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PROOF OF INSURANCE (2018) CLOSED DATE(MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE
I 8/10/2017
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(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 pan ACT
Bolton
3475 E. Foothill ill B vd., Suite 100 PHONE.Fxt); ),
[AIG, v (626),799-7000
Pasadena, CA 91.107 E MAI 1 ic,N� (626)583-2117
ADDRESS:
INSURERS)AFFORDING COVERAGE „NAIC#,
www.boltonco.com 0008309 wsURERA: Hartford Fire Insurance Company 19682
INSURED INSURERB: Travelers Property Casualty
Siaiic Contractors Corporation INSURER c: Hartford Accident and Indemnity insurance Co 36161
dba: Shawnan Company 22357
12240 Woodruff Avenue INSURER D:
DowneyCA 90241
INSURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER: 37196027 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
II .
NSR TYPE OF INSURANCE AODL SUER' POLICY EFF POLICY EXP
LTR u
NSD wVO POLICY NUMBER IMMIDDIYYYY) IMM.IDD/YXYYI Y LIMITS
A ,f" COMMERCIAL GENERAL LIABILITY ✓ �/ 72UEAHA5196 6/1/2017 6/1/2018 EACH OCCURRENCE $ 1,000,000
TO REN FC
CLAIMS-MADE ,/ OCCUR PHiEMISE ,S(Ea occurrence)„ $ 300,000
MED EXP(Any one person) $ 5,000
PERSONAL BADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY P_✓ II j Loc PRODUCTS Dt c'r's•COMP/CP AGG $ 2,000,000
OTHER $ 0
A AUTOMOBILE LIABILITY72UEAHA5198 6/1/2017 6/1/2018 COMBINED SINGLE LIMIT $
✓ ✓ (Fa accident) 1,000,000
,✓ ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE
$
AUTOS ONLY , AUTOS ONLY (Per accident)
$
B ✓ UMBRELLA LIAB ✓ OCCUR ZUP15S9047617NF 6/1/2017 6/1/2018 EACH OCCURRENCE $ 9,000,000
EXCESS LIAR CLAIMS-MADE AGGREGATE $ 9,000,000
..... DED ..✓ ( RETENTION$.0..„, .,
$
C WORKERS COMPENSATION � ✓ 72WEAZI8410 6/1/2017 6/1/2018 �/ P R UTE ER
AND EMPLOYERS'LIABILITYYIN ER
ANYPROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? N NIA
EE.., .,,,...., 1,000,000
if describe under
ESC
DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT
(Mandatory m E L DISEASE-EA EMPLOY $ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
The Certificate of Insurance is subject to policy terms,conditions.limitations„and exclusions,
GL Additional Insured and Primary Wording applies per HS24800713 attached,onlyy if required by written contract/agreement.
Auto Additional Insured and Primary Wording applies per HA99160312 pg1-2 attactted,GL,Auto and WC Waivers of Subrogation apply per
HG00010605 pg 15,HA99160312 pg 4-5 and WCD40306 attached.GL,Auto and WC Cancellation Clauses per H824501214 pg 1&6,
IH03130611 and WC990548 attached.Re:Shawnan Job#288,Project#'PW 16-10,Irripedal Highway Overlay Project. _Cont...
CERTIFICATE HOLDER CANCELLATION
Shawnan Job#288
Clt Ot EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
35 main Street ACCORDANCE WITH THE POLICY PROVISIONS.
EI Segundo, CA 90245
AUTHORIZED REPRESENTATIVE
Cassandra Rosales
©1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
37196037 1 SIALCON-01 1 17-18 Jobs-Public Agencies - All Lines I Shannon Smith 1 8/10/2017 11:49:41 AM (PDT) I Page 1 of 14
AGENCY CUSTOMER ID: SIALCON-01
LOC#:
..............
A�I'�" ADDITIONAL REMARKS SCHEDULE Page . .....mm.of
AGENCY NAMEDINSURED
Bolton&Company
Sialic
Shawnanors Corporation
POLICY NUMBER 12240 Woodruff Avenue
G Downey CA 90241
CARRIER NAIC CODE
EFFECTIVE DATE: ...............................
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE:Certificate of Liability(03/16)
HOLDER:City of EI Segundo _............
ADDRESS:350 Main Street EI Segundo,CA 90245
Additional Insured(s) : City of E1 Segundo its officials and employees.
ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD ADDENDUM
37196027 1 SIALCON-01 117-18 Jobe-Public Agencies - All Linea I Shannon Smith 8/10/2017 11:49:41 AM (PDT) I Page 2 of 14
POLICY NUMBER:72UEAHA5196 r .
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - OPTION I
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) Designated Project(s)Or Location(s)
Or Organization(s): Of Covered Operations:
When Required by Written Contract, Written
Agreement or Permit
Information required to complete this Schedule, if not shown above,will be shown in the Declarations.
A. With respect to those person(s) or organization(s) (3)In connection with "your work" for
shown in the Schedule above when you have the additional insured at the project(s) or
agreed in a written contract or written agreement location(s) designated in the Schedule
to provide insurance such as is afforded under and included within the "products-
this policy to them, Subparagraph f., Any Other completed operations hazard", but only if:
Party, under the Additional Insureds When (a) The written contract or written
Required By Written Contract, Written agreement requires you to provide
Agreement Or Permit Paragraph of Section II - such coverage to such additional
Who Is An Insured is replaced with the following: insured at the project(s) or location(s)
f. Any Other Party designated in the Schedule; and
Any other person or organization who is not an (b) This Coverage Part provides
insured under Paragraphs a.through e. above, coverage for "bodily injury" or
but only with respect to liability for "bodily "property damage" included within the
injury", "property damage" or "personal and "products-completed operations
advertising injury" caused, in whole or in part, hazard".
by your acts or omissions or the acts or The insurance afforded to the additional
omissions of those acting on your behalf: insured shown in the Schedule applies:
(1) In the performance of your ongoing (1) Only if the "bodily injury" or "property
operations for such additional insured at damage" occurs, or the "personal and
the project(s) or location(s) designated advertising injury" offense is committed:
in the Schedule; (a) During the policy period; and
(2) In connection with your premises owned (b) Subsequent to the execution of such
by or rented to you and shown in the
Schedule; or written contract or written agreement;
and
Form HS 24 80 07 13 Page 1 of 2
©2013, The Hartford
(Includes copyrighted material of Insurance Services Office, Inc.,with its permission.)
37196027 SIALCON-01 1 17-18 Jobs-Public Agencies - All Lines I Shannon Smith 1 8/10/2017 11:49:41 AM (PDT) I Page 3 of 14
(c) Prior to the expiration of the period of When You Add Others As An Additional
time that the written contract or written Insured To This Insurance
agreement requires such insurance be (a) Primary Insurance When Required By
provided to the additional insured. Contract
(2)Only to the extent permitted by law; and This insurance is primary if you have agreed in
(3)Will not be broader than that which you a written contract or written agreement that
are required by the written contract or this insurance be primary. If other insurance is
written agreement to provide for such also primary, we will share with all that other
additional insured. insurance by the method described in
With respect to the insurance afforded to the Paragraph (c) below. This insurance does not
person(s) or organization(s) that are apply to other insurance to which the
additional insureds under this endorsement, additional insured in the Schedule has been
the following additional exclusion applies: added as an additional insured.
This insurance does not apply to "bodily (b) Primary And Non-Contributory To Other
injury", "property damage" or "personal and Insurance When Required By Contract
advertising injury" arising out of the rendering This insurance is primary to and will not
of, or the failure to render, any professional seek contribution from any other
architectural, engineering or surveying insurance available to an additional
services, including: insured under your policy provided that:
(1)The preparing, approving, or failing to (I) The additional insured in the Schedule
prepare or approve maps, shop is a Named Insured under such other
drawings, opinions, reports, surveys, insurance; and
field orders, change orders, designs or (ii) You have agreed in a written contract or
specifications; or written agreement that this insurance
(2)Supervisory, inspection, architectural or would be primary and would not seek
engineering activities. contribution from any other insurance
The limits of insurance that apply to the additional available to the additional insured in the
insured shown in the Schedule are described in Schedule.
the Limits Of Insurance section. (c) 'Method Of Sharing
How this insurance applies when other insurance If all of the other insurance permits
is available to the additional insured is described contribution by equal shares, we will follow
in the Other Insurance Condition in Section IV - this method also. Under this approach, each
Commercial General Liability Conditions, except insurer contributes equal amounts until it has
as otherwise amended below. paid its applicable limit of insurance or none of
B. With respect to insurance provided to the the loss remains, whichever comes first.
person(s) or organization(s) that are additional If any of the other insurance does not permit
insureds under this endorsement, the When You contribution by equal shares, we will
Add Others As An Additional Insured To This contribute by limits. Under this method, each
Insurance subparagraph, under the Other insurers share is based on the ratio of its
Insurance Condition of Section IV— Commercial applicable limit of insurance to the total
General Liability Conditions is replaced with the applicable limits of insurance of all insurers.
following: All other terms and conditions in the policy
remain unchanged.
Page 2 of 2 Form HS 24 80 07 13
37196077 1 SIALCON-01 1 17-18 Jobs-Public Agencies - All Lines 1 Shannon Smith 1 8/10/2017 11:49:41 AM (PDT) 1 Page 4 of 14
72UEAHA5198 COMMERCIAL AUTOMOBILE
HA 99 16 03 12
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
COMMERCIAL, AUTOMOBILE, BROAD FOS
ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
To the extent that the provisions of this endorsement provide broader benefits to the "insured" than other
provisions of the Coverage Form, the provisions of this endorsement apply.
1. BROAD FORM INSURED d. Any "employee" of yours while using a
A. Subsidiaries and Newly Acquired or covered "auto" you don't own, hire or
Formed Organizations borrow in your business or your
The Named Insured shown in the personal affairs.
Declarations is amended to include: C. Lessors as Insureds
(1) Any legal business entity other than a Paragraph A.1. -WHO IS AN INSURED -of
partnership or joint venture, formed as a Section II - Liability Coverage is amended to
subsidiary in which you have an add:
ownership interest of more than 50% on e. The lessor of a covered "auto" while the
the effective date of the Coverage Form. "auto" is leased to you under a written
However, the Named Insured does not agreement if:
include any subsidiary that is an (1) The agreement requires you to
"insured" under any other automobile
policy or would be an "insured" under provide direct primary insurance for
the lessor and
such a policy but for its termination or
the exhaustion of its Limit of Insurance. (2) The"auto" is leased without a driver.
(2) Any organization that is acquired or Such a leased "auto" will be considered a
formed by you and over which you covered "auto" you own and not a covered
maintain majority ownership. However, .,auto"you hire.
the Named Insured does not include any D. Additional Insured if Required by Contract
newly formed or acquired organization: (1) Paragraph A.1. -WHO IS AN INSURED
(a) That is a partnership or joint - of Section II - Liability Coverage is
venture, amended to add:
(b) That is an "insured" under any other f. When you have agreed, in a written
policy, contract or written agreement, that a
(c) That has exhausted its Limit of person or organization be added as
Insurance under any other policy, or an additional insured on your
(d) 180 days or more after its business auto policy, such person or
acquisition or formation by you, organization is an "insured", but only
unless you have given us notice of to the extent such person or
the acquisition or formation. organization is liable for "bodily
Coverage does not apply to "bodily injury" or "property damage" caused
injury" or "property damage" that results by the conduct of an "insured" under
from an "accident" that occurred before paragraphs a. or b. of Who Is An
you formed or acquired the organization. Insured with regard to the
B. Employees as Insureds ownership, maintenance or use of a
covered"auto."
Paragraph A.1. -WHO IS AN INSURED - of
SECTION II - LIABILITY COVERAGE is
amended to add:
©2011, The Hartford (Includes copyrighted material
Form HA 99 16 03 12 of ISO Properties, Inc., with its permission.) Page 1 of 5
37196017 SIALCON-01 1 17-18 Jobs-Public Agencies - All Lines I Shannon Smith 1 8/10/2017 11:49:41 AM (PDT) I Page 5 of 14
The insurance afforded to any such E. Primary and Non-Contributory if
additional insured applies only if the Required by Contract
"bodily injury" or "property damage" Only with respect to insurance provided to
occurs: an additional insured in 1.D. - Additional
(1) During the policy period, and Insured If Required by Contract, the
(2) Subsequent to the execution of such following provisions apply:
written contract, and (3) Primary Insurance When Required By
(3) Prior to the expiration of the period Contract
of time that the written contract This insurance is primary if you have
requires such insurance be provided agreed in a written contract or written
to the additional insured. agreement that this insurance be
(2) How Limits Apply primary. If other insurance is also
If you have agreed in a written contract primary, we will share with all that other
or written agreement that another insurance by the method described in
person or organization be added as an Other Insurance 5.d.
additional insured on your policy, the (4) Primary And Non-Contributory To Other
most we will pay on behalf of such Insurance When Required By Contract
additional insured is the lesser of: If you have agreed in a written contract
(a) The limits of insurance specified in or written agreement that this insurance
the written contract or written is primary and non-contributory with the
agreement; or additional insured's own insurance, this
(b) The Limits of Insurance shown in insurance is primary and we will not
seek contribution from that other
the Declarations.
insurance.
Such amount shall be a part of and not Paragraphs (3) and (4) do not apply to other
in addition to Limits of Insurance shown insurance to which the additional insured
in the Declarations and described in this has been added as an additional insured.
Section.
When this insurance is excess, we will have no
(3) Additional Insureds Other Insurance duty to defend the insured against any "suit" if
If we cover a claim or "suit" under this any other insurer has a duty to defend the
Coverage Part that may also be covered insured against that "suit". If no other insurer
by other insurance available to an defends, we will undertake to do so, but we will
additional insured, such additional be entitled to the insured's rights against all
insured must submit such claim or"suit" those other insurers.
to the other insurer for defense and When this insurance is excess over other
indemnity. insurance, we will pay only our share of the
However, this provision does not apply amount of the loss, if any, that exceeds the sum
to the extent that you have agreed in a of:
written contract or written agreement (1) The total amount that all such other
that this insurance is primary and non- insurance would pay for the loss in the
contributory with the additional insured's absence of this insurance; and
own insurance.
(2) The total of all deductible and self-insured
(4) Duties in The Event Of Accident, Claim, amounts under all that other insurance.
Suit or Loss
If you have agreed in a written contract We will share the remaining loss, if any, by the
or written agreement that another method described in Other Insurance 5.d.
person or organization be added as an 2. AUTOS RENTED BY EMPLOYEES
additional insured on your policy, the Any "auto" hired or rented by your "employee"
additional insured shall be required to on your behalf and at your direction will be
comply with the provisions in LOSS considered an"auto"you hire.
CONDITIONS 2. - DUTIES IN THE The OTHER INSURANCE Condition is amended
EVENT OF ACCIDENT, CLAIM , SUIT by adding the following:
OR LOSS — OF SECTION IV —
BUSINESS AUTO CONDITIONS, in the
same manner as the Named Insured.
©2011, The Hartford (Includes copyrighted material
Form HA 99 16 03 12 of ISO Properties, Inc., with its permission.) Page 2 of 5
37196027 SIALCON-01 1 17-18 Jobs-Public Agencies - All Lines I Shannon Smith 1 8/10/2017 11:49:41 AM (PDT) I Page 6 of 14
72UEAHA5196
If any of the other insurance does not permit insured will bring "suit" or transfer those rights to us
contribution by equal shares, we will contribute by and help us enforce them.
limits. Under this method, each insurer's share is b. Waiver Of Rights Of Recovery (Waiver Of
based on the ratio of its applicable limit of Subrogation)
insurance to the total applicable limits of insurance
of all insurers. If the insured has waived any rights of recovery
against any person or organization for all or part of
5. Premium Audit any payment, including Supplementary Payments,
a. We will compute all premiums for this Coverage we have made under this Coverage Part, we also
Part in accordance with our rules and rates. waive that right, provided the insured waived their
b. Premium shown in this Coverage Part as advance rights of recovery against such person or
premium is a deposit premium only. At the close of organization in a contract, agreement or permit that
each audit period we will compute the earned was executed prior to the injury or damage.
premium for that period and send notice to the first 9. When We Do Not Renew
Named Insured. The due date for audit and If we decide not to renew this Coverage Part, we will
retrospective premiums is the date shown as the mail or deliver to the first Named Insured shown in the
due date on the bill. If the sum of the advance and Declarations written notice of the nonrenewal not less
audit premiums paid for the policy period is greater than 30 days before the expiration date.
than the earned premium, we will return the excess
to the first Named Insured. If notice is mailed, proof of mailing will be sufficient
proof of notice.
c. The first Named Insured must keep records of the SECTION V—DEFINITIONS
information we need for premium computation, and
send us copies at such times as we may request. 1. "Advertisement" means the widespread public
6. Representations dissemination of information or images that has the
a. When You Accept This Policy purpose of inducing the sale of goods, products or
services through:
By accepting this policy, you agree: a. (1) Radio;
(1) The statements in the Declarations are accurate (2) Television;
and complete;
(3) Billboard;
(2) Those statements are based upon
representations you made to us; and (4) Magazine;
(3) We have issued this policy in reliance upon your (5) Newspaper; or
representations. b. Any other publication that is given widespread
b. Unintentional Failure To Disclose Hazards public distribution.
If unintentionally you should fail to disclose all However, "advertisement"does not include:
hazards relating to the conduct of your business a. The design, printed material, information or images
that exist at the inception date of this Coverage contained in, on or upon the packaging or labeling
Part, we shall not deny coverage under this of any goods or products; or
Coverage Part because of such failure. b. An interactive conversation between or among
7. Separation Of Insureds persons through a computer network.
Except with respect to the Limits of Insurance, and any 2. "Advertising idea" means any idea for an
rights or duties specifically assigned in this Coverage "advertisement".
Part to the first Named Insured, this insurance applies: 3. "Asbestos hazard" means an exposure or threat of
a. As if each Named Insured were the only Named exposure to the actual or alleged properties of
Insured; and asbestos and includes the mere presence of asbestos
b. Separately to each insured against whom claim is in any form.
made or"suit" is brought. 4. "Auto" means a land motor vehicle, trailer or semitrailer
8. Transfer Of Rights Of Recovery Against Others To designed for travel on public roads, including any
Us attached machinery or equipment. But "auto" does not
a. Transfer of Rights Of Recovery include "mobile equipment".
If the insured has rights to recover all or part of any 5. "Bodily injury" means physical:
payment, including Supplementary Payments, we a. Injury;
have made under this Coverage Part, those rights b. Sickness; or
are transferred to us. The insured must do nothing c. Disease
after loss to impair them. At our request, the sustained by a person and, if arising out of the above,
mental anguish or death at any time.
HG 00 01 06 05 Page 15 of 18
37196027 1 SIALCON-01 1 17-18 Jobs-Public Agencies - All Lines 1 Shannon Smith 8/10/2017 11;49;41 AM (PDT) 1 Page 7 of 14
72UEAHA5198
(4) Necessary for the normal If another Hartford Financial Services Group,
operation of the covered "auto"or Inc. company policy or coverage form that is not
the monitoring of the covered an automobile policy or coverage form applies to
"auto's"operating system. the same"accident", the following applies:
b.Section III — Version CA 00 01 03 10 of the (1) If the deductible under this Business Auto
Business Auto Coverage Form, Physical Coverage Form is the smaller (or smallest)
Damage Coverage, Limit of Insurance, deductible, it will be waived;
Paragraph C.2 and Version CA 00 01 10 01 of (2) If the deductible under this Business Auto
the Business Auto Coverage Form, Physical Coverage Form is not the smaller (or
Damage Coverage, Limit of Insurance, smallest) deductible, it will be reduced by
Paragraph C are each amended to add the the amount of the smaller (or smallest)
following: deductible.
$1,500 is the most we will pay for"loss" in 12. AMENDED DUTIES IN THE EVENT OF
any one "accident" to all electronic ACCIDENT,CLAIM, SUIT OR LOSS
equipment(other than equipment designed
solely for the reproduction of sound, and The requirement in LOSS CONDITIONS 2.a. -
accessories used with such equipment) DUTIES IN THE EVENT OF ACCIDENT,CLAIM,
that reproduces, receives or transmits SUIT OR LOSS - of SECTION IV - BUSINESS
audio, visual or data signals which, at the AUTO CONDITIONS that you must notify us of
time of"loss", is: an "accident" applies only when the"accident" is
known to:
(1) Permanently installed in or upon
the covered "auto" in a housing, (1) You, if you are an individual;
opening or other location that is not (2) A partner, if you are a partnership;
normally used by the "auto" (3) A member, if you are a limited liability
manufacturer for the installation of company; or
such equipment; (4) An executive officer or insurance manager, if
(2) Removable from a permanently you are a corporation.
installed housing unit as described 13. UNINTENTIONAL FAILURE TO DISCLOSE
in Paragraph 2.a. above or is an HAZARDS
integral part of that equipment; or
(3)An integral part of such equipment. If you unintentionally fail to disclose any hazards
existing at the inception date of your policy, we
c.For each covered "auto", should loss be limited will not deny coverage under this Coverage
to electronic equipment only, our obligation to Form because of such failure.
pay for, repair, return or replace damaged or 14. HIRED AUTO -COVERAGE TERRITORY
stolen electronic equipment will be reduced by
the applicable deductible shown in the Paragraph e. of GENERAL CONDITIONS 7. -
Declarations, or $250, whichever deductible is POLICY PERIOD, COVERAGE TERRITORY -
less. of SECTION IV - BUSINESS AUTO
9. EXTRA EXPENSE - BROADENED CONDITIONS is replaced by the following:
COVERAGE e. For short-term hired "autos", the coverage
Under Paragraph A. -COVERAGE -of SECTION territory with respect to Liability Coverage is
III - PHYSICAL DAMAGE COVERAGE, we will anywhere in the world provided that if the
pay for the expense of returning a stolen covered "insured's" responsibility to pay damages for
"auto"to you. "bodily injury" or "property damage" is
determined in a suit,"the"suit" is brought in
10. GLASS REPAIR-WAIVER OF DEDUCTIBLE the United States of America, the territories
Under Paragraph D.-DEDUCTIBLE-of SECTION and possessions of the United States of
III - PHYSICAL DAMAGE COVERAGE, the America, Puerto Rico or Canada or in a
following is added: settlement we agree to.
No deductible applies to glass damage if the 15. WAIVER OF SUBROGATION
glass is repaired rather than replaced. TRANSFER OF RIGHTS OF RECOVERY
11. TWO OR MORE DEDUCTIBLES AGAINST OTHERS TO US - of SECTION IV -
Under Paragraph D.-DEDUCTIBLE-of SECTION BUSINESS AUTO CONDITIONS is amended by
III - PHYSICAL DAMAGE COVERAGE, the adding the following:
following is added:
©2011, The Hartford (Includes copyrighted material
Form HA 99 16 03 12 of ISO Properties, Inc., with its permission.) Page 4 of 5
37196077 SIALCON-01 1 17-18 Jobs-Public Agencies - All Linea I Shannon Smith 1 8/10/2017 11:49:41 AM (PDT) I Page 8 of 14
We waive any right of recovery we may have c.Regardless of the number of autos deemed a
against any person or organization with whom total loss, the most we will pay under this
you have a written contract that requires such Hybrid, Electric, or Natural Gas Vehicle
waiver because of payments we make for Payment Coverage provision for any one
damages under this Coverage Form. "loss" is$10,000.
16. RESULTANT MENTAL ANGUISH COVERAGE For the purposes of the coverage provision,
The definition of "bodily injury" in SECTION V- a.A "non-hybrid" auto is defined as an auto that
DEFINITIONS is replaced by the following: uses only an internal combustion engine to
"Bodily injury" means bodily injury, sickness or move the auto but does not include autos
disease sustained by any person, including powered solely by electricity or natural gas.
mental anguish or death resulting from any of b.A "hybrid" auto is defined as an auto with an
these. internal combustion engine and one or more
17. EXTENDED CANCELLATION CONDITION electric motors; and that uses the internal
combustion engine and one or more electric
Paragraph 2. of the COMMON POLICY motors to move the auto, or the internal
CONDITIONS - CANCELLATION - applies combustion engine to charge one or more
except as follows: electric motors,which move the auto.
If we cancel for any reason other than 19. VEHICLE WRAP COVERAGE
nonpayment of premium, we will mail or deliver
to the first Named Insured written notice of In the event of a total loss to an "auto" for which
cancellation at least 60 days before the effective Comprehensive, Specified Causes of Loss, or
date of cancellation. Collision coverages are provided under this
18. HYBRID, ELECTRIC, OR NATURAL GAS Coverage Form, then such Physical Damage
VEHICLE PAYMENT COVERAGE Coverages are amended to add the following:
In addition to the actual cash value of the "auto",
In the event of a total loss to a "non-hybrid" auto we will pay up to $1,000 for vinyl vehicle wraps
for which Comprehensive, Specified Causes of which are displayed on the covered "auto" at the
Loss, or Collision coverages are provided under time of total loss. Regardless of the number of
this Coverage Form, then such Physical autos deemed a total loss, the most we will pay
Damage Coverages are amended as follows: under this Vehicle Wrap Coverage provision for
a.lf the auto is replaced with a "hybrid" auto or any one "loss" is $5,000. For purposes of this
an auto powered solely by electricity or natural coverage provision, signs or other graphics
gas, we will pay an additional 10%, to a painted or magnetically affixed to the vehicle are
maximum of$2,500, of the "non-hybrid" auto's not considered vehicle wraps.
actual cash value or replacement cost,
whichever is less,
b.The auto must be replaced and a copy of a bill
of sale or new lease agreement received by us
within 60 calendar days of the date of"loss,"
©2011, The Hartford (Includes copyrighted material
Form HA 99 16 03 12 of ISO Properties, Inc., with its permission.) Page 5 of 5
37196027 SIALCON-01 1 17-19 Jobs-Public Agencies - All Lines I Shannon Smith 1 8/10/2017 11;49:41 AM (PDT) I Page 9 of 14
72UEAHA5196
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CONTRACTORS BROAD FORM ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
INDEX
1. Alienated Premises Coverage.........................................................................................................................1
2. Damage To Your Work...................................................................................................................................1
3 Contractors Limited Professional Liability........... ................................................................. ...................... ..1
4. Per Project and Per Location General Aggregate Limits Of Insurance........................................................ ..2
5. Motor Vehicle Laws.........................................................................................................................................3
6. Medical Payments Coverage—Including Products-Completed Operations .................................................3
7. Insured Contract—Construction Operations And Municipal Work..................................................................3
8. Injury To Employee's Reputation With Respect To Incidental Medical Malpractice .......................................3
9. Bodily Injury Employee Suits...........................................................................................................................4
10. Consolidated Insurance (Wrap-Up) Programs................................................................................................4
11. Access Or Disclosure Of Confidential Or Personal Information And Data-Related Liability ..........................4
12. Contractual Liability Coverage For Personal And Advertising Injury...............................................................5
13. Supplementary Payments...............................................................................................................................6
14. Two Or More Coverage Parts Or Policies Issued By Us.................................................................................6
15. Notice of Cancellation to Certificate Holders.................................................................... 6
1. ALIENATED PREMISES COVERAGE This exclusion does not apply if the damaged work
Exclusion j. Damage To Property of Section I — or the work out of which the damage arises was
Coverage A is amended as follows: performed on your behalf by a subcontractor.
a. The following exception to the exclusion is This provision does not apply if exclusion I.
deleted: Damage To Your Work has been otherwise
modified by endorsement.
Paragraph this exclusion does not apply 3CONTRACTORS LIMITED PROFESSIONAL
if the premises
ess are your work .and were LIABILITY
never occupied, rented or held for rental by
you. The following exclusion is added to Paragraph 2.,
b. This exception is replaced by the following: Exclusions of Section I - Coverage A - Bodily
Paragraph (2) of this exclusion does not apply Injury And Property Damage Liability, and to
Paragraph 2., Exclusions of Section I -
if the premises are"your work". Coverage B - Personal And Advertising Injury
2. DAMAGE TO YOUR WORK Liability:
Exclusion I. Damage To Your Work of Section I - This insurance does not apply to "bodily injury",
Coverage A is replaced by the following: "property damage" or "personal and advertising
I. Damage to Your Work injury" arising out of the rendering of or failure to
"Property damage" to that particular part of render any professional services by you with
respect to your providing engineering, architectural
"your work" out of which damage arises and or surveying services in your capacity as an
included in the products-completed engineer, architect or surveyor.
operations hazard".
Form HS 24 50 12 14 Page 1 of 6
©2014, The Hartford
37196077 1 SIALCON•01 1 17-18 Jobe-Public Agencies - All Lines I Shannon Smith 1 8/10/3017 11;49:11 AM (PDT) I Page 10 of 14
B. Subparagraph f. of the definition of 13. SUPPLEMENTARY PAYMENTS
"insured contract" (Section V — In the Supplementary Payments—Coverages A
Definitions) is replaced by the following: and B provision:
f. That part of any other contract or The limit for the cost of bail bonds in increased to
agreement pertaining to your business $2,500.
(including an indemnification of a 14. TWO OR MORE COVERAGE PARTS OR
municipality in connection with work
performed for a municipality) under POLICIES ISSUED BY US
which you assume the tort liability of If this policy and any other policy issued to an
another party to pay for"bodily injury", insured by us or any affiliated company provides
"property damage", or "personal and coverage that applies to the same claim or
advertising injury" to a third person or damages, the maximum applicable limit(s) of
organization. Tort liability means a liability or limit of insurance under all the policies
liability that would be imposed by law will not exceed the highest applicable limit of
in the absence of any contract or liability or limit of insurance under any one policy.
agreement. Paragraph f. includes that This condition does not apply to any policy issued
part of any contract or agreement that by us or an affiliated company specifically written
indemnifies a railroad for "bodily to apply as excess insurance over this policy.
injury", "property damage", or 15. NOTICE OF CANCELLATION TO CERTIFICATE
personal and advertising injuryHOLDER(S)
arising out of construction or
demolition operations, within 50 feet This policy is subject to the following additional
of any railroad property and affecting Conditions:
any railroad bridge or trestle, tracks, A. If this policy is cancelled by the Company,
road-beds, tunnel, underpass or other than for nonpayment of premium, notice
crossing. of such cancellation will be provided at least
However, Paragraph f. does not thirty (30) days in advance of the cancellation
include that part of any contract or effective date to the certificate holder(s) with
agreement: mailing addresses on file with the agent of
(1) That indemnifies an architect, record or the Company.
engineer or surveyor for injury or B. If this policy is cancelled by the Company for
damage arising out of: nonpayment of premium, or by the insured,
notice of such cancellation will be provided
(a) Preparing, approving, or within (10) days of the cancellation effective
failing to prepare or approve, date to the certificate holder(s) with mailing
maps, shop drawings, addresses on file with the agent of record or
opinions, reports, surveys, the Company.
field orders, change orders or
drawings and specifications; If notice is mailed, proof of mailing to the last
or known mailing address of the certificate holder(s)
on file with the agent of record or the Company will
(b) Giving directions or be sufficient proof of notice.
instructions, or failing to give
them, if that is the primary Any notification rights provided by this
cause of the injury or endorsement apply only to active certificate
damage; or holder(s) who were issued a certificate of
insurance applicable to this policy's term.
(2) Under which the insured, if an Failure to provide such notice to the certificate
architect, engineer or surveyor, holder(s) will not amend or extend the date the
assumes liability for an injury or cancellation becomes effective, nor will it negate
damage arising out of the cancellation of the policy. Failure to send notice
insured's rendering or failure to shall impose no liability of any kind upon the
render professional services, Company or its agents or representatives.
including those listed in (1) above
and supervisory, inspection,
architectural or engineering
activities.
Page 6 of 6 Form HS 24 50 12 14
37196027 I SIALCON-01 1 17-18 Jobs-Public Agencies - All Linea 1 Shannon Smith 1 8/10/3017 11:49:41 AM (PDT) 1 Page 11 of 14
72 U EAHA5198 lk
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
NOTICE OF CANCELLATION TO CERTIFICATE HOLDER(S)
This policy is subject to the following additional If notice is mailed, proof of mailing to the last known
Conditions: mailing address of the certificate holder(s) on file with
A. If this policy is cancelled by the Company, other the agent of record or the Company will be sufficient
than for nonpayment of premium, notice of such proof of notice.
cancellation will be provided at least thirty (30) Any notification rights provided by this endorsement
days in advance of the cancellation effective date apply only to active certificate holder(s) who were
to the certificate holder(s) with mailing addresses issued a certificate of insurance applicable to this
on file with the agent of record or the Company. policy's term.
B. If this policy is cancelled by the Company for Failure to provide such notice to the certificate
nonpayment of premium, or by the insured, notice holder(s) will not amend or extend the date the
of such cancellation will be provided within (10) cancellation becomes effective, nor will it negate
days of the cancellation effective date to the cancellation of the policy. Failure to send notice shall
certificate holder(s) with mailing addresses on file impose no liability of any kind upon the Company or its
with the agent of record or the Company. agents or representatives.
Form 103 13 06 11 Page 1 of 1
O 2011, The Hartford
31195037 1 SIALCION-01 1 17-18 Joba-Public Agencies - All Linea 1 Shannon Smith 10/10/1017 11;49;41 AM (PDT) I Page 12 of 14
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CANCELLATION BY US
Policy Number:72WEAZI8410 Endorsement Number:
Effective Date: 6/1/2017 Effective hour is the same as stated on the Information Page of the policy,
Named Insured and Address:Sialic Contractors Corporation
dba: Shawnan
12240 Woodruff Avenue
Downey CA 90241
Paragraph 2. Of Part Six-Conditions, D. Cancellation in the Workers' Compensation and Employers' Liability
Insurance Policy Provisions is replaced by the following:
2.We may cancel this policy by mailing or delivering to the Named Insured written notice of cancellation at least:
a. 30 days before the effective date of cancellation or as required by statute whichever is
longer if we cancel for nonpayment of premium; or
b. 10 days before the effective date of cancellation or as required by statute, whichever is
longer, if we cancel for any other reason.
Nothing herein contained shall be held to vary, waive, alter, or extend any of the terms, conditions,
agreements or declarations of the policy, other than as herein stated.
Form WC 99 05 48 Printed in USA
Process Date: Policy Expiration ate:6/1/2018
37196037 1 81ALCON-01 1 17-18 Jobs-Public agencies - A11 Linea I Shannon smith 1 0/10/2017 11:®9:41 AN (PDT) I Page 13 of 14
it
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF OUR RIGHT TO RECOVER FROM
OTHERS ENDORSEMENT - CALIFORNIA
Policy Number:72 WEA Z18410
Effective Date:06/01/2017
Named Insured and Address:SIALIC CONTRACTORS CORPORATION
12240 WOODRUFF AVENUE
DOWNEY,CA 90241
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 % of the California workers' compensation premium
otherwise due on such remuneration.
SCHEDULE
Person or Organization Job Description
CITY OF EL SEGUNDO, ITS OFFICIALS, SHAWNAN JOB#288, PROJECT#PW 16-10
EMPLOYEES,AGENTS AND VOLUNTEERS IMPERIAL HIGHWAY OVERLAY PROJECT
CITY OF EL SEGUNDO
350 MAIN STREET
EL SEGUNDO, CA 90245
Countersigned by
Authorized Representative
Form WC 04 03 06 (1) Printed in U.S.A.
Process Date: Policy Expiration Date:06/01/2018
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