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PROOF OF INSURANCE (2017) CLOSED
0 DATE(MMIDDIYYYY) .,.ACC)R" CERTIFICATE OF LIABILITY INSURANCE 5/18/2017 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 pol'lcy(ie's) 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 endorsoment(s), PRODUCER CONI'ACT Elizabeth Flinders NAME: g Y PHONE FXt); (a� ,,N.: 41 Flinders/DePalma Insurance A enc PHN ADDRESS: (818)843-8600 calels66-se License #0447329 liz @flindersins.com P.O. Box 510 INSURER(S)AFFORDING COVERAGE NAIL# Burbank CA 91503 INSURERA:Colony Insurance Company 39993 INSURED INSURERB:Century National Insurance, Company 2690,5 INSURER C: Clean Scene Services INSURER D: 9909 Escondido Cyn Rd. INSURER E! Agua Dulce CA 91390 INSURER F: COVERAGES CERTIFICATE NUMBER' aster Cert 2017-2018 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 ANODL SUB A' MMIDDYYYYI,WMfI TYPE OF INSURANCE SyD l�lVf} ICY EXp LIMITS POLICY FFF POLICY NUMBER 1 DDdYYY'YR A X COMMERCIAL GENERAL LIABILITY 101 GL 0044831-01 01/21/2017 01/21/2018 EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE �OCCUR PREMIIa"E5((Ea ocCulr,9rg*,) $„ 100,000, X MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL f AGGREGATE $ 3,000,000 X POLICY( PRO-JECT LOC PRODUCTS-COMP/OP AGG $ included .... d':t'E MXP"R I B AUTOMOBILE LIABILITY BAP0174325 11/03/2016 11/03/2017 COM004ED SIN('LE L,9MI'i' $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCUTOS BODILY INJURY(Per accident) $ A X HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Pei,acdclent) V $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I pp RETENTION$......., $ WORKERS COMPENSATI'ON' PER I OTH AND EMPLOYERS'LIABILITY Y/N (,STATUTE ( I ER ANY PROPRIETOR/PARTNER/EXECUTIVE NIA EL EACH ACCIDENT $ S:IFFICFWMEMaER V XR:I.UDED7 P (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ describe under O:JESCRIPTIO'N OF OPE"RATII:XNS bMow EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) City of E1 Segundo is named as an additional insured on the General Liability policy as per written contract. Endorsement attached. 10 day notice of cancellation for non payment of premium. CERTIFICATE HOLDER CANCELLATION (310)524-2200 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of E1 Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 348 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. E1 Segundo, CA 90245 AUTHORIZED REPRESENTATIVE E Flinders/LAF ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 ont4ml Policy# 101 GL 0044831-01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES ONE CONTRACTORS - BLANKET COVERAGE INCLUDING A / NON-CONTRIBUTORY AND WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART _ SCHEDULE Name of Additional Insured Person(s)or Organiza tion(s) (Additional Insured) Location(s)of Covered Operations: All persons or organizations as required by a written Locations as required by a written contract or contract or agreement with the named insured. agreement with the named insured. 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 for whom you are performing operations 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. Such person or organization is an additional insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury"caused, in whole or in part, by: 1. your acts or omissions; or 2. the acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: Additional Insured Contractual Liability "bodily injury" or "property damage" for which the additional insured(s) are obligated to pay damages by reason of the assumption of liability in a contract or agreement. Finished Operations at Work "bodily injury"or"property damage" occurring after: 1. all work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. that portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization. Negligence of Additional Insured "bodily injury"or"property damage" arising directly or indirectly out of the negligence of the additional insured(s). U156A-0313 Includes copyrighted material of ISO Properties, Inc., Page 1 of 2 with its permission. ...................... C. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance is amended and the following added: The insurance afforded by this Coverage Part for the additional insured required by a written contract or agreement with the named insured is primary insurance and we will not seek contribution from any other insurance available to that additional insured. D. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 8. Transfer Of Rights Of Recovery Against Others To Us is amended and the following added: 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, U156A-0313 Includes copyrighted material of ISO Properties, Inc., Page 2 of 2 with its permission. NMi W'.g Request fDr Taxpayer Ohe Fwn to the (R-.08c."ber 2011) Mquester.cto MA DqMVhTWWl:of the flu" Iden-fiftation Number and Certifleation, fat WR*v%,W Saiv- seW to the JR& oases oases(as i;;W an—your fneon"tax Michael Nicholson auwnm namordilmardw WKY nam%hOftwll&M ohm* W& lean Scads Services, Inc. n' Chwk appraPrista box for(Oderal tax oftWilcalknu C1 kndMduallWir progwistor 0 0 Gwoofation M 3 coqXMIlon [] PartNIVIlp [] 1rust/astats Wined l co"Vany.Bvw the in ctagsj 0'�Wro'suw'3-8&%1QAWUIWa'Paponnesewp)D, DEMMtp&M Other is"iftalnxtIawma)I,- AWros$(Aumboc Wrote,&W spiL or Wis AoJ Roquotees narro and add rms(opuonoiI 0 ,9909 Escondido Cyn Rd. & Cry,state,WW ZIP code Santa Clarita, CA 91390-3412 W1 account aurnbetle)MM,(option so a or Identification MUMber(TINL Enter your TJN In the appropriate bo)L The*nN provIded must match the name given 0#1 the"Narne"llne to avoId backup vAthholding,For WNI&mis,this Is your socIat sawfir/numcer(SSN).Howevor,ter a resWent alkn,We prop"or,or disragardedonOty,see tha Part I Instnictions on page 3�For other entMes,It Is your empk�w Identification numba(151M.It you do riot tuive a number,sea How to got a 'nN oil page 3. Now 9 Om a0munt is In more than one neirm,we the chart an page 4 for quidaNnw on whose gn*,!YW nurnber to enter. M35 Jda22* 5 n " T81w 7 14 16 1 MM Certification Under perialfies of pe4ury,I c*dtfy that 1. The number shown on this farm is my OMW taxpayw Identification mAydw(br I am waiting for a numba to be Issued to me).and Z 1 am net subject to back W withholding becmvse:(so I am exempt from backup withho4ding,or(b)I hmm not been notified by the InturnalRevanue Service OPQ that I am subject to backup withholding as a result of a tenure to report afl:Interest or dIvIdewhy,or(c,)the IRIS hits notillkid iv*that I am no IWW suNect to backup withholdIng,and 3- 1 am a US,eiften or of U.S.person(deffned batow). Oortificaflon Inabudlons.You must cross out am 2above It you have been notflod by this IRS that you am currently subjeolt to backup withholding because you have Failed to mpon all interest and dlyWands on:your tax return.For real estate transactions,item 2 does,not apply.For mortgage Intwest pa•id,,soquWMoo or abmvdimment of secured property,cancellation of debt,contributicng to an hdividual retain amit arrangement qenerally to otheir ffm Interest and dMdends,you we not mqutred to sign"ceoMmItIon,but you must pr ✓de yaw corml-M,Sea the Instuctlorts cm page 4. ii[Ort Warratinvi 04 Here Date P 3/3.1117 General Instructions Note.IF a requestar gives you a favy)WIW'um 1-01171 W-9 to roquest your TIN,you Muot use the requeslae's,foirn It it is substanfielly Mmilar Saefion references we to the Internet Revenue Code unless otherwise to this Fenn W-9. rMted, Definition of m LOA,persorv,For rmlaral tax puqiosos,y*u ore Purpose of For constd4wed a US,,pamn V ycvj:are: A person Who is required to file an information rattan with the IRS must a An�ndMdual oft Is a US,Litizen,or US.raddootolen, obtain,your correct taxpayer Identification number(T[ to report for a A parmerd-iip"rorporall(m,"wipwiy,or amcciatkin c(ealed cw O'Umple'WONM PW to you.rew astate fransadlons"rnortgags intereat aVanlmd In the UAW Wtas or undat Ute Iowa of No UnRW Slates, you paid,acquisition or abandonment of secured properly,coicalIadon An estate(cow than a ftjreNQ'n estate),or of debt,or contribullons you made to an 111k A domautic trust(as,defined In Regulallonsswdon 301.770'0-7), Use Form W-it Wy It you we a US.person,(Oncluding,a w1dont Mien),to provOay"correct TIN to the person requesting it(We Spaclal rutou lor p&rhwrWpa,,Piutnaishkjs IhM 4xmdurA a trade OV requesteu kable,to: business in flier OnIkW States are genwafly rwo)Ured to pay a WthholdhV tax on any lafdgn poirtmashare Of Inwre from such business. t.oertKy that the TIN you am 9h4rV is correct(or, are waArg for a Furthsr„in certain rasW Wive a FOM W-9 hau not been roceived,a number to be Issued), painersHp is w0had to Imume that a FriatIner is a fbrdgn pwm, 2-CoMy that you am not subject to backup wilift",or and pay the M111hakh'if)tax,Therefore,9 YM are a td. ..poison that is a 3,Claim exemption ftm backw v4thholding I ym we a UA exeimpt partner in&pw1narship conducting a traft or bushiess in the United payee,V app&-aWe,you we also cadifying that as a UA parson,ym &ates,P�Ovido rVM V"to ft parmers4*1 to astehfish,Yotr Us, aflocable dam of any partnership kwom from a UA IrMe or thjs4iess status and avokl whhhokl:109 on your share cN pattnsrsVp�incorne, is misiblad to the withholding W an forsign partimm"share of effecMAY connected ftome. O'L ....... CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: (� I have and will maintain a certificate of consent of self-insure for workers'compensation, issued by the Director of Industrial Relations as provided for by Labor Code§3700 for the performance of the work set forth the agreement with the City of El Segundo. Policy No. (_J 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# (,C 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 provisions or th e agreement will automatically become void. Si g nature of A pplicant Date 6A, 17 Agreement for: °b Dated: Reviewed b 1