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PROOF OF INSURANCE (2018) CLOSED DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE I 302017 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 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 endorsement(s). PRODUCER Ed q�eWood Partners Insurance Center(EPIC) PHONE AAME� 1'94 00 MacArthur Blvd. PH Floor �a fat); (949)263-0606 FAX Irvine, (949y 263 0906 Irvine, CA 92612 E-MAIL ADORES$: INSURER(S)AFFORDING COVERAGE NAIC# www.edgewoodins com INSURERA: Rockhill Insurance Company 28053 INSURED INSURER B: Robert's Liquid Disposal 14018 Carmenita Rd. wsuRERC: Santa Fe Springs CA 90670 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 34498972 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. INSIR�. ADDL(SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (Mmf0q Yl1 `�)Y i'MMODNYYYII LIMITS A ✓ COMMERCIAL GENERAL LIABILITY ✓ ENVP01272302 3/5/2017 3/5/2018 EACH OCCURRENCE $ 1,000,000 DAMAGE CLAIMS-MADE I 10 OCCUR PREM SES�a PEN 1'80 occ urrro;r Cep $ 50,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000', GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000, PRO POLICY�- —) JFCT � , LOG JFL,q -- PRODUCTS 7 COMP/OPAGG $$ ,2,000,00 OTN 1E AUTOMOBILE LIABILITY CONtBINEo,O,tf SINGLE Lo M9� -..$ ...... .,..., ..................... ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS AUTOS ONLY AUTOS ONLY (Pe ac+id fp Y OAMAC,L $ HIRED NON-OWNED PROPERT �ga , $ A UMBRELLA LIAB ✓ OCCUR ENVP01272502 3/5/2017 3/5/2018 EACH OCCURRENCE $ 4,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4,000,000 DED I ✓I'RETENTION$10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N �„STATUTE FR ANYPROPRIETOR/PARTNER/EXECUTIVE E L,EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? I U NIA (Mandatory in NH) E L DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ A Pollution Liability ENVP01272402 3/5/2017 3/5/2018 $5,000,000 per Occurrence/Aggregate Limit Transportation Pollution Liability $5,000,000 per Occurrence/Aggregate Limit DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Certificate holder is named as additional insured as respects the general liability,but only if required by written contract with the named insured,prior to an occurrence,per form CG 2010 07/04. Subject to all policy terms and conditions. CERTIFICATE HOLDER CANCELLATION City Ot El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Y g utl0 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN De artment of Public Works ACCORDANCE WITH THE POLICY PROVISIONS. 15 616inois Street El Segundo CA 902453813 AUTHORIZED REPRESENTATIVE I Tony D"Asaro ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 34498972 1 17-18 GL/UMB AI MAIN MASTER I Jan Schwartz 1 3/2/2017 11:49:46 AM (PDT) I Page 1 of 3 AGENCY CUSTOMER ID: ............... .............................. LOC#: ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED Ed ewood Partners Insurance Center(EPIC) Robert's Liquid Disposal ........................................................................................................................................................ 14018 Carmenita Rd. POLICY NUMBER Santa Fe Springs CA 90670 ... ........................ . . ..................... CARRIER _...._. ��.....�.�.�..� NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE:Certificate of Liability(03/16) ............................................................................ ww. HOLDER: City of El Segundo Department of Public Works ADDRESS: 150 Illinois Street El Segundo CA 902453813 ........................._................................................................................................. City of El Segundo, its officials, and employee as "additional insureds" with respects to general liability ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ADDENDUM 34498972 1 17-1B GL/UMB AI MAIN MASTER 1 Jan Schwartz 1 3/2/2017 11:49:46 AM (PDT) I Page 2 of 3 I Robert's Liquid Disposal POLICY NUMBER:ENVP01272302 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES O 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 Omanization(s): Location(s)Of Covered Operations Any person or organization for whom you are performing In respect to any location where the named insured is operations when you and such person or organization have performing"your work". agreed in writing in a contract or agreement,effected prior to the date your operations for that person or organization commenced,that such person or organization be added as an additional insured on your policy. -Information r�uir_d_t o _om ms e1 e thise Schedule,if not shown,will be shown in the Declarations A. Section II—Who Is An Insured is amended to include B. With respect to the insurance afforded to these as an additional insured the person(s)or additional insureds,the following additional exclu- organization(s)shown in the Schedule,but only with sions apply: respect to liability for"bodily injury","property damage" This insurance does not apply to"bodily injury'or or"personal and advertising injury"caused,in whole or "property damage"occurring after: in part,by: 1. All work, including materials, parts or equip- 1. Your acts or omissions;or 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 the additional insured(s)at the location of the in the performance of your ongoing operations for the covered operations has been completed;or additional insured(s) at the location(s)designated 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 ihn90971. 1 17 AO (n,flgW Al NAM JAAF.TYM 1 ,7;1. 11;V):11; new WIYN I i,g, J �f 3 't= CERTIFICATE OF LIABILITY INSURANCE °A ` "'' 03/061201 7 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. It 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 NAME,ACR,IUdy Beth Bettger Insurance Agency, Inc. 2ss-100o .W Np AXII; PVC p 562:.809-s StateFarm 20220 State Road , . IN�suReR�)_...._ ..�..................-.... ADD RES's:Jud y bethbett er.com Cerritos, CA. 90703 _ AFFORDING COVERAGE NAIC 4 State Farm Mutual Automobile Insurance Company 25"178 . .. ..m_,_._ INSURER A: _........ ................................................. INSURED Robert& Peggy Herricks INSURER B: DBA Roberts Liquid Disposal INSURER C: 14018 Carmenita Rd INSURERD: Santa Fe Springs, CA 90670-4919 INSURER E: mmIT INSURER F: COVERAGES CERTIFICATE NUMBER: 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 ... ADDttL.'"S'UBn"._ ___ ..�....., ----- ---- °'"...POLICOY&F 'POLICYF.XP -_._..�. ._...... POLICY NUMBER IMMID rMAMiCI[B,ryYYY1 LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ -M CLAIMS ADE 0 OCCUR PREMISES PEA ocdwor tW $ MED EXP(Any one person) - __ P ONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PR4' ❑ .1,ECT LOC PRODUCTS-COMPlOPAGG S 7 OPIPR 00,000 AUTOMOBILE LIABILITY COMBINED WNf"vl.Eu.tlMIT. . . .$...... .......—..,...................�_ ANY AUTO 521.2117-D21-75B 10121/2016 0412112017 BODILY INJURY(Per parson) $ HIRED n OWNED ros NON-OWNED UU P73-6852-A06-75Q 0110612017 0710612017 'tP�w e ry AMAOP $ - i"w BODILYINJURY(Peraccident) $ p a UMBRELLA LIAR p OCCUR ROCCURRENCE $ EXCESS LIAB I� .. .H ELATE $ CLAIMS-MADE AG G .... �& WORKERS COMPENSATION YIN N PER�� TH- DED �f RETENTION$ $ AND EMPLOYERS'LIABILITY ER �0 ANY PROPRIFTOWPARTNER07 C� NIA TATIJCCID, „R ANY V"FdO'PRtlPWm"Or�aARTNER/EJRI`'C4.NTtlVE E.L EACH ACCIDENT^. }4$ M Zt1dRan"TON OF 06 ERArIONS Wow EI DISEASE-POLICY LIIMIT�I$ NT a $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addldonal Remarks Schedule,may be attached Nmore apace Is required) CERTIFICATE HOLDER CANCELLATION City Of El Segundo/Public Works Dept. 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. HORI7E,D REPRESENTATIVE i I �- ©1988- AC RD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo a registered marks of ACORD 1001486 132849.9 02-04-2014 CERTHOLDER COPY 5C STATE P.O. BOX 8192, PLEASANTON, CA 94588 ■ CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 03-07-2017 GROUP: POLICY NUMBER: 1446891-2016 CERTIFICATE tO: 289 CERTIFICATE EXPIRES: 12-31-2017 12-31-2016/12-31-2017 CITY OF EL SEGUNDO, PUBLIC WORKS DEPT Sc 350 MAIN ST EL SEGUNDO CA 90245-3813 This is to certify trial we have issued a valid Workers' Compensation insurance policy to a form approved by the California Insurance Commissmric- tc the employer named below for the policy pericd indicaled. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer, We will also give you 30 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. Nolwilf,standing any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. X . V Authorized Represoimal;ve President and CEO UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' COMPENSATION LAW. — EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE, ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2017-03-07 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF EL SEGUNDO, PUBLIC WORKS DEPT ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 12-31-1998 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2017-03-07 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO, PUBLIC WORKS DEPT EMPLOYER HERRICKS, ROBERT LEE (II) AND HERRICKS, PEGGY LEE 14018 CARMENITA RD SANTA FE SPRINGS CA 90670 [RAA,CN) ecJ.'7 .zs7ttl PRINTED : 03-07-2017 ADDITIONAL INSURED EMPLOYER 1446891-16 RENEWAL SC HOME OFFICE 1-37-56-44 SAN FRANCISCO PAGE 1 OF ALL EFFECTIVE DATES ARE AT 12;01 AM PACIFIC EFFECTIVE MARCH 7 , 2017 AT 12. 01 A.M. STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME ROBERT' S LIQUID DISPOSAL 14018 CARMENITA RD SANTA FE SPRINGS, CA 90670 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT CITY OF EL SEGUNDO, PUBLIC WORKS DEPT IS HEREBY NAMED AS AN ADDITIONAL INSURED EMPLOYER ON THIS POLICY BUT ONLY AS RESPECTS EMPLOYEES WHOSE NAMES APPEAR ON THE PAYROLL RECORDS OF ROBERT'S LIQUID DISPOSAL (HEREIN CALLED THE PRIMARY INSURED) WHILE THOSE EMPLOYEES ARE ENGAGED IN WORK UNDER THE SIMULTANEOUS DIRECTION AND CONTROL OF THE PRIMARY INSURED AND THE ADDITIONAL INSURED EMPLOYER. IT IS FURTHER AGREED THAT THE PAYMENT OF THE FULL PREMIUM DUE AND PAYABLE UNDER THIS POLICY SHALL REMAIN THE SOLE RESPONSIBILITY OF THE PRIMARY INSURED. 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: MARCH 9, 2017 0015 AIJ"I"HC"RI 7r:J) REPRESENT A4 VE PRESIDENT AND CEO scar FORM 10217 (REm-2014) OLD C ENDORSEMENT AGREEMENT WAIVER OIL SUBROGATION 1446891--16 RENEWAL SC HOME OFFICE 1-37-56-44 SAN FRANCISCO PAGE 1 OF 1 ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC EFFECTIVE MARCH 7 , 2017 AT 12.01 A.M. STANDARD TIME OR THE TIME INDICATED AT AND EXPIRING DECEMBER 31 , 2017 AT 12 .01 A.M. PACIFIC STANDARD TIME ROBERT' S LIQUID DISPOSAL 14018 CARMENITA RD SANTA FE SPRINGS; CA 90670 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, PUBLIC WORKS DEPT WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, ROBERT'S LIQUID DISPOSAL 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 SANS FRANCISCO; MARCH 9, 2017 2570 AUTHORIZED REPRESENT `IVF, PRESIDENT AND CEO SCIF FORM 10217 (REV.7°2014) OLD OP 217