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PROOF OF INSURANCE (2017 - 2017) CLOSED '1-1-14"11111 0 CC > CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 07/24/2017 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 policy(les)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 CONTACT Radius Insurance ,APNick Roumi 135 S. State College Blvd., #200 q 0, (800) 400-7283 FAX g AMAIL nick@radiueina.com ) x,8-0704 PHONE INSURER( Brea CA 92821 SSS; Ext); (APC,,f8o:d 8 B 8 I. 9 6)AFFORDING COVERAGE NAIC# INSURERA:Associated Industries Insurance 23140 INSURED (310) 669-8949 INSURER B:Great American E & S Insurance C 37532 Alfaro Communications Construction Inc. . ., ........ ... INSURERC:Arch Insurance Company 11150 15614 S Atlantic Ave INSURERD: Compton CA 90221 INSURERS: INSURER F: COVERAGES CERTIFICATE NUMBER:Cert ID 1972 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. /INSD P POLICY EFF.( IMMIDD — - LTR TYPE OF INSURANCE --- .. I POLICY EXP ....I (NSR OLICYNUMBER IMM/PD/Yl'YK PY'Y'YYtl� LIMITS LLIABILITY E:ACH000URRENCE $ 1,000,000 X COMMERCIAL GENE p CLAIMS-MADE 4 X (OCCUR Y Y AE51042132 10/09/2016 10/09/2017 OA044Fr1"'rORf;t4TIrb PREMISES(Ea ooggrra,q„ e,i $ 100,000 MED EXP(Any one person) ..,,,. $ 10,000 ............. ,,,,,,, , PERSONAL&ADV INJURY $ 1,000,000__ _ GEN'L AGGREGATELOC GENDUCTS-COMP/OP AGG $ 2 PRO _ , � POLICY� X JECT APPLIES PER: PRO RAL AGGREGATE $ 2 000,000 000,000 I 01 HER; $ AUTOMOBILE LIABILITY I MBI4 ED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHED AUTOS ONLY AUTOSULED BODILY INJURY(Per accident) $ ,OP 'RTY DAduIAG AUTOS ONLY AUTOS ONLY ( -- RED NON-OWNED �4k ml o dent $ H X U M E LALIAB X OCCUR XS 9952652 10/09/2016 10/09/2017 EACH OCCURRENCE $ 5,000,000 EXCESS L AB CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION$ I $ WORKERS COMPENSATION PER OTH- CMandato in NH E.L.DISEASE-EA EMPLOYEE $ 1,000,000 Y� E L(EACH ACCIDENT ANDEMPLOYERS'LIABILITY Y ZAWC12524700 11/26/2016 11/26/2017 STATUTE ER ANYPROPRI ETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED� NIA $ 11000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E .DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space Is required) *30 day notice of cancellation, 10 day notice of cancellation in the event of nonpayment of premium City of E1 Segundo, its officers, its officials, and employees are named as Additional Insured regarding the General Liability policy per form CG 20 37 07 04. Waiver of Subrogation applies regarding the General Liability policy per form CG 24 04 05 09 and the Workers Compensation policy per form WC 04 03 06. Insurance is primary regarding the General Liability and Excess policy per form NX GL 009 08 09. /P z CERTIF'ICAT'E MOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street AUTHORIZED REPRESENTATIVE El Segundo CA 90245 I �JtL �QC�Vht I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Page 1 of 1 POLICY NUMBER: AES1042132 00 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES O CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operations All persons or organizations where written contract with the Named Insured requires additional insured completed operations.This form does not apply to your work on "residential property". Information required to complete this Schedule, if not shown above,will be shown in the Declarations. 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 dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sche- dule of this endorsement performed for that addi- tional insured and included in the "products- completed operations hazard". lu CG 20 37 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 ❑ POLICY NUMBER: AES1042132 00 COMMERCIAL GENERAL LIABILITY NX GL 009 08 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AMC NON-CONTRIBUTING INSURANCE (THIRD-PARTY) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Third Party: All persons or organizations where required by written contract with the Named Insured (Absence of a specifically named Third Party above means that the provisions of this endorsement apply as required by written contractual agreement with any Third Party for whom you are performing work.) Paragraph 4. of SECTION IV: COMMERCIAL GENERAL LIABILITY CONDITIONS is replaced by the following: 4. Other Insurance: With respect to the Third Party shown above, this insurance is primary and non-contributing. Any and all other valid and collectable insurance available to such Third Party in respect of work performed by you under written contractual agreements with said Third Party for loss covered by this policy, shall in no instance be considered as primary, co-insurance, or contributing insurance. Rather, any such other insurance shall be considered excess over and above the insurance provided by this policy. NX GL 009 08 09 Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission POLICY NUMBER:AES1042132 00 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: All persons or organizations where required by written contract with the Named Insured Information required to complete this Schedule, if not shown above, will be shown in the Declarations. V 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 ©Insurance Services Office, Inc., 2008 Page 1 of 1 0 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) POLICY NUMBER: ZAWCI2524700 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 2 % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION WHERE ALL JOBS UNDER CONTRACT WAIVER OF OUR RIGHT TO RECOVER IS PERMITTED BY LAW AND IS REQUIRED BY WRITTEN CONTRACT PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR TO DATE OF LOSS This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the poky.) Endorsement Effective 11-26-16 Policy No. ZAWCI2524700 Endorsement No. Insured ALFARO COMMUNICATIONS Premium $ INCL. Insurance Company ARCH INSURANCE COMPANY Countersigned By DATE OF ISSUE: 11-22-16 ©1998 by the Workers'Compensation Insurance Rating Bureau of Califomia. All rights reserved. From the WCIRB's California Workers'Compensation Insurance Forms Manual©1999. 0 DATE(MM/DDIYYYY) 'llC" CERTIFICATE OF LIABILITY INSURANCE o7/z4/2o17 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(les) 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 I CONTACT FRANCISCO SANTANA NAME. PHON ARIA GALLI INSURANCE ^�Iu(NIn juuVlufft 1^5352 PARAMOUNT LVD AGENCY INC ( �`EX1)FRANCISCO20GALLIAGENCY.COM ( C,N ) 6 621 MAI 5„ 2817b @ INSURER(S)AFFORDING COVERAGE NAIC# PARAMOUNT CA 90723 INSURERA: State Farm Mutual Automobile Insurance Company 25178 INSURED INSURER B: ALFARO COMMUNICATIONS CONSTRUCTION INC INSURER C: 620 S BRADFIELD AVE INSURER D t INSURER E: COMPTON CA 90221 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, TYPE OF INSURANCE ...,, I'tdSlwt...!AG1GA CY AFF POLICY'EXF" 512 110DL SUDR' POLI TR d POLICY NUMBER I I LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ bAM CLAIMS-MADE OCCUR PREMISES(Fa Mw urre,n,4p) ....$ MED EXP(Any one person) $ PERSpNgL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY _ PEO LOC PRODUCTS-COMP/OP AGG $ OTHER: TOMOBILE LIABILITY Y Y 554 5818-B29-75 09/06/2016 09/06/2017 Ea aI.IINEd�"d'SING.6LE LUMI'r $ 1,000,000 AU „QE. atddenl) ANY AUTO BODILY INJURY(Per person) $ ASCHEDULED OWNED AUTOS ONLY „V AUTOS INJURY(Per accident) $ HIRED V NON-OWNED PRD RTY DAMAGE AUTOS ONLY AUTOS ONLY lPer acrid nl $ „ UMBRELLA LIAB OCCUR „ C H OGGURRENGE $ EXCESS LIAR LAIMS-MADE EACH $ DED D RETENTION$ $ WORKERS COMPENSATIONP R Y/N OTH U AND EMPLOYERS'LIABILITY N„ST�mJUTF. V FR ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E L.EACH ACCIDENT $ OFFICERWEMBER EXCLUDED' N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE_$ If yes,describe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) This policy shall not be Canceled except by written notice to the Risk Manager at:City Clerk City of EI Segundo 350 Main St EI Segundo,CA 90245. at least thirty(30)days prior to the date of such cancellation.With respect to such insurance as is afforded by this policy,the City of EI Segundo and its officers,employees,elected officials,volunteers,and members of boards and commissions shall be named as additional insured.This additional insured coverage only applies with respect to liability of the named insured or other parties acting on their behalf arising out of the activities of the undertaking specified in paragraph No.5(Indemnification Clause). CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Clerk ACCORDANCE WITH THE POLICY PROVISIONS. City of EI Segundo AUTHORIZED REPRESENTATIVE Main Street EI Segundo CA 90245 �c2�LC1dC.B �CL+L�CLILfL I @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849.12 03-16-2016 Policy No.: 554 5818-1329-75 FE-6609 SECTION II ADDITIONAL INSURED ENDORSEMENT Policy No.: 554 5818-1329-75 Named Insured: ALFARO COMMUNICATIONS CONSTRUCTION INC. Additional Insured (include address): City Clerk City of EI Segundo 350 Main St EI Segundo Ca, 90245 PW 17-20, LIGHTED CROSSWALK REPAIRS ON MAIN STREET BETWEEN EL SEGUNDO BLVD. AND PINE AVE. WHO IS AN INSURED, under SECTION II DESIGNATION OF INSURED, is amended to include as an insured the Additional Insured shown above, but only to the extent that liability is imposed on that Additional Insured solely because of your work performed for that Additional Insured shown above. Any insurance provided to the Additional Insured shall only apply with respect to a claim made or a suit brought for damages for which you are provided coverage. The Primary Insurance coverage below applies only when there is an "X" in the box. Primary Insurance. The insurance provided to the Additional Insured shown above shall be primary insurance. Any insurance carried by the Additional Insured shall be noncontributory with respect to coverage provided to you. All other policy provisions apply. FE-6609 Printed in U.S A. Form r Request for Taxpayer Give Form to the (Rev.December 2011) Identification Number and Certification requester.Do not Department of the Treasury send to the IRS. Internal Revenue Service Naar[ ( hewn on your income tax rr ) oFf r rad W Name.ass co ;[torero N Business name(fisregarded entity name,it d" e e i from above .. as rn cu - o- Check appropriate box for federal tax cias4ication: C N ❑ Individual/sole proprietor J'C Corporation ❑ S Corporation ❑ Partnership ❑Trust/estate u ElLimited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership)► ❑Exempt payee C N a ❑ Other(see instructions)► !_ Address(number,street,and apt.or suite no.) R'er:quester"s name and aa0dress(optional) U ) C 6ty,state,and ZIP codem u � List acc onnt number(s)here(op6onal) "taxpayer Identification Number(TIN) Enter your TIN in the appropriate box.The TIN provided must match the name given on the"Name"line U Social security 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 identification number q number to enter. [37o 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 notified 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). Certification 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 ofy Here U.S.person► Date► General InstruCtioris Note.If a requester gives you a or other than Form W-9 to request your TIN,you must use the requester's form if it is substantially similar Section references are to the Internal Revenue Code unless otherwise 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)