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PROOF OF INSURANCE (2017) CLOSED "�_0441111i SOUTCOA-04 TYA_PP � CERTIFICATE OF LIABILITY INSURANCE L.....DA E(MMI 016 Y) ........ 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�. w_ _..................___ PRODUCER License#OE63493 NAMEc Orr&Associates Ste 0 Single Oak D Insurance Services �I,'Ext):(9 1)service@orrandassocl::ates.com C"N*)) (800)474-3003 g P M 951 506-5859 Temecula,CA 92590 °-!�'�'-AFSS. es.com INSURER($)AFFORDING COVERAGE NAIC# INSURER A:m IrRuRER aSSecialt Insurance Compaqµ 9599 INSURED n ... an ...... „2 742 to on National Insurance Com 9 SOUTH COAST PAINTING INC. INSURER I::State Compensation Insurance Fund 35076 Bobbie&George Mantiks 28364 S Weatern Ave.#465 INSURER D Rancho Palos Verdes,CA 90275 INSURER 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLIC ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH DOLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY RAID CLAIMS. INSk UbO SUBIrt _ P666Y EFF, POLICY EXP LIMIT. TYPE OF yyyO POLICY NUMBER _ _ tMM/DI)_/1"(W�""(MMIOD/1/YYlfi"_ _ S A X COMMERCIAL GENERAL LIABILITY _ EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE I OCCUR X X U16AC87006-01 05/01/2016 05/01/2017 s,Ea E§2n4rrencp $ 0 X I, DAMAGE G ) 100,00.... MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO• �` X POLICY JECT u LOC PRODUCTS COMP/OP AGG $ 2,000,000 OTHER - � AUTOMOBILE LIABILITY (rOMBINgni? LBLIMfT �$ gN,,a�r�ralsenl) B ANY AUTO /2002234 04/27/2016 04/27/2017 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ 1,000,000 AUTOS AUTOS HIRED AUTOS . NON-OWNED �'I OPC-R'TY D A GE $ 1,000,000 AUTOS I'ora�rcNded $ UMBRELLA LIAB. ..�...„ .... ..............w....w.... w ...... .._.. X OCCUR EACH OCCURRENCE $ 1,000,000 A DIED ryr"r" AB CLAIMS MADE U16AC87006-01 05/0112016 05/01/2017 AGGREGATE $ 1,000,000 WORKERSCOMP $J RETENTION NSATION _.rr..........................,............................. X� AND EMPLOYERS'LIABILITY E L .STATLITF I Ek�.H� C ANY PROPRIETORIPARTNERIEXECUTIVE YIN 9125712.2016 0610112016 0610112017 EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED N/A - - (Mandatory In NH) """""""""" E.L.DISEASE-EA EMPLOYEE $ 1,000,00 If n,,describe under Df:SCftIP"V IyJN("uF rJg E'RA"q'ICrMdS fx�row E L DISFJtSE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/"LOCATIONS"/"VEHICLES"(ACORD .., ............... D 707,Additional Remarks Schedule,may be attached ff more space Is required) CITY OF EL SEGUNDO ITS OFFICIALS,AND EMPLOYEES ARE ADDITIONAL INSURED PER ATTACHED ENDORSEMENT FORMS. . �..... .... ......_._.,._....... _ ............................................................... .........._....................................................................... CERTIFICATE HOLDER CANCELLA'TI'ON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF EL SEGUNDO ITS OFFICIALS,AND EMPLOYEES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 MAIN STREET Q ACCORDANCE WITH THE POLICY PROVISIONS. EL SEGUNDO,CA 90245 /�rJ( v - AUTHORIZEDREPRESENTATI�VE_� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: U16AC87006-01 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OI 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 Any person or organization for whom you are performing operations during the policy period when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. 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 exclu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage" or "personal and advertising injury" „ pp y y caused, in whole or in part, by: 'property damage occurring after: 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 in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) desig- covered operations has been completed; or nated 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 ❑ POLICY NUMBER: U16AC87006-01 COMMERCIAL GENERAL LIABILITY HCS 040 06 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY ARY AND NONCONTRIBUTORY AND BLANKET WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. PRIMARY AND NON-CONTRIBUTORY TO B. WAIVER OF SUBGROGRATION—BLANKET OTHER INSURANCE Under SECTION IV — COMMERCIAL GENERAL With respect to any person or organization that is LIABILITY CONDITIONS, The Transfer Of an additional insured under this Coverage Part, Rights Of Recovery Against Others To Us the following is added to paragraph 4. of Condition is amended by the addition of the SECTION IV — COMMERCIAL GENERAL following: LIABILITY CONDITIONS: We waive any right of recovery we may have If you have agreed in writing in a contract or against any person or organization because of agreement that this insurance is primary and non- payments we make for injury or damage arising contributory relative to an additional insured's own out of: insurance, then this insurance is primary and we a. Your ongoing operations; or will not seek contribution from that other insurance. For the purpose of this endorsement, b. "Your work" included in the "products- the additional insured's own insurance means completed operations hazard". insurance on which the additional insured is a However, this waiver applies only when you have Named Insured. agreed in writing to waive such rights of recovery When this endorsement is attached to the policy it in a contract or agreement, and only if the contract supersedes all other insurance conditions within. or agreement: a. Is in effect or becomes effective during the term of this policy; and b. Was executed prior to loss. HCS 040 06 10 13 Page 1 of 1 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. � ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION 9125712-15-2 RENEWAL SP FUND PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE FEBRUARY 12 , 2016 AT 12 . 01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING JUNE 1 , 2016 AT 12. 01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME SOUTH COAST PAINTING INC 2255 PALOS VERDES DR N ROLLING HILLS ESTATES, CA 90274 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. SOUTH COAST PAINTING INC 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: FEBRUARY 19, 2016 2570 AUTHORIZED f E'I RESEN'T 'VE PRESIDENT AND CEO