PROOF OF INSURANCE (2017 - 2018) CLOSED ARCPLUM-01 PPEM
CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
`64 - ^`" 03/3012017
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 endomement(s).
n
Licese#OC36891 c
PRODUCER N24JA CT Pati Perez
Lyddy Martin Company PHONE FAX
20300 Ventura Blvd.Suite 340 (A/C,No,Ext);(310)548-1959 IBC,Noi,(310,)548-1346
Woodland Hills,CA 91364 p'ati @lyd'd,ymartin.com
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A:ICAT(ICAT 4242,Syndicate of Lloyds)
INSURED INSURER B:Hartford Accident and Indemnity Company 22367
Ruben Chavarin DBA ARC Plumbing INSURERC:TwIn City Fire Insurance Company 29459
3124 Rosecrans Avenue INSURER D:
Hawthorne,CA 90250
INSURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER: 1 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.
INSR IADDLISUeR POLICY EFF POLICY EXP
TR TYPE OF INSURANCE INSD WVD POLICY NUMBER I P LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 2,000,000
CLAIMS-MADE X OCCUR )( , X CISDTW000246 07/1812016 07/18/2017 PREMI Sa aoow,^Tence) S 100,000
MED EXP(Any one,person) S 5,000
PERSONAL&ADV INJURY S 1,000,000
GEN1 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000
X POLICY j LOG PRODUCTS-COMP/OP AGG S 2,000,000
OTHER S
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000
(Ea PP Ide PI) S
ANY AUTO 72UECGZ4996 09/0912016 09/09/2017 BODILY INJURY(Per person) $
OWNED X SCHEDULED
AUTOS ONLY I AUTOS BODILY INJURY(Per accident) S
X 01%ONLY X AUTOSWN p OI�Y ire eEc en,pAMAGB E
S
UMBRELLA LAB OCCUR EACH OCCURRENCE $
EXCESS LAB CLAIMS-MADE AGGREGATE $
DIED RETENTION$ $
C WORKERS COMPENSATION X PER OTH-
AND EMPLOYERS'LIABILITY YIN STATUTE ER,
ANY PROPRIETOR/PARTNER/EXECUTIVE 72WECZI9066 04101/2017 04101/2018 1,000,000
C � E EXCLUDED? NIA E L EACH ACCIDENT $
ManFIdaEto�Mry In M
E.L.DISEASE•EA EMPLOYEE $ 1,000,000
H ea,describe under 1,000,000
_DESCRIPTION OF OPERATIONS below E DISEA%•POLBCY LIMIT' E
i
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Addlllonal Remarks Schedule,may be stlachad If more space Is re ulred)
The City Of El Segundo,a general law city and municipal corporation("City")are named as additional Insureds)as pertains to general liability per the
attached blanket additional Insured endorsements 101 PKG 0032838.00.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CI Of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City 9 ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
El Segundo,CA 90245
AUTHORIZED REPRESENTATIVE
ACORD 25(2016/03) u ®1988-2016 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: CISDTW000246 16 COMMERCIAL GENERAL LIABILITY
CG 20 10 10 01
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, L SSEES O
CONTRACTORS - SCHEDULED PERSON O
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 II - 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 injury
This insurance does not apply to "bodily in- or damage arises has been put to its intended
jury"or"property damage" occurring after: 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.
CG 20 10 10 01 Copyright ISO Properties, Inc., 2000 Page 1 of 1
POLICY NUMBER: CISDTW000246 16 COMMERCIAL GENERAL LIABILITY
CG 24 04 10 93
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OFTRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO CIS
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 04 10 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 ❑
POLICY NUMBER EFFECTIVE DATE AND TIME INSURED
CISDTW000246 16 7/18/2016 12:01 AM DBA:A R C Plumbing
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY AND NON-CONTRIBUTING INSURANCE
(Third Party's Sole Negligence)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
OWNERS AND PROTECTIVE LIABILITY 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 provisions of this endorsement apply
"as required by written contractual agreement with any Third Party for whom you 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
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF OUR RIGHT TO RECOVER FROM
OTHERS ENDORSEMENT CALIFORNIA
Policy Number: 72 WEC ZI9068 Endorsement Number:
Effective Date: 04/01/16 Effective hour is the same as stated on the Information Page of the policy,
Named Insured and Address: RUBEN CHAVARIN
DBA ARC PLUMBING
3124 W ROSECRANS AVE STE B
HAWTHORNE, CA 90250
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 AS REQUIRED BY WRITTEN
FROM WHOM YOU ARE REQUIRED CONTRACT.
BY WRITTEN CONTRACT OR
AGREEMENT TO OBTAIN THIS
WAIVER OF RIGHTS FROM US.
Countersigned by
Authorized Representative
Form WC 04 03 06 (1) Printed in U.S.A.
Process Date: 04/15/16 Policy Expiration Date: 04/01/17