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PROOF OF INSURANCE (2018) CLOSED Certificate of Insurance
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON YOU THE CERTIFICATE HOLDER. THIS CERTIFICATE IS NOT AN
INSURANCE POLICY AND DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED BELOW. POLICY LIMITS ARE NO LESS THAN
THOSE LISTED,ALTHOUGH POLICIES MAY INCLUDE ADDITIONAL SUBLIMIT/LIMITS NOT LISTED BELOW
This is to Certify that
Sully-Miller Contracting Co.
10 A
135 S. State College Blvd., Ste. 400 NAME AND LADDRESS ib OF
Brea CA 92821 INSURED mutu
is,at the issue date of this certificate,insured by the Company under the policy0es)listed below Ille inSUTIACC afforded by the listed policy(ics)is subject to all their terms,exclusions and
Conditions and is not altered by any requirement,term or condition ofaay contract or other document with respoca to which this certificate may be issued
EXP DATE
TYPE OF POLICY CONTINUOUS POLICY NUMBER LIMIT OF LIABILITY
E] EXTENDED
ID POLICY TERM
WORKERS WC7-631-004125-657 COVERAGE AFFORDED EMPLOYERS LIABILITY
4/11/2018 UNDER WC
COMPENSATION LAW OF THE FOLLOWING Bodily Injury Accident
STATES: ry$2,000,000 Each Accident
CA, NV,AZ Bodily Injury b Disease
$�'6 `00000 Policy Limit
Bodily Injury Dks"lse
'Y$2,000,000 L'.ach Person
COMMERCIAL 4/1/2018 TB2-631-004125-667 General Aggregate $3,000,000
GENERAL LIABILITY
11toducls I C'olnpicw l)jnerations o�vgrcpalc
$3,000,000
OCCURRENCE RE TRo DATE Each Occurrence
CLAIMS MADE Personal&Advertising Injury $2,000,000
$2,000,000 Per Person/Organization
heIncludes Per Job Aggreg; amages to Premises:$100,000
"XCU"Coverages land Medical Payments:$10,000
AUTOMOBILE 4/11/2018 AS2-631-004125-677 $2,000,000 Each Accident--Single Limit
LIABILITY B.I.And P.D.Combined
Each
OWNED Person
NON-OWNED Each Accident or Occurrence
HIRED Each Accident or Occurrence
OTHER RE: PW 15-01,Richmond Street Improvements Project(from El Segundo Blvd.to Holly Ave.)
Job# 10178538 1503
ADDITIONAL COMMENTS Added as additional insureds per endorsement attached.
Certificate holder,City of El Segundo,its officers,officials,employees,agents and volunteers is/are additional insured with regards to general liability and auto liability
as their interests may appear where required by written contract. The insurance afforded by the Policies for the benefit of the Additional Insured is Primary,but only
with respect to Claims and Loss of Liability arising out of the operations of the Named Insured and any insurance maintained by the Additional Insured shall be Non-
Contributory.The auto liability coverage afforded applies separately to each insured who is seeking coverage,or against whom a claim or"suit"is brought.Waiver of
subrogation in favor of the certificate holder on General Liability and/or Auto Liability applies only to specific jobs of the insured performed under written contract.
Waiver of subrogation in favor of the certificate holder on WC where allowed by statute and applies only to the specific jobs of the insured performed under written
contract.(See attached endorsements to the policies)
If the certificate expiration date is continuous or extended term,you will be notified if coverage is terminated or reduced before the certificate expiration dater
NOTICE OF CANCELLAFION:(NOT APPLICABLE UNLESS A NUMBER OF,DAYS IS ENTERED BELOW)
BEFORE THE STATED EXPIRATION DATE.THE COMPANY WILL NOT CANCEL OR RE DUCE THE Liberty Mutual
INSURANCE,AFFORDED UNDER THE ABOVE POLICIES UNTIL AI'LEAST'30 DAYS NOTICE Insurance Group
OF SUCH CANCELLATION HAS BEEN MAILED TO: GrywaruLd_ ryl.Conrwyt�
Courtney Connolly
AUTHORIZED REPRESENTATIVE
0 Attn: Orlando Rodriguez, Public Works Dept. New York/0202
CD
0 City of El Segundo 114 West 47th St.
New York NY 10036 781-647-8138 4/11/2017
350 Main Street OFFICE PHONE DATE ISSUED
CD
El Segundo CA 90245-3813
This certificate is executed by LIBERTY MUTUAL INSURANCE GROUP as respects such insurance as is afforded by those Companies NM 772
Policy Number T62-631-004125-667
Issued by Liberty Mutual Fire Insurance Company
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED— City of El Segundo
This endorsement modifies insurance provided under the following:
COMMERICAL GENERAL LIABIITY COVERAGE PART
EXCESS COMMERICAL GENERAL LIABIITY COVERAGE PART
A. City of El Segundo, 350 Main St, El Segundo, CA 90245-3813 (Attn: Orlando Rodriquez), its officers,
employees, agents and representatives are named as additional insureds ("additional insureds") with
regard to liability and defense of suits arising from the operations and uses performed by or on behalf of
the named insured.
B. With respect to claims arising out of the operations and uses performed by or on behalf of the named insured,
such insurance as is afforded by this policy is primary and is not additional to or contributing with any other
insurance carried by or for the benefit of the additional insureds.
C. This insurance applies separately to each insured against whom claim is made or suit is brought except with
respect to the company's limits of liability. The inclusion of any person or organization as an insured shall not
affect any right which such person or organization would have as a claimant if not so included.
D. We waive any right of recovery we may have against the additional insureds because of payments we make
for injury or damage arising out of the operations or work of the named insured under this policy.
E. With respect to the additional insureds, this insurance shall not be cancelled, or materially reduced in
coverage or limits except after thirty(30)days written notice has been given to the organization, department or
individual listed in the Schedule below:
Schedule
Organization, Department or Individual:
The City of El Segundo, its officers, officials, employees,agents and volunteers
I
LD 20 26 01 12 ©2011 Liberty Mutual Group of Companies.All rights reserved. Page 1 of 1
Includes copyrighted material of Insurance Services Office, Inc.,with
its permission.
POLICY NUMBER:TB2-631-004125-667 CONNERCIAL 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
A. Section II — Who Is An Insured is amended to 1. All work, including materials, parts or
include as an additional insured the person(s) or equipment furnished in connection with such
organization(s) shown in the Schedule, but only with work, on the project (other than service,
respect to liability for "bodily injury", "property maintenance or repairs) to be performed by or
damage" or "personal and advertising injury" on behalf of the additional insured(s) at the
caused, in whole or in part, by: location of the covered operations has been
1. Your acts or omissions; or completed; or
2. The acts or omissions of those acting on your 2. That portion of "your work" out of which the
behalf; injury or damage arises has been put to its
in the performance of your ongoing operations for intended use by any person or organization
the additional insured(s) at the location(s) other than another contractor or subcontractor
designated above. engaged in performing operations for a
principal as a part of the same project.
However: C. With respect to the insurance afforded to these
1. The insurance afforded to such additional additional insureds, the following is added to
insured only applies to the extent permitted by Section III—Limits Of Insurance:
law; and If coverage provided to the additional insured is
2. If coverage provided to the additional insured is required by a contract or agreement, the most we
required by a contract or agreement, the will pay on behalf of the additional insured is the
insurance afforded to such additional insured will amount of insurance:
not be broader than that which you are required 1. Required by the contract or agreement; or
by the contract or agreement to provide for such
additional insured. 2. Available under the applicable Limits of
B. With respect to the insurance afforded to these Insurance shown in the Declarations;
additional insureds, the following additional whichever is less.
exclusions apply: This endorsement shall not increase the
This insurance does not apply to "bodily injury" or applicable Limits of Insurance shown in the
"property damage" occurring after: Declarations.
SCHEDULE
Name Of Additional Insured Person(s) Location(s) Of Covered Operations
Or Organization(s):
The City of El Segundo, its officers, officials, employees PW 15-01, Richmond Street Improvements Project
agents and volunteers (from El Segundo Blvd.to Holly Ave.)
Information required to complete this Schedule,if not shown above, will be shown in the Declarations.
CG 20 10 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1
POLICY NUMBER:TB2-631-004125-667 CONWERCIAL 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
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 hazard". 1. Required by the contract or agreement; or
However: 2. Available under the applicable Limits of
1. The insurance afforded to such additional Insurance shown in the Declarations;
insured only applies to the extent permitted by whichever is less.
law; and This endorsement shall not increase the applicable
2. If coverage provided to the additional insured is Limits of Insurance shown in the Declarations.
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.
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s): Location And Description Of Completed Operations
The City of El Segundo, its officers, officials, PW 15-01, Richmond Street Improvements Project
employees, agents and volunteers (From El Segundo Blvd.to Holly Ave.)
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
CG 20 37 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED CONSTRUCTION PROJECT(S)
GENERAL AGGREGATE LIMIT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Designated Construction Project(s):
PW 15-01, RICHMOND STREET IMPROVEMENTS PROJECT(from El Segundo Blvd.to Holly Ave.)
Information required to complete this Schedule, if not shown above, will be shown in the Declarations. j
A. For all sums which the insured becomes legally 3. Any payments made under Coverage A for
obligated to pay as damages caused by "occur- damages or under Coverage C for medical
rences" under Section I—Coverage A, and for all expenses shall reduce the Designated Con-
medical expenses caused by accidents under struction Project General Aggregate Limit for
Section 1 — Coverage C, which can be attributed that designated construction project. Such
only to ongoing operations at a single designated payments shall not reduce the General Ag-
construction project shown in the Schedule gregate Limit shown in the Declarations nor
above: shall they reduce any other Designated Con-
t. A separate Designated Construction Project struction Project General Aggregate Limit for
General Aggregate Limit applies to each des- any other designated construction project
ignated construction project, and that limit is shown in the Schedule above.
equal to the amount of the General Aggregate 4. The limits shown in the Declarations for Each
Limit shown in the Declarations. Occurrence, Damage To Premises Rented To
2. The Designated Construction Project General You and Medical Expense continue to apply.
Aggregate Limit is the most we will pay for the However, instead of being subject to the
sum of all damages under Coverage A, ex- General Aggregate Limit shown in the Decla-
cept damages because of "bodily injury" or rations, such limits will be subject to the appli-
"property damage" included in the "products- cable Designated Construction Project Gen-
completed operations hazard", and for medi- eral Aggregate Limit.
cal expenses under Coverage C regardless of
the number of:
a. Insureds;
b. Claims made or"suits" brought;or
c. Persons or organizations making claims or
bringing "suits".
CG 25 03 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 2 ❑
B. For all sums which the insured becomes legally C. When coverage for liability arising out of the
obligated to pay as damages caused by 'occur- "products-completed operations hazard" is pro-
rences" under Section I—Coverage A, and for all vided, any payments for damages because of
medical expenses caused by accidents under "bodily injury" or "property damage" included in
Section I — Coverage C, which cannot be at- the "products-completed operations hazard" will
tributed only to ongoing operations at a single reduce the Products-completed Operations Ag-
designated construction project shown in the gregate Limit, and not reduce the General Ag-
Schedule above: gregate Limit nor the Designated Construction
1. Any payments made under Coverage A for Project General Aggregate Limit.
damages or under Coverage C for medical D. If the applicable designated construction project
expenses shall reduce the amount available has been abandoned, delayed, or abandoned
under the General Aggregate Limit or the and then restarted, or if the authorized contract-
Products-completed Operations Aggregate ing parties deviate from plans, blueprints, de-
Limit,whichever is applicable; and signs, specifications or timetables, the project will
2. Such payments shall not reduce any Desig- still be deemed to be the same construction pro-
nated Construction Project General Aggre- ject.
gate Limit. E. The provisions of Section III — Limits Of Insur-
ance not otherwise modified by this endorsement
shall continue to apply as stipulated.
This endorsement is executed by the LIBERTY MUTUAL FIRE INSURANCE COMPANY
Premium $
Effective Date Expiration Date
For attachment to Policy No. T2-631-004125-667
Audit Basis
Issued To
Countersigned by
...., ........,... M1.walla¢'n:::e........,�......................... _........
d u1.J:ptd�CC'kl[d Y4V:G'.
Issued Sales Office and No. i,.`eriJ R;r.
Page 2 of 2 © Insurance Services Office, Inc., 2008 CG 25 03 05 09
Policy Number TB2-631-004125-667
Issued by Liberty Mutual Fire Insurance Company
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
OTHER INSURANCE AMENDMENT—SCHEDULED ADDITIONAL INSURED
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
LIQUOR LIABILITY COVERAGE PART
Schedule
Person or Organization
The City of El Segundo„ its officers, officials,employees, agents and volunteers
If you are obligated under a written agreement to provide liability insurance on a primary, excess, contingent, or
any other basis for any person or organization shown in the Schedule of this endorsement that qualifies as an
additional insured on this policy, this policy will apply solely on the basis required by such written agreement and
Paragraph 4. Other Insurance of Section IV - Conditions will not apply. If the applicable written agreement does
not specify on what basis the liability insurance will apply, the provisions of Paragraph 4. Other Insurance of
Section IV - Conditions will govern. However, this insurance is excess over any other insurance available to the
additional insured for which it is also covered as an additional insured by attachment of an endorsement to another
policy providing coverage for the same'occurrence", claim or"suit".
LC 24 20 02 13 ©2013 Liberty Mutual Insurance.All rights reserved. Page 1 of 1
Includes copyrighted material of Insurance Services Office, Inc.,with its permission.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO CIS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Person Or Organization:
The City of El Segundo, its officers, officials, employees, agents and volunteers
I
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
The following is added to Paragraph 8. Transfer Of
Rights Of Recovery Against Others To Us of
Section IV—Conditions:
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 05 09 0 Insurance Services Office, Inc., 2008 Page 1 of 1
Policy Number TB2-631-004125-667
Issued by LIBERTY MUTUAL FIRE INSURANCE COMPANY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.,.
NOTICE OF CANCELLATION TO THIRD PARTIES
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE PART
MOTOR CARRIER COVERAGE PART
GARAGE COVERAGE PART
TRUCKERS COVERAGE PART
EXCESS AUTOMOBILE LIABILITY INDEMNITY COVERAGE PART
SELF-INSURED TRUCKER EXCESS LIABILITY COVERAGE PART
COMMERCIAL GENERAL LIABILITY COVERAGE PART
EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
LIQUOR LIABILITY COVERAGE PART
COMMERCIAL LIABILITY—UMBRELLA COVERAGE FORM
Schedule
Name of Other Person(s)/ Email Address or mailing address.: Number Days Notice:
Organization(s):
City of El Segundo 350 Main St. _ 30
(Attn: Orlando Rodriquez) El Segundo, CA 90245-3813
A. If we cancel this policy for any reason other than nonpayment of premium, we will notify the persons or
organizations shown in the Schedule above. We will send notice to the email or mailing address listed above
at least 10 days, or the number of days listed above, if any, before the cancellation becomes effective. In no
event does the notice to the third party exceed the notice to the first named insured.
B. This advance notification of a pending cancellation of coverage is intended as a courtesy only. Our failure to
provide such advance notification will not extend the policy cancellation date nor negate cancellation of the
policy.
All other terms and conditions of this policy remain unchanged.
LIM 99 01 0511 ©2011 Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1
Includes copyrighted material of Insurance Services Office, Inc., with
its permission.
Policy Number: TB2-631-004125-667
Issued by: Liberty Mutual Fire Insurance Company
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
NOTICE OF CANCELLATION OR MATERIAL CHANGE IN COVERAGE
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE PART
OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART
RAILROAD PROTECTIVE LIABILITY COVERAGE PART
Schedule
Name: Address
• Number of Days:
City of El Segundo 350 Main St. 10
El Segundo, CA 90245-3813
(Attn: Orlando Rodriguez)
We will not cancel this policy nor make changes that reduce the insurance afforded by this policy until written
notice of cancellation or reduction has been mailed by certified mail, return receipt requested to those scheduled
above at least:
1. 10 days before the effective date of cancellation, if we cancel for non-payment of premium; or
2. the number of days indicated in the Schedule above before the effective date of the cancellation or reduction
if we cancel or reduce the insurance afforded by this policy for any other reason.
LD 02 02 0511 ©2011 Liberty Mutual Group of Companies.All rights reserved. Page 1 of 1
Includes copyrighted material of Insurance Services Office, Inc.,with
its permission.
Policy Number: AS2-631-004125-677
Issued by: Liberty Mutual Fire Insurance Co.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED INSURED-NONCONTRIBUTING
This endorsement modifies insurance provided underthe following:
BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORM
MOTOR CARRIERS COVERAGE FORM
TRUCKERS COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless
modified by this endorsement.
This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured
Provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage form.
Schedule
Name of Person(s)or Organizations(s):
The City of E1 Segundo, its officers, officials, employees, agents and
volunteers
Regarding Designated Contract or Project:
PW 15-01. Richmond Street Improvements Project
(from El Segundo Blvd. to Holly Ave.)
Each person or organization shown in the Schedule of this endorsement is an "insured" for Liability Coverage, but
only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision
contained in Section II of the Coverage Form.
The following is added to the Other Insurance Condition:
If you have agreed in a written agreement that this policy will be primary and without right of contribution
from any insurance in force for an Additional Insured for liability arising out of your operations, and the
agreement was executed prior to the "bodily injury" or "property damage", then this insurance will be
primary and we will not seek contribution from such insurance.
AC 84 23 0811 ®2010, Liberty Mutual Group of Companies. All rights reserved. Page 1 of 1
Includes copyrighted material of Insurance Services Office, Inc.,
with its permission.
POLICY NUMBER: AS2-631-00412577 CONINIERCIAL AUTO
CA 04 4410 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER F' TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US (WAIVER OF SUBROGATION)
This endorsement modes insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified
by the endorsement.
SCHEDULE
................... ......
Name(s)Of Person(s)Or Organization(s):
The City of El Segundo, its officers, officials, employees,
,agents and volunteers
Premium: $ INCL
Information required to complete this Schedule, if not shown above,will be shown in the Declarations.
The Transfer Of Rights Of Recovery Against
Others To Us condition does not apply to the
person(s) or organization(s) shown in the Schedule,
but only to the extent that subrogation is waived prior
to the "accident" or the "loss" under a contract with
that person or organization.
CA 04 44 10 13 0 Insurance Services Office, Inc., 2011 Page 1 of 1
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—
CALIFORNIA
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 0% of the California workers' compensation premium
otherwise due on such remuneration.
Schedule
Additional premium is a percent of the California Manual Workers Compensation premium. Subject to a minimum
premium charge of$
Person or Orcanization Job DescrOtion
The City of El Segundo, its officers, PW-15-01, Richmond Street
officials, employees, agents and Improvements Project
volunteers (from El Segundo Blvd. to Holly
Ave.)
Premium is included in the state's
blanket waiver charge.
Issued by Co 7-Liberty Insurance Corporation
For attachment to Policy No. WC7-031-004125-657 Effective Date Premium$
Issued to Sully-Miller Holding Corporation
WC 04 03 06 Page 1 of 1
Ed.04/1984