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PROOF OF INSURANCE (2018 - 2018) CLOSED AIDBU-1 OP to:SO
A�""rCJ►RO
�� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
09/06/2017
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 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
071Ma n Streettage Insurance EV0191.LL �.Iji ,Ne) 91.1.6-7.8.4.1-9799
CONT
Bui
ders
AX
AC
sey Carmack
916-784-9793
Roseville CA 95678 ADDRESS;lynsey@btjitdersad!vatitagein�s.com
Lynsey Carmack
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A:ATAIN SPECIALTY INSURANCE COMP 17159
INSURED Aid Builders Inc. INSURERB:State Comp Ins Fund ,35076
Ed Al-Badry 14821 Ansford St. INSURER C:California Automobile Ins.Co.
Haceieda,CA 91745 INSURER E:Evanston Insurance Co 35378
II ........ .. ..................
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.
............ LIMITS. .... ........
/LTR "NOL1's'0'OR POLICY EFF' f POLICY EXP
TYPE OF INSURANCE �0�. 1�. POLICY NUMBER (MM/DD•IYVYX)I(MMPDDd'r"Y'Y'Y1
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE f X OCCUR X X CIP326104 06/01/2017 06/0112018 PREMSESD(EaolccurDunce 9 100,000
MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY T PRO- LOC PRODUCTS $..................................2,0....0....0,0.0.0
OTHER JECT ...
AUTOMOBILE LIABILITY COMBINED
INGL..E...'..LIMIT
................$.........................
C ANY AUTO X BA040000035108 07/2512017 0712512018 BODILY INJURY(Per person) $ 1,000,000
ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $
_ AUTOS AUTOS
HIRED AUTOS
NON- (Pena ,5NE DA.MA.�.f
1
UMBRELLA
CCUR EACH
1,000,000
D X EXCESS AB AB X CLAIMS-MADE XSMP1107317 08/30/2017 06/01/2018 AGGREGATE RRENGE $ 1,000,0„00
DED RETENTION$ $
WORKERS COMPENSATION ]STATUTE PER OTH-
AND EMPLOYERS'LIABILITY B OFFICEPROPRIETOR/PARTNER/EXECUTIVE
/IETO
OFFICER/MEMBER R/E ECUTIVE Yj/N•'( N/A 9211820-2017 06/03/2017 06103/2018 XL EACH ACCIDENT ER „$ 1,000,0,00
(Mandatory In NH) E L DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E L D6EA$E•POI.CY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required)
Certificate holder is named as additional insured under the commercial
general liability policy per attached endorsement.
RE: 314 Main Street EI Segundo,CA 90245
u
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
The City of EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
EI Segundo,CA 90245 AUTHORIZED REPRESENTATIVE
�" Ja61a �1
I ,
©1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: CIP326104 COMMERCIAL GENERAL LIABILITY
CG 20 10 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES S OR.
CONTRACTORS - SCHEDULED PERSON O
ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s) Location(s)Of Covered Operations
THE CITY OF EL SEGUNDO 314 MAIN STREET
350 MAIN STREET EL SEGUNDO, CA 90245
EL SEGUNDO, CA 90245
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
organization(s) shown in the Schedule, but only exclusions apply:
with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or
damage or personal and advertising injuryVroperty damage"occurring after:
caused, in whole or in part, by:
1. All work, including materials, parts or
1. Your acts or omissions; or equipment furnished in connection with such
2. The acts or omissions of those acting on your work, on the project (other than service,
behalf; maintenance or repairs) to be performed by or
in the performance of your ongoing operations for on behalf of the additional insured(s) at the
the additional insured(s) at the location(s) location of the covered operations has been
designated above. completed; or
However: 2. That portion of "your work" out of which the
injury or damage arises has been put to its
1. The insurance afforded to such additional intended use by any person or organization
insured only applies to the extent permitted by other than another contractor or subcontractor
law; and engaged in performing operations for a
2. If coverage provided to the additional insured is principal as a part of the same project.
required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
CG 2010 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 2
C. With respect to the insurance afforded to these 2. Available under the applicable Limits of
additional insureds, the following is added to Insurance shown in the Declarations;
Section III—Limits Of Insurance: whichever is less.
If coverage provided to the additional insured is This endorsement shall not increase the
required by a contract or agreement, the most we applicable Limits of Insurance shown in the
will pay on behalf of the additional insured is the Declarations.
amount of insurance:
1. Required by the contract or agreement; or
Page 2 of 2 0 Insurance Services Office, Inc., 2012 CG 2010 0413
POLICY NUMBER: CIP326104 COMMERCIAL GENERAL LIABILITY
CG 20 37 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED, OPERATIONS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s) Location And Description Of Completed Operations
THE CITY OF EL SEGUNDO 314 MAIN STREET
350 MAIN STREET EL SEGUNDO, CA 90245
EL SEGUNDO, CA 90245
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 is added to
organization(s) shown in the Schedule, but only Section III—Limits Of Insurance:
with respect to liability for "bodily injury" or If coverage provided to the additional insured is
"property damage"caused, in whole or in part, by required by a contract or agreement the most we
'dour work' at the location designated and will pay on behalf of the additional insured is the
described in the Schedule of this endorsement amount of insurance:
performed for that additional insured and
included in the "products-completed operations 1. Required by the contract or agreement; or
hazard". 2. Available under the applicable Limits of
However: Insurance shown in the Declarations;
1. The insurance afforded to such additional whichever is less.
insured only applies to the extent permitted This endorsement shall not increase the applicable
by law; and Limits of Insurance shown in the Declarations.
2. If coverage provided to the additional insured
is required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
CG 20 37 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1
COMMERCIAL GENERAL LIABILITY
CG 20 33 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY,
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS -AUTOMATIC STATUS WHEN
REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU
This endorsement modifies insurance provided under the following
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A. Section II - Who Is An Insured is amended to B. With respect to the insurance afforded to these ad-
include as an additional insured any person or or- ditional insureds, the following additional exclu-
ganization for whom you are performing opera- sions apply:
tions when you and such person or organization This insurance does not apply to:
have agreed in writing in a contract or agreement
that such person or organization be added as an 1. "Bodily injury", "property damage"or"personal
additional insured on your policy. Such person or and advertising injury" arising out of the ren-
organization is an additional insured only with re- dering of, or the failure to render, any profes-
spect to liability for "bodily injury", "property dam- sional architectural, engineering or surveying
age"or"personal and advertising injury"caused, in services, including:
whole or in part, by: a. The preparing, approving, or failing to
1. Your acts or omissions; or prepare or approve, maps, shop draw-
ings, opinions, reports, surveys, field or-
t. The acts or omissions of those acting on your ders, change orders or drawings and
behalf; specifications; or
in the performance of your ongoing operations for
the additional insured. b. Supervisory, inspection, architectural or
engineering activities
However, the insurance afforded to such additional This exclusion applies even if the claims against
insured: any insured allege negligence or other wrongdoing
1. Only applies to the extent permitted by law; in the supervision, hiring, employment, training or
and monitoring of others by that insured, if the "occur-
2. Will not be broader than that which you are re- rence" which caused the "bodily injury" or "prop-
quired by the contract or agreement to provide erty damage", or the offense which caused the
for such additional insured. "personal and advertising injury", involved the ren-
dering of or the failure to render any professional
A person's or organization's status as an addi- architectural, engineering or surveying services.
tional insured under this endorsement ends when
your operations for that additional insured are
completed.
CG 20 33 04 13 Copyright, Insurance Services Office, Inc.,2012 Page 1 of 2
2. 'Bodily injury" or "property damage"occurring C. With respect to the insurance afforded to these
after: additional insureds, the following is added to Sec-
a. All work, including materials, parts or tion III -Limits Of Insurance:
equipment furnished in connection with The most we will pay on behalf of the additional in-
such work, on the project(other than serv- sured is the amount of insurance:
ice, maintenance or repairs) to be per- 1. Required by the contract or agreement you
formed by or on behalf of the additional have entered into with the additional insured;
insured(s) at the location of the covered or
operations has been completed; or
2. Available under the applicable Limits of Insur-
b. That portion of "your work" out of which ance shown in the Declarations;
the injury or damage arises has been put
to its intended use by any person or or- whichever is less.
ganization other than another contractor This endorsement shall not increase the applicable
or subcontractor engaged in performing Limits of Insurance shown in the Declarations.
operations for a principal as a part of the
same project.
Page 2 of 2 Copyright, Insurance Services Office, Inc., 2012 CG 20 33 04 13
POLICY NUMBER:CI P326104 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:
COM M ERCIAL G EN ERAL LIABILITY COVERAGE PART
PRODUCTS/COM PLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Person Or Organization:
ANY PERSON OR ORGANIZATION WITH WHOM THE INSURED HAS AGREED TO WAIVE
RIGHTS OF RECOVERY, PROVIDED SUCH AGREEMENT IS MADE IN WRITING AND PRIOR
TO THE LOSS
Information required to complete this Schedule, if not shown above,will be shown in the Declarations.
The following is added to Paragraph 8. Transfer Of
Rights Of Recovery Against Others To Us of Section IV-
Conditions:
We waive any right of recovery we may have against the
person or organization shown in the Schedule above
because of payments we make for injury or damage
arising out of your ongoing operations or "your work"
done under a contract with that person or organization
and included in the "products completed operations
hazard". This waiver applies only to the person or
organization shown in the Schedule above.
CG 24 04 05 09 Insurance Services Office, Inc.,2008 Page 1 of 1
CG 25 03 03 97
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED CONSTRUCTION PRO�JECT(S) GENERAL
AGGREGATE LIMIT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Designated Construction Projects:
LOCATIONS AS REQUIRED BY SPECIFIC WRITTEN CONTRACT
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
A. For all sums which the insured becomes legally ob- subject to the General Aggregate Limit shown in
ligated to pay as damages caused by "occurrences" the Declarations, such limits will be subject to
under COVERAGE A (SECTION 1), and for all medi- the applicable Designated Construction Project
cal expenses caused by accidents under COVERAGE General Aggregate Limit.
C (SECTION 1), which can be attributed only to & For all sums which the insured becomes legally ob-
ongoing operations at a single designated construc- ligated to pay as damages caused by "occurrences"
tion project shown in the Schedule above: under COVERAGE A (SECTION 1), and for all medi-
1. A separate Designated Construction Project Gen- cal expenses caused by accidents under COV-
eral Aggregate Limit applies to each designated ERAGE C (SECTION 1), which cannot be attributed
construction project, and that limit is equal to only to ongoing operations at a single designated
the amount of the General Aggregate Limit construction project shown in the Schedule above:
shown in the Declarations. 1. Any payments made under COVERAGE A for
2. The Designated Construction Project General Ag- damages or under COVERAGE C for medical
gregate Limit is the most we will pay for the sum expenses shall reduce the amount available
of all damages under COVERAGE A, except dam- under the General Aggregate Limit or the
ages because of "bodily injury" or "property Products-Completed Operations Aggregate Limit,
damage" included in the operations hazard", and whichever is applicable; and
for medical expenses under COVERAGE C re- 2. Such payments shall not reduce any Designated
gardless of the number of: Construction Project General Aggregate Limit.
a. Insureds; C. When coverage for liability arising out of the
b. Claims made or "suits" brought; or "products-completed operations hazard" is provided,
c. Persons or organizations making claims or any payments for damages because of "bodily
bringing "suits". injury" or "property damage" included in the "pro-
ducts-completed operations hazard" will reduce the
3. Any payments made under COVERAGE A for Products-Completed Operations Aggregate Limit, and
damages or under COVERAGE C for medical not reduce the General Aggregate Limit nor the Des-
expenses shall reduce the Designated Construc- ignated Construction Project General Aggregate Lim-,
tion Project General Aggregate Limit for that it
designated construction project. Such payments
shall not reduce the General Aggregate Limit D. If the applicable designated construction project has
shown in the Declarations nor shall they reduce been abandoned, delayed, or abandoned and then re-
any other Designated Construction Project Gen- started, or if the authorized contracting parties dev-
eral Aggregate Limit for any other designated iate from plans, blueprints, designs, specifications or
construction project shown in the Schedule timetables, the project will still be deemed to be the
above. same construction project.
4. The limits shown in the Declarations for Each E. The provisions of Limits Of Insurance (SECTION III)
Occurrence, Fire Damage and Medical Expense not otherwise modified by this endorsement shall
continue to apply. However, instead of being continue to apply as stipulated.
"
CG 25 03 03 97 Copyright, Insurance Services Office, Inc., 1996 �ortlerNo 14eEO44
California Automobile Insurance Company
P.O. Box 10730 A/ %,I
Santa Ana, CA 92711-0730 AA M1 E 0HO"C U R Y
INSURANCE�C ,
Customer Service: (800) 503-3724 J
BUSINESS AUTO 'POLICY
ADDITIONAL INSURED Amended Declarations
Effective Date: 08/08/2017
NAMED INSURED: AGENT:
ED AL-BADRY BUILDERS ADVANTAGE INS SV
14821 Ansford St 107 MAIN STREET
Hacienda Heights,CA 91745-1300 ROSEVILLE, CA 95678
(916)784-9793
SCHEDULE
Insurance Company: California Automobile Insurance Company
Policy Number: BA040000035108
Policy Period: From: 07/25/2017 to 07/25/2018 at 12:01 AM Standard Time at your mailing
address
Additional Insured: THE CITY OF EL SEGUNDO
Address: 350 Main St, EI Segundo CA 90245
Endorsements Attached:
CA 20 48 02 99 - Designated Insured
AUTOMOBILE LIABILITY PROVIDED
Covered Autos: Symbol 7 -Specifically Described "Autos"
Limits of Insurance: $1,000,000 CSL
MCADS910711 Page 1 of 1
Policy Number: BA040000035108 AoMERCURYI I S U R A I�C E
Effective Date: 08/08/2017 Ail
Amended Declarations: Add Loss Payee/Addl InsuredMaiver
This policy change has resulted in an additional premium of$24.00
This declarations supersedes any previous declarations bearing the same number for this policy period
BUSINESS AUTO DECLARATIONS
S
Issued By: Agent:
California Automobile Insurance Company BUILDERS ADVANTAGE INS SV
P.O. Box 10730 107 MAIN STREET
Santa Ana,CA 92711-0730 ROSEVILLE,CA 95678
Billing: (888)637-2176 Agent Number:04CO16
Claims: (800)503-3724 Agent Phone: (916)784-9793
ITEM ONE GENERAL INFORMATION '
Named Insured: ED AL-BADRY
Mailing Address: 14821 Ansford St,
Hacienda Heights,CA 91745-1300
Policy Period: From 07/25/2017 to 07/25/2018 at 12:01 AM Standard Time at your mailing address
Form of Business: Corporation
Total Policy Premium: $1,519.76
This policy may be subject to final audit. In return for the payment of the premium, and subject to all the terms of this policy,
we agree with you to provide the insurance as stated in this policy.
ENDORSEMENTS ATTACHED TO THIS POLICY
IL 00 17 1198-Common Policy Conditions
IL 00 2109 08-Nuclear Energy Liability Exclusion
IL 00 03 09 08-Calculation of Premium
CA 00 0103 10-Business Auto Coverage Form
CA 01 21 02 99-Limited Mexico Coverage
CA 0143 05 07-California Changes
IL 02 70 09 12-California Changes-Cancellation and
CA 23 94 03 06-Silica or Silica Related Dust Exclusion
U-245-Auto Body Repair Consumer Bill of Rights
CA 20 48 02 99-Specified Additional Insured
CA 2154 09 09-California Uninsured Motorists-Bodily
CA 04 24 04 06-California Auto Medical Payments Coverage
MCADS030112-CA Page 1 of 4 08/08/2017 12:01 AM PT
'41AI" MERCURY
Policy Number: BA040000035108 INSURANCE
Effective Date: 08/08/2017
ITEM TWO SCHEDULE OF COVERAGES AND COVERED AUTOS
This policy provides only those coverages where a charge is shown in the premium column below. Each of these coverages
will apply only to those "autos" shown as covered "autos". "Autos" are shown as covered "autos" for a particular coverage
by the entry of one or more of the symbols from the Covered Autos Section of the Business Auto Coverage Form next to
the name of the coverage.
Coverages Coverage Limit Premium
Symbol The Most We Will Pay For Any One Accident Or Loss
Liability 7 $1,000,000 CSL $1,027
Medical Payments 7 $5,000 per person $57
Uninsured Motorists Bodily 7 $1,000,000 CSL $166
Injury
Uninsured Motorists
Property Damage Rejected
Actual Cash Value Or Cost Of Repair,Whichever Is Less,
Minus Deductible Shown in ITEM THREE For Each Covered
Comprehensive 7 Auto, But No Deductible Applies To Loss Caused By Fire $81
Or Lightning.See ITEM FOUR For Hired Or Borrowed
Autos.
Actual Cash Value Or Cost Of Repair,Whichever Is Less,
Specified Causes of Loss Minus Deductible Shown in ITEM THREE For Each Covered
Auto For Loss Caused By Mischief Or Vandalism.See ITEM
FOUR For Hired Or Borrowed Autos.
Actual Cash Value Or Cost Of Repair,Whichever Is Less,
Collision 7 Minus Deductible Shown in ITEM THREE For Each Covered $162
Auto.See ITEM FOUR For Hired Or Borrowed Autos.
Towing and Labor See ITEM THREE LIMIT Shown For Each Disablement of An
Auto.
Premium For ITEM FOUR(Hired Auto Coverage)
Premium For ITEM FIVE(Non-Ownership Liability)
Premium For Endorsements $25.00
Miscellaneous Fees and Expense
California Consumer Services and Fraud Program Fees I $1.76
Total Policy Premium $1,519.76
MCADS030112-CA Page 2 of 4
Policy Number: BA040000035108 MERCURY
.Ao"' N S U t�A I"�I C E
Effective Date: 08/08/2017 Ail
ITEM THREE SCHEDULE OF COVERED AUTOS YOU OWN
CoveredGaraging Cost New
Auto No. Description VIN City ST Zip Code-� Vehicle Equip.
1 2003 CHEVROLET SILVERADO 3500 1GBJC34UX3E136061 Glendora CA 91740 $29,260 I $2,500
I I
Covered Radius
Auto No. (In Miles) Usage Special Industry Class Loss Payee
1 Up to 100 Service Use
I
I u I I
COVERAGES,PREMIUMS,LIMITS,AND DEDUCTIBLES
(Absence of a deductible or limit entry in any column below means that the limit or deductible entry in the corresponding ITEM
TWO column applies instead.)
Covered Auto Medical UM Bodily Injury UM Property Comprehensive
Liability Premium Payments Damage
Auto No. Premium Premium Premium Deductible V Premium
.....................
1 $1,027 $57 $166 $500 I $81
I q �
d
b
I
Covered
Specified Causes Of Loss Collision, CDW Towing&Labor
Auto No. Deductible Premium Deductible Premium Premium Limit Per Premium
Disablement
1 $500 $162 li
I
I
Rental Reimbursement I I Audio Visual &Data Equipment
Covered Auto Loan/Lease Total Vehicle
Auto No. Maximum Payment Gap Premium Premium
Each Covered Auto Premium Limit Premium
1 I $1,493.00
W I
I
� I I
MCADS030112-CA Page 3 of 4
�MERCRY
Policy Number: BA040000035108 INSURANCE
Effective Date: 08/08/2017
TOTAL PREMIUMS
Liability $1,027
Medical Payments $57
Uninsured Motorists Bodily Injury $166
Uninsured Motorists Property Damage
Collision Deductible Waiver
Comprehensive $81
Specified Causes of Loss
Collision $162
Rental Reimbursement
Loan/Lease Gap
YAudio,Visual and Data Electronic Equipment
ITEM FOUR SCHEDULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMS
Cost of hire means the total amount you incur for the hire of"autos"you don't own (not including"autos"you borrow or rent
from your partners or"employees" or their family members). Cost of hire does not include charges for services performed by
motor carriers of property or passengers.
Estimated Liability Coverage Physical Damage Coverage p Total ITEM
Annual FOUR
Cost Of Hire Premium Limit Of Insurance Premium I Premium
Actual Cash Value Or Cost Of Repair,
Whichever Is Less, Minus$500 Deductible
For Each Covered Auto.
ITEM FIVE SCHEDULE FOR NON-OWNERSHIP LIABILITY
Number Of Employees(Including Volunteers) Total ITEM FIVE Premium
ADDITIONAL INFORMATION
Discounts
• Pay in Full
• Years In Business
• Multi-Line
Driver Information
. . ........ ....................
Listed Drivers Excluded Drivers
ED AL-BADRY
Additional Insureds
THE CITY OF EL SEGUNDO
--. ----------------
350 Main St
EI Segundo,California 90245-3813
MCADS030112-CA Page 4 of 4
ENDORSEMENT AGREEMENT
WAIVER OF SUBROGATION
9211820-17
NEW
.;URANCE NF
FUND
PAGE 1
HOME OFFICE
SAN FRANCISCO EFFECTIVE AUGUST 8, 2017 AT 12 . 01 A.M.
ALL EFFECTIVE DATES ARE AND EXPIRING JUNE 3, 2018 AT 12 .01 A.M.
AT 12:01 AM PACIFIC
STANDARD TIME OR THE
TIME INDICATED AT
PACIFIC STANDARD TIME
AID BUILDERS INC
14821 ANSFORD ST
HACIENDA HEIGHTS, CA 91745
ANYTHING IAT THIS POLICY TO THE CONTRARY NOTWITHSTANDING,
IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND
WAIVES ANY RIGHT OF SUBROGATION AGAINST,
THE CITY OF EL SEGUNDO
WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS
POLICY IN CONNECTION WITH WORD PERFORMED BY:
AID BUILDERS INC
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: AUGUST 14 , 2017 2570
AUTHORIZED REPR ' ENT IVE PRESIDENT AND CEO
SCIF FORM 10217 (REV.7-2014) OLD DP 217