037,when required by written contract.A Waiver of Subrogation applies in favor of the additional insureds on the Workers Compensation policy,when required by written contract. CERTIFICATE HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo,CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. I Manashi Mukherjee _M(_L1AO40,M1.i @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 457102 LOC#: Atlanta AC"lr, f> ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh USA,Inc. Robertson Industries,Inc. 2414 W.121h Street POLICY NUMBER Suite 5 Tempe,AZ 85281 ................................ CAR .....................................................................�.....�mm�. RIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance ____....._a________.... ..............___......................_______..... _www...__rrrrrr.... INSURERS AFFORDING COVERAGE/NAIC# INSURER G: N/A (N/A) ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD INSURED: RECESS HOLDINGS, INC. INSURER AFFORDING COVERAGE: POLICY EFFECTIVE DATES:02-01-2017-08-01-2018 Westchester Surplus Lines Insurance Co. POLICY NUMBER: G2821800A 001 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -- OWNERS, LESSEES O CONTRACTORS ACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 0 SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location(s)Of Covered Operations City of El Segundo, CA George E. Gordon Clubhouse Playground its officers and employees Resurfacing Project- Project No. PW 14-10 350 Main Street El Segundo, CA 90245 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 organization(s) shown in the Schedule, but only exclusions 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. All work, including materials, parts or 1. Your acts or omissions; or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work" out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of the same project. required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 10 0413 0 Insurance Services Office, Inc.,2012 Page 1 of 2 C. With respect to the insurance afforded to these 2. Available under the applicable Limits of additional insureds, the following is added to Insurance shown in the Declarations; Section III—Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the most we applicable Limits of Insurance shown in the will pay on behalf of the additional insured is the Declarations. amount of insurance: 1. Required by the contract or agreement; or Page 2 of 2 0 Insurance Services Office, Inc., 2012 CG 2010 0413 INSURED: RECESS HOLDINGS, INC. INSURER AFFORDING COVERAGE: POLICY EFFECTIVE DATES: 02-01-2017- 08-01-2018 Westchester Surplus Lines Insurance Co. POLICY NUMBER: G2821800A 001 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS,S, LESSEES O CONTRACTORS - COMPLETED OPERATIONS S This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE ed Operations Name Of Additional O rganizaotion(s�Parson(s) Location And Description Of Complet .. City of El Segundo, CA George E. Gordon Clubhouse Playground its officers and employees Resurfacing Project- Project No. PW 14-10 350 Main Street El Segundo, CA 90245 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 organization(s) shown in the Schedule, but only Section III—Limits Of Insurance: with respect to liability for 'bodily injury" or If coverage provided to the additional insured is ,property damage"caused, in whole or in part, by required by a contract or agreement, the most we your work at the location designated and will pay on behalf of the additional insured is the described in the Schedule of this endorsement amount of insurance: performed for that additional insured and included in the 'products-completed operations 1. Required by the contract or agreement; or hazard". 2. Available under the applicable Limits of However: Insurance shown in the Declarations; 1. The insurance afforded to such additional whichever is less. insured only applies to the extent permitted This endorsement shall not increase the applicable by law; and Limits of Insurance shown in the Declarations. 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 37 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 1 TRAM ELERS J WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 00 03 13 (00)- POLICY NUMBER: TC2NUS-9D90031-4-16 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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.) This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. SCHEDULE DESIGNATED PERSON: DESIGNATED ORGANIZATION: Any person or organization for which the insured has, agreed by written contract executed prior to loss to furnish this waiver. EFFECTIVE DATES: AUGUST 1,2016 TO AUGUST 1,2017 NAMED INSURED: PLAYCORE HOLDINGS,INC. INSURER: TRAVELERS INSURANCE COMPANY OF AMERICA DATE OF ISSUE: 08-05-16 ST ASSIGN: