PROOF OF INSURANCE (2018) CLOSED ql SCOTWEA-01 P1101,?^Il:;p� I R
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"ll Ile.,,, oIIIV iIIII 0V'diPl VII .mllily VV DATE(MM/DD/YYYY)
3/16/2017
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).
O 11 111111"�^uI 1 ul�Y Ii�'.7I 1 Ili ICI 1"1 I,
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INSURERI5)AFFORDING COVERAGE NAIC q
1111 11 I I II ;II1111 tl„:V V ')'II"'Y"'V I;;!I"V!'"tl'^,r 1 11 9 I,,,I,1 911
INSURED 111 III k!P I'1 '11'II 11„!„ N�yll 114;V111631 1111 III will"II N:: IN IV 1'�:II d:'{I I' 29742
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National Union Fire Insurance Company of Pittsburgh,Pa,l 1.;
Scott Weaver I INSURER C: '!'�'��I""'�""''",��rr
1114 St.George Drive INSURER D
San Dimas,CA 91773 INSURER E
INSURER F
1� N'I"111.:�'�E Y'wu�
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
INdK TYPE OF INSURANCE AUUL bubk POLICY EFF VULIi.Y ekP LIMITS
LTR INSD Won' POLICY NUMBER IMMIDDIYYYY) (MMIDD/YYYYI
COMMERCIAL GENERAL LIABILITY I I 1 ' IINI I III'1 1,000,000
C' In'y 0105107004 03/13/2017 03/1312018 UAMAUt i U IN 1 EU 100,000
CLAIMS-MADE OCCUR PRFMI.SFA lF nr,urranc
MED EXP(Any one person) 5,000
PERSONAL&ADV INJURY 1,000,000
;1 III �I',l I, II 111',111 '1'1'I II r1I h,I d GENERAL AGGREGATE 1 `i 2000,000
X I' I 2,000,0001
PRODUCTS-COMP/OP AGG
1,
AN i COMBINED SINGLE LIMI I 1 000 0001
AUTOMOBILE BILE LIABILITY 1112001934 01/20/2017 YNI (dent)
(Ea accident)
B Y AUTO 01/20/2018 '11 u'"1 1111 I,'
Ill Irli,�wYl'11 I� '� 111 VI lll� I,,,•,�; i, ,
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PI
In11
UM I
BRELLA LAB ,1°'��, I OCCUR 9, '1 III I,I'!I;'Pr 4,000,000
C X EXCESS LAB I CLAIMS-MADE EBU015886270 03/13/2017 a 03/13/2018 1 4,000,000
DED
WORKERS COMPENSATION " PER 'I U I H- I
AND EMPLOYERS'LIABILITY YIN STATUTE 8 ER
ANY PROPRIETOR/PARTNER/EXECUTIVE N I A EL EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? 1
(Mandatory in NH) 1 IEL DISEASE-EA EMPLOYEE T.
If yes,describe under
DESCRIPTION OF OPERATIONS below u E L DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
Re:Engineering Plan Check Service,City of El Segundo.
Certificate holder and its officials,officers,agents and employees are included as additional insured per 49-0116(07/11)endorsement including primary
wording&waiver of subrogation.
Via email:jhegvold @elsegundo.org
CERTIFICATE HOLDER N:Aih1'(':"I''U.1A I ION
THE SHOULD EXPIRATION DATE DAB EVE,H..,
ESCRIBED POLICIES BE CANCELLED BEFORE
Cot of Ifc.O Segundo THEREOF, NOTICE WILL BE DELIVERED IN
City g ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
li:::i Segundo,CA 90245
AUTHORIZED REPRESENTATIVE
I
@ 1988.2014 ACORD CORPORATION. All rights(reserved.
ACORID 25(2014101) The ACOIRD Inams and logo are(registered marks of ACORID
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This endorsement modifies insurance provided under the following
COMMERCIAL GENERAL LIABILITY COVERAGE PART
i,II^ 0W.,,^II'hvi E3 ii
;IN Ma m i
3b,
Policy Number: NA105107004 uu'Mm a uuu I 11 " . u� : i min M
1"Jar°u°w"N.] IIIpi sul.:r ill:MuJ countersigned By:
S C 1�. i...i""NwA'll, .."n..H;!EkM'::IIL.,, Uli,(Er: V III III,.,u
S'L,��W� IM II'91111Y V""",M Yj M 1999k'
Name of Person
V, ,,"'i���'���iu'..... [!!!11 S VIII V..h IJ IC;;;�"nIIG II
31,01 r0 a'"m II M'' S N Illl M Ii.
....
VARIOUS LOCATIONS THROUGHOUT EL SEGUNDO, CA
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the
Schedule, but only with respect to liability arising out of"your work'for that insured by or for you.
The following additional provisions apply to any entity that is an insured by the terms of this endorsement:
1. Primary Wording
If required by written contract or agreement: Such insurance as is afforded by this policy shall be primary
insurance, and any insurance or self-insurance maintained by the above additional insureds)shall be excess
of the insurance afforded to the named insured and shall not contribute to it.
2. ,°;'w by
If required by written contract or agreement:We waive any right of recovery we may have against an entity
that is an additional insured per the terms of this endorsement because of payments we make for injury or
damage arising out of"your work"done under a contract with that person or organization.
3. Neither the coverages provided by this insurance policy nor the provisions of this endorsement shall apply to
any claim arising out of the sole negligence of any additional insured or any of their agents/employees.
4. This endorsement does not apply to any work involving or related to properties intended for permanent
residential or habitational occupancy(other than apartments).
The words"you" and "your" refer to the Named Insured shown in the Declarations.
'Your work" means work or operations performed by you or on your behalf; and materials, parts or equipment
furnished in connection with such work or operations.
48-0115 0711 May Include Copyrighted Material of Insurance Services Offices, Inc. page 'l of 1
Used with permission
CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
WARN G; FAILURE TO SECURE WORKE RS' COMPVµ ISAT ON COW---RAGE
IS (JNLAWFUL AND SUBJECTS AN EMP'LOYER T(.) CRIMINAL `)ENAL'flES
AND DID 6I.. FI NES UP TO ONE, H6 NN DOLL.ARS ($Ioo,000),
lN ADDrrloN i,o "mF., COST OF COMPENSATVJ, DAI0AGES AS 1ROV0ED
F,014', IN LABOR CODE § 3706,, &NTERES-r, ANf,.) AT-T ORNEYS FEES,
I affirm under penalty of perjury under the laws of California one of the following declarations:
ha and will maintain a certificate of consent of self-insure for workers compensation. issued by the Director
of ln(,fius,,,ria1 Relations as provided for by Labor Code§3700 for the performance of the work set forth the agreement
with U-e ,,'0y of El Segundo.
Policy No
I have and will maintain workers'compensation insurance as required by Labor Code§3700 for the performance
of the work for which the agreement with the City of El Segundo is executed My workers compensation insurance
carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent ..... Phone 4
I certify that in the performance of the work set forth in the agreement with the City of El Segundo, i will not
employ any person in any manner so as to become subject to the workers' -compensation laws of California, and
agree that. if I should become subject to the workers compensation provisions of Labor Code § 3700 1 must
immediately comply with those ;,,,rovisions or the agreement will automatically become void
Signature of Applicant
Date
Agreement for:or: SCOTT WEAVER T.I. -
Dated, 0
Reviewed by,