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PROOF OF INSURANCE (2017) CLOSED RAMEROO-01 CARAV-4.9 ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE 05/04/201 YY) 05/04/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION WWWTI ..................................... ORMATION 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 endorsement(s). PRODUCER License#OE63493 CONT CT Orr&Associates Insurance Services PHONE,Eat):(951)506-5859 INC,Ney;(50Q 474-3003 28780 Single Oak Dr (AIC. L ) Ste 255 E-MAIL er6�Nce@c"rrantN'asstacfatos.COm Temecula,CA 92590 NSURER(S)AFF'OR'DING COVERAGE NAIC# INSURERA:James River Insurance Company 122Q3 INSURED INSURER B;,State Compensation Insurance Fund 35076 Ramey Roofing Inc. INSURERC: 142 Sheldon St. INSURER D: El Segundo,CA 90245 INSURER E INSURER I` COVERAGES CERTIFICATE' ,wNUMBER: 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 ADDL.SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE .......................IN,5.I.t...y.Ill.Aa......._......rr.........w. POLICY NUMBER L!J?,A')5�, .h....dl.l! .,ICI:.Y..Xl•E............. LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR X X 000721190 06/02/2016 06102/2017 DAMAGE PEN T ar��) $ 50,000 PRE MED EXP,(Any one person) $ 1,000 PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JERef LOC PRODUCTS-COMP/OP AGG $ 2,000,000 O'TIr9E:'R.1 m.................................................................................r $ ................................................................. AUTOMOBILE LIABILITY COMBINED SNQ1 GI.E LIMIT ('Ea acr,dernl) $ ANY AUTO BODILY VNJ!U'RY'(Pier'person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY'(Pot acclocnG) S HIRED NON-Q ED P,;,OPERT'Y't",P�AMAf;F AUTOS ONLY AUTOaa ONLY ()er ercidew $ ................................................................................................ -.....w. UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ ....DED . . ...............RETENTION$ ..............._.........$....................... B . ANDEMPLOYERS'NA COMPENSATION X PERTLIT� k'FI,q, ANY PROPRIETOR/PARTNER/EXECUTIVE YIN X 9162512-2016 06128/2016 06/2812017 1,000,000 OFFICER/MEMBER EXCLUDED? N/A E'G. kAC'.Yi ACP;IDf,NI $ (Mandatory In NH) E L 9JI'SEASE EA MAWLOY"E E $ 1,000,000 describe under mDESCIf _. _ y I':L d:ia FIwt;,.,uu.?......_ . ... 1,000,000 .RIPTION OF QPERATIQ k ow ..�..�. d�"•'Y'1'OM.I�T .............................................. .......m....................................................................................... ......................... .._ ,.. ................................................................ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The City of El Segundo,its officials,officers,agents and employees are named as additional insured as respects to General Liability,including primary& non-contributory. CERTIFICATE HOLDER HIOi_Dtl R ........................ .............. ...... ...� CANCELLA CNON .... SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ty 9 ACCORDANCE WITH THE POLICY PROVISIONS. Attn:Floriza Rivera,PW Dept 350 Main Street ............rww........ El Segundo,CA 90245 AUTHORIZED REPRESENTATIVE 9 ..........._._._..................................................... ................ ..�...................................... _..................... ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 00072119-0 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSENS OR CONTRACTORS - SCHEDULED PERSON OR ORGAN'''IZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): I Location(s)Of Covered Operations Where required by written contract or written agreement All operations of the Named Insureds 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. Your acts or omissions; or 1. All work, including materials, parts or equip- 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 oth- er than another contractor or subcontractor engaged in performing operations for a princi- pal as a part of the same project. CG 20 10 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 ❑ POLICY NUMBER: 00072119-0 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS - APARTMENTS AND ALL CONSTRUCTION OTHER THAN RESIDENTIAL DEVELOPMENT- SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: ,''""" COMMERCIAL GENERAL LIABILITY SCHEDULE Name Of Additional Insured Person(s) Covered Completed Operations Or Organization(s): Where required by written contract or written All non-residential construction projects of the agreement Named Insured 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 include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for"bodily injury"or"property damage" caused, in whole or in part, by"your work", as described in the schedule of this endorsement performed for that additional insured and included in the"products-completed operations hazard" as described in the Covered Completed Operations, schedule above. B.The insurance provided to the additional insured under this endorsement is limited as follows: Covered Completed Operations shown in the schedule above shall not include"residential development" of any description. C. For the purposes of this endorsement, the following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to the additional insured designated in the Schedule, provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. D. The following definitions are added to SECTION V—DEFINITIONS of this Policy: "Residential development" means a structure or structures, including the land upon which it is situated, designed or intended for occupancy in whole or in part as a residence by any person or persons. "Residential development" does not include"apartments" or"apartment buildings." "Apartments" means one or more rooms of a building used as a dwelling unit separate from others in the building and which are rented from others by those dwelling in them. "Apartments building" means a structure containing two or more separate"apartments." ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. Includes copyrighted material of Insurance Services Office, Inc., with its permission. MC2037US 09-12 Page 2 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON CONTRIBUTORY UTORY IF I ORSE ENT This endorsement modifies insurance provided under the following; ALL COVERAGE PARTS Name Of Additional Insured Person(s) Or Organization(s): If no entry appears above, this endorsement applies to all Additional Insureds covered under this policy. Any coverage provided to an Additional Insured under this policy shall be excess over any other valid and collectible insurance available to such Additional Insured whether primary, excess, contingent or on any other basis unless a written contract or written agreement specifically requires that this insurance apply on a primary and noncontributory basis. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED, AP5031 US 04-10 Page 1 of 1 POLICY NUMBER: 00072119-0 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US 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: Where required by written contract or written agreement 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 We waive any right of recovery we may have against Rights Of Recovery Against Others To Us of the person or organization shown in the Schedule Section IV—Conditions: 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 ©Insurance Services Office, Inc., 2008 Page 1 of 1 13 AC � CERTIFICATE OF LIABILITY INSURANCE DATE/12/201'7"' 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). PRODUCER CONTAC'r Remon Wasfi REMON WASFI FAX N Xta,,3.�.. .:322-.�..� .t± o.NaM,310-640-1057 .. 0.. Sta'.. .. ... (Ho of r corn 32 SfafeFarm 3737 TORRANCE BLVD STE 201 rafnpn Wisfi ....w ....�.......... ' I.. .., TORRANCE, CA 90503 INSURER A:Stet@ Farm MUtUaIAAU OfT10b11gOVERAGE NAIC# Insurance Company 25178 INSURED JON A RAMEY INSURER B: „,. ...,..._......................................................... ...... ............. 142 SHELDON ST INSURER C: EL SEGLI NDO, CA 90245 - 3715 INSURERD: 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 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH 3OLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. imsk ASBI — ... , POLICY-.M._.____. R...©..%.....E....X LTR TYPE OF INSURANCE INSD w POLI C Y NUMBER (MM/DD/IYYI _(��D VM.Y.._P�I. LIMITS COGENERAL ER � LIABILITY EACH OCCURRENCE qq $ . . I . A ka ; 7t C) OCCUR Iu(Le $ MED EXP e PerSOn $ . ;m _.. .. ...._. ... R DV.INJ.0 R.Y.... GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 1­$ POLICY❑ jERCO1 71 LOC PRO UCTS $ ....................................................,.,, -COMP/OP AGG �$ �'47'IftlC°.f8 $ AUTOMOBILE LIABILITY CONIMNL0'SINOI.�'L.1.ImIT .�.._ pl $ 1,000,000 A Y 526 2687-A05-75 0110512017 07105/2017 ANY AUTO 434 0432-D05-75 04/05/2017 10/05/2017 BODILY INJURY(Per person) $ 1,000,000 X AWEO ° i uINJURY er�.^a Ad 5262686-A05-75 01/0512017 I F 11REDAUros NON-OWNED �rr= YA 1,000,000 AUTOS 434 0431-D05-75 04105/2017 1010512017 Med c I Payments $ 100,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB U CLAIMS-MADE AGGRE ATE $ DED ( �RETENTION$ $ WORKERS COMPENSATION II OTH- AND EMPLOYERS'LIABILITY Y/N _T ST TUT'Ew,.I�............Y..�K................................................�..................EL EACH OFFICERIMEMBE EXCLU E[PROPRIETORIPARTNER/EXECUTIVE N/A (Mandatory in NH) E.L.D SEASECIDA EMPLOYEE.a ............................................................. If yes,describe under � DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ A Deductible Comprehensive $100 Collision $250 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) 526 21387-A05-75,2014 FORD F150 PICKUP 434 0432-D05-75, 2004 FORD F250 SD PICKUP 526 2686-A05-75,2014 FORD F150 PICKUP 434 0431-1305-75,2004 FORD F250 SD PICKUP CERTIFICATE HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Public Works Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main St ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo,CA 90245 I A.U. TNO . 8 A-TIVE 1S 20 4 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 1001486 132849.9 02-04-2014 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION REP 04 STATE 9162512-16 NEW INSURANCE SP FUND 4-47-88-58 PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE APRIL 20, 2017 AT 12 . 01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING JUNE 28, 2017 AT 12 . 01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME RAMEY ROOFING 142 SHELDON ST EL SEGUNDO, CA 90245 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, RAMEY ROOFING 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: APRIL 25, 2017 2570 AUTHORIZED REPRESENT IVE PRESIDENT AND CEO SCIF FORM 10217 (REV.7-2014) OLD DP 217