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PROOF OF INSURANCE (2017 - 2017) CLOSED
Client#:1291580 305CORRACON DATE(MMIDD/1(YYIf) ACORD. CERTIFICATE OF LIABILITY INSURANCE 03116/2017 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 policypes)must be endorsed.If SUBROGATION IS WANED,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 BB&T Insurance Servicessuch anrfGrsemant 1«. (' Angelique Lopez .m mm certificate holder In lieu M . FA Exww:714 941-2800 (A/C.UP):877 29T 9259 of Orange County 122811 , an a ue.l'opex @bbandt.com 2400 Katella Avenue Ste 1100 INSURER(S)AFFORDING COVERAGE NAIC t Anaheim,CA 92806 1 INSURER A:Colony Insurance Company 39993 INSURED I INSURER B:S't'ate Compensation Ins.Fund of 35076 Corral Construction&Development Inc 5211 E.Washington Blvd.#2-122 I INSURER C!Westchester Surplus Lines Insur 10172 9 I INSURER D,American Fire and Casualty Co 24066 Commerce,CA 90040 IN&URER_E: 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 CONTRACTOR 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. .�' • —TYf+E,TINSURANCE ........•..._.,'( ,S ya Poucv„NUMBER (`NI _ FY-FY) (MMiI w,�'�'} LIMITS _ 101GL000316103 121OW2016 1VOW017 EACH OCCURRENCE x2,000 A �(' COMMERCIALOENERALLIABILnY ,GOO _ CLAIMS-MADE rX OCCUR F1'E'HTEO X BVPD DIeId,F11XI �MFP :Y rlJ......_..5.5.0.000 _ s ,000 PERSONAL A ADV INJURY s2!,000,000 GENL AGGREGATE UMITAPPLIESPER: GENERAL AGGREGATE x3,000,000 PRO- PRODUCTS-COMP/OPAGG s3,000,000 POLICY❑JECT LOC OTHER; $ p AUTOMOBILE UABIUTY BAA57476683 121 SM16 12/08/201 COMBINED 4=* 1 S(NGLE LIMIT 1,000,000 ANY AUTO BODILY INJURY(Per Person) $ _ ._.._ ALL OWNED SCHEDULED I BODILY INJURY(Per accident) s HIRED AUTOS AUTOS NON-OWNED V PROPERTY DAMAGE ; AUTOS N.G.A(..4d0E11 I ...•.• tl Is UMBRELLA LIAR OCCUR __.._.._. I EACH OCCURRENCE s EXCESS UAD FI CLAIMS- MADE A AGGREGATE OED 1 RETENTION$ $ B AND WORKERS E EMPLOYERS' IT EOU�nrL 903611816 12/01/2016 12101/2017�XA, O p� �p tl PERA'w'�,[.T.�._._..I....�.,...I ..�...�..r_,000 R/P/IEMaER EJL�UD� .YIN E.L.DL9E E EA EMPLOYEE x1,O0tI,pQ,O..•.. OM EMS ii ER5 uABILITY N/A (Mandatory ggroand d r4In under _ D'ESU"RI'PItON OFOPERATINS below - E.L.DISEASE-POLICY UMIT s1,000,000 C Pollution G27572376001 03/16/2016 03/1612017 $1,000,000 Ea Pollution Condition$2,000,000 Agreegate w/5000 DIED DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 101,Additional Remrks Schedule,may be attached if mom apace le mqulmd) City of El Segundo,Its officials,and employees are Included as additional insured with respect to general liability as required by written contract.Waiver of Subrogation and Primary wording also applies,endorsement U156A-0313 attached. CERTIFICATE HOLDER CANqELLATION Of El Undo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED W 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo,CA 90245 ' AUTHORIZED REPRESENTATIVE I ` � ®1988-2014 ACORD CORPORATION.All rights reserved. ACORD 26(2014101) 1 of 1 The ACORD name and logo are registered marks of ACORD #S17'8116 17258004 ATMAR REVISED 04/03/2017 22:07 UTC 101 GL 0003161-03 ENDT.#002 EFF: 04/03/2017 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Endorsement Premium $0 Stamping Fee $.00 Surplus Lines Tax $.00 Total $.00 POLICY CHANGES POLICY NUMBER POLICY CHANGES COMPANY EFFECTIVE 101 GL 0003161-03 04/03/2017 Colony Insurance Company NAMED INSURED AUTHORIZED REPRESENTATIVE Corral Construction & Development Inc. Craig Comeaux COVERAGE PARTS AFFECTED COMMERCIAL GENERAL LIABILITY COVERAGE PART CHANGES In consi_c.do ation of the prerLY_Lum charged, i.t i-S LarLCIGYr.,stoocd and agreed that the pol.i.cy i.,s amended as fellows P.r.em.iurn for the foil.owi_Lac1 Coverages i_s FulLy Earned: 1. BLeanket Addi.Li.onal. I.LL,sur.ed forms (.:Ca2010 04/13 and CO20137 04/13, gadded at LILe lac>l.i.cy i.rLc.:.epti.on, are hereby arnended to _include F'rlmary Non-Contributory GaLtguage Ever attached. 2. Blanket w ai.ver of subrogation i.,s added to the policy pFar_ t.'onn 17047 03/10 atLached. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED V Authorized Representative Signature IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1 Copyright, ISO Commercial Risk Services, Inc., 1983 REVISED 04/03/2017 22:07 UTC 101 GL 0003161-0< ENDT.#002 EFF: 04/03/201 i COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 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 Additional Insured Person(s) Or Organization(s) Location(s)Of Covered Operations AS DESIGNATED IN WRITTEN CONTRACT WITH THE All Commercial and/or Residential-Remodel/Repair NAMED INSURED work as required by written contract with the insured It is further agreed that this insurance is primary and non-contributory but only in the event of a Named Insureds sole negligence. 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 other insured only applies to the extent permitted by 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 CG 20 10 0413 ©Insurance Services Office, Inc., 2012 Page 1 of 2 REVISED 04/03/2017 22:07 UTC 101 GL 0003161-03 ENDT.#002 EFF: 04/03/2017 provide for such additional insured. 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 ©Insurance Services Office, Inc., 2012 CG 20 10 04 13 REVISED 04/03/2017 22:07 UTC 101 GL 0003161-03 ENDT.#002 EFF: 04/0312017 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations AS DESIGNATED IN WRITTEN CONTRACT WITH All Commercial and/or Residential-Remodel/Repair THE NAMED INSURED work as required by written contract with the insured It is further agreed that this insurance is primary and non-contributory but only in the event of a Named Insureds sole negligence. 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 04 13 ©Insurance Services Office, Inc., 2012 Page 1 of 1 REVISED 04/03/2017 22:07 UTC 101 GL 0003161-03 ENDT.#002 EFF: 04/03/2017 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. TRANSFER OF RIGHTS OF RECOVERY RY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to Paragraph 8.Transfer Of Rights Of Recovery Against Others To Us of Section IV— Conditions: We waive any rights of recovery we may have against any person or organization because of payments we make for injury or damage resulting from your ongoing operations or"your work"done under a contract with that person or organization and included in the "products-completed operations hazard" if: a. you agreed to such waiver; b. the waiver is included as part of a written contract or lease; and c. such written contract or lease was executed prior to any loss to which this insurance applies. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. U047-0310 Includes copyrighted material of ISO Properties, Inc., Page 1 of 1 with its permission. ENDORSEMENT AGREEMENT BROKER COPY STATE WAIVER OF SUBROGATION INSURANCE 9036118-16 FUND RENEWAL SP HOME OFFICE 2-83-35-91 SAN FRANCISCO PAGE 1 OF 1 ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC EFFECTIVE MARCH 21, 2017 AT 12.01 A.M. STANDARD TIME OR THE TIME INDICATED AT AND EXPIRING DECEMBER 1, 2017 AT 12.01 A.M. PACIFIC STANDARD TIME CORRAL CONSTRUCTION & 5211 E WASHINGTON BLVD STE 2 COMMERCE, CA 90040 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 WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, CORRAL CONSTRUCTION & 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 SAN FRANCISCO: MARCH 22, 2017 2570 AI�TMORIED REPRESENT IVE PRESIDENT AND CEO CC-IC CnPM IA917 IRF11 7-9111A1 OLD DP 217 Form Request for Taxpayer Give Form to the (Rev.December 2011) Identification Number and Certification requester.Do not Deppartnrot of the 1'rearaey send to the IRS. lntexnai Revenue Service Name(as shown on your income tax return) Corral Construction&Development Inc k`i Business namaldh3rogarded entity name,if dMerent from alcove M Check appropriate box for federal tax classification: I ❑ Individual/sole proprietor ® C Corporation ❑S Corporation ❑ Partnership ❑Trust/estate 4 P payes ❑ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership)Bo- o ❑ t 2 ..........».............. (L Other(see instructions)► ?�- Address(number,street,and apt.or suite no.) Requester's name and address(optional) 5211 E. Washington Blvd 2-122 H City,state,and ZIP code Commerce CA 90040 List account number(s)here(optional) Taxpayer Identification Number(TIN) Enter your TIN in the appropriate box.The TIN provided must match the name given on the"Name"line I Sooial sooarflty number to avoid backup withholding.For individuals,this is your social security number(SSN).However,for a resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other entities,it is your employer identification number(EIN).if you do not have a number,see How to get a TIN on page 3. Note.If the account is in more than one name,see the chart on page 4 for guidelines on whose Employer ide'nt'ification number' number to enter. Certification Under penalties of perjury,I certify that: 1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me),and 2. 1 am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been noted by the Internal Revenue Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am no longer subject to backup withholding,and 3. 1 am a U.S.citizen or other U.S.person(defined below). Certfication instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the instructions on page 4. Sign Signature of , Here I US.person► " c" Date► / General Instructions Note.lt a requester gives you a form other than Form W-9 to request Section references are to the Internal Revenue Code unless otherwise your TIN,you must use the requester's form if it is substantially similar to this Form W-9. noted. Definition of a U.S.person.For federal tax purposes,you are Purpose of Form considered a U.S.person If you are: A person who is required to file an information return with the IRS must •An individual who is a U.S.citizen or U.S.resident alien, obtain your correct taxpayer identification number(TIN)to report,for •A partnership,corporation,company,or association created or example,income paid to you,real estate transactions,mortgage interest organized in the United States or under the laws of the United States, you paid,acquisition or abandonment of secured property,cancellation •An estate(other than a foreign estate),or of debt,or contributions you made to an IRA. •A domestic trust(as defined in Regulations section 301.7701-7). Use Form W-9 only if you are a U.S.person(including a resident alien),to provide your correct TIN to the person requesting it(the Special rules for partnerships.Partnerships that conduct a trade or requester)and,when applicable,to: business in the United States are generally required to pay a withholding tax on any foreign partners'share of income from such business. 1.Certify that the TIN you are giving is correct(or you are waiting for a Further,in certain cases where a Form W-9 has not been received,a number to be issued), partnership is required to presume that a partner is a foreign person, 2.Certify that you are not subject to backup withholding,or and pay the withholding tax Therefore,if you are a U.S.person that is a 3.Claim exemption from backup withholding if you are a U.S.exempt partner in a partnership conducting a trade or business in the United payee.If applicable,you are also certifying that as a U.S.person,your States,provide Form W-9 to the partnership to establish your U.S. allocable share of any partnership income from a U.S.trade or business status and avoid withholding on your share of partnership income. is not subject to the withholding tax on foreign partners'share of effectively connected income. Cat.No.10231X Form W-9(Rev.12-2011)