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PROOF OF INSURANCE (2018) CLOSED
-� DATE(MMIDD/YYYY) Ac ''a CERTIFICATE OF LIABILITY INSURANCE I 08/23/2017 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 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 CA LIC OB29370 1-925-244-7700 CONT CT Certificates Department lEdgewoo PHONE (925) [InlanddEmpiree aBranchaIDe14542)ra (EPIC) IAIC4_NQ"' O EPICcerts epOcbrrrkezo.com �( M o)0 FAR (925) 901-0671 P EMAIL P.O. Box 5003 AP..._ ........................................�-.__...__ — - .... INSURERS)AFFORDING COVERAGE NAIC# San Ramon, CA 94583INSURERA: ARCH SPECIALTY INS CO 21199 ___............................................. INSURED INSURER B: ZURICH AMER INS CO 16535 ..... All American Asphalt „I,NSU.RER.C: _...., . ....................._...... ..7 P AMERICAN GUAR & LIAB INS 2624 P.O. Box 2229 INSURER..D....S......................................-,__, ,.,.,... ............... Corona, CA 92878-2229 INSURER F; COVERAGES CERTIFICATE NUMBER: 50638418 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 IOLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID_CLAIMS. it SR' ....................Ab dD SUB POLICY NUMB.,.,.......... POLICY'EF'F POLICY'EXP LIMITS _LTR TYPE OF INSURANCE ER iMMIOWY'YYYI fMfADDIYYYYt A X COMMERCIAL GENERAL LIABILITY DPCIO0585601 08/01/17 08/01/18 EACHOCCURRENCE $ 1,000,000 N �uI _DWMGt"�6A�ffl,0...............�.... .,,,...................... ..,.m.,.,..W............tl CLAIMS-MADE OCCURI',RriaWl .(Ea,-r��c;cabrc;e)awx.).,, $ 100,000 MED EXP(Any one person) $ __. ._..................._................................. PERSONAL 8 ADV INJURY..........$ 1,000,000 GEN'LAGGREGAT_E LIMIT APPLIES PER: GENERAL AGGREGATE' _._._.....�............. GATE $ 00 POLICY Ln.X-�Pi o' LOC PRODUCTS-CO,MPIOPmAGG $ 2, , JE OTHER: $ B AUTOMOBILE LIABILITY HAP557108805 08/01/17 08/01/18COMBINED SINGLELIMIT m$X 2,000,000 OMII X ANY AUTO BODILY INJURY(Per person) $ V ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOSAUTOS ................._....w..............,,,,..,.,,,__ .....,.., . HIRED AUTOS AUTGOWNED iPPor sdccrdwero9,),,,,, $ �... ....CLAIM.. ..AD.. ......1 UMBRELLA EACH 0,000,000 C X EXCESS ARAB X O CUS-M E SX5019797001 08/01/17 08/01/18 AGGREGATE 0,000,000 $mmm .. IT DED �X I,RETENTION$ 10,000 Following-Form $ B WORKERSCOMPENS�ATION �-WC593205704 08/01/17 08/01/18 X,�,STATUTE ERPER H__„ AND EMPLOYERS'LIABILITYYIN 1 000 ANY P'R'OPRFETORIPARTNER1EXEEUNV'L (,'"""� N/A E L EACH ACCIDENT $ 1,000,000 OF�F'ICERIMEMBER EXCI.UDf:07 ............... ... ( r'A ) .. EA EMPLOYEE $ ,000 Mandato In Nfi E.L.DISEASE.,, ............................. it m,describe�under E.L.DISEASE-POLICY LIMIT $ DESCRIP TION OF OPERATIONS below 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Project #17-27 / RE: East of Sepulveda Boulevard Pavement Rehabilitation / Certificate Holder is Additional Insured if Required by Written Contract Excluding Workers Compensation [2) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street AUTHORIZED REPRESENTATIVE E1 Segundo, CA 90245 I USA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD SRapley-ie 50638418 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED ENDORSEMENT This endorsement modifies Insurance provided urKler tho fallovonq COMMERCIAL GENERAI LiASILITY COVERAGE FORM COMMERCIAL GENERAI, LkABII_ffY SELF-INSURED RETENTION COVERAGF FORM SECTION 11 —WHO IS AN INSURED is amended to include as arts Wonal insured those persons or arganl2aflons wtw) are required tinder a wrilten contract wlih you to be named as an atwitiecrial insured, but onty with reqwcl to flablilty for"bodlly Injuoy', 'property carry rim, or"personal and advortilsing lnjo,ry' used,irp whole or in part, by your acts or UrOssions of tfvd acts or ornl5skme';Of Your Subcunlractutt;, A. in the performance of your ongoing operations or"your work", including'yc4ir worl<'Iriat has been rxmpI(.,u,,d;or B, Incon4adion with y(xjr prorn1w. .F.owned oy or wented to you, As used in this endorsewerti,the words'you'and"your"refer to the Named insured, All citlipf tefrns and condltio,)s of this Policy rernsin unchanged. Schedule Project City of El Segundo, it's officers, officials, employees, agents, Project#17-27/RE: East of Sepulveda Boulevard and volunteers Pavement Rehabilitation a. Endorsement Number: This"orsement is afleclive on the tnrx:litlon date of this pok;y unless othanviso f4aled heroin. (The information beitwo is tequtred only Mien this enclorsenient Is lssRjed subsexluent to preparalkio ofihe pdl(,y,) FlollcyNumber: DPC100585601 harried fnsure& Alt Anierwcan.Asphalt et al Endotsernent Effective Date; August 1, 2017 4885 {HCl GGLO006 00 05 07 Page i of I THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OTHER INSURANCE - BROAD FORM. CGL POLICY ENDORSEMENT This endorsement n-kodif les insurance provided under the follnw�q COMMERCIAL GENERAI, LIABILITY COVERA6E FORM Under SECTION IV— COMMERCIAL GENERAL LIABILITY CONDITIONS, ft follo%aung paragraph is added to Gond lion 4.Other Insurance.,. Where the Narrw(J Insured Is requk-ed ty a written contract to prOvIde ifturance that I..%prlrrwri,, and nd non-contributcry, and the written contract so requinnQ is executed by Itw-, lar Rd knsured before. arty'oocur•ence"or offense,this insuralice mil be primary:but orgy if arxJ to the extent requtred by that war'ii"en co n1fact. All of teums and wndltions of thLq Pial icy remain unchmigpd Schedule Project City of El Segundo, it's officers, officials, employees, agents, Project#17-27/RE: East of Sepulveda Boulevard and volunteers Pavement Rehabilitation Endorsement Number, This"orse-nent is fillective an the inception d")of this poilcy unless otherwisn staged hfiroln. (The information Wow is rergored only when this erulorseinent Is lssued subsEqoent to preparation of thra olay') PokyNurnber, DPC100585601 N Insured: All Ame4can Asphalt et al EndwsernentEffectivelate August 1® 2017 00 CGLO1 30 00 09 06 Page 2 of 1 4885 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF SUBROGATION ENDORSEMENT This"orsirment modifies Insurance provided under the following, COMIAERCIALGENERAI LIABILITYCOVERAGE FORM COMMERCIAL GENERAL LIABILWY SELF-INSURED RETENTION COVERAGF FORM SCHEDULE Natne of Person or Organization., Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, Condition 8. Transfer Of Rights Of Recovery Against Others To Us is amended ty the addition of the following provision: We waive any right of recovery we may have agairk4. 1he person or organization sN)wn in the SCHEDULE abr)vc bmiuse of parnantswe rnako for iniury or damage arlsing out of your opt2rallorm or .your work"done uqder a written contract w4h that tson or sir ganizam All other terms and conditions of fts Po hely remain unchanged Schedule Project City of El Segundo, it's officers, officials, employees, agents, Project#17-27/RE: East of Sepulveda Boulevard and volunteers Pavement Rehabilitation Endofsernent Number TNs enclomement is effective cxi the irveptlon to of iWis poilcy unless atherxi-,e tMaled herein. (The Information Wow Is ruirfu[red only Dien this endorsernent Is Issued subsc-Avent to preparation of the pollcyj Policy Number- DPC100585601 homed insured.-. AK Aniericart Asphalt at al Endoisement Eisective Date, August 1, 2017 00 CGLO 12100 09 06 Includes copyriWited material of Insurance ServIces Office, inc., Page I of 1 with Its perailssicmi, 4885 POLICY NUMBER BAP557108805 COMMERCIAL AUTO CA 20464299 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO CCYVEFV-%(.,E FORM (,,ARAGE COVERAG,11 FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM Vdh rex.,pect to coverage provtdol by this endorsewient,the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement Identifies person(s.) or organization(s) who are'Insureds"under the Who Is An Insured Provision of the Coverage Form,This endorsement does riot atter euverige provided in the Overage Form. This enders 1t changes the policy effective on the Inception date of the policy unless another date is Indicated below. Endorsement Effective: 8/l/17 Counterslgrvxi By,: Named Insured: All American Asphalt (Authorized Representative) SCHEDULE Nam of PersovXs)or Organization(s): ANY PERSON OR ORGANIZATION TO WHOM OR WHICH YOU ARE REQUIRED TO PROVIDE ADDITIONAL INSURED STATUS OR ADDITIONAL INSURED STATUS ON A PRIMARY, NON—CONTRIBUTORY BASIS, IN A WRITTEN CONTRACT OR WRITTEN AGREEMENT EXECUTED PRIOR TO LOSS, EXCEPT WHERE SUCH CONTRACT (DR AGREEMENT IS PROHIBITED BY LAW. Schedule Project City of El Segundo, it's officers, officials, employees, agents, Project#17-27/RE: East of Sepulveda Boulevard and volunteers Pavement Rehabilitation/ (If no entry appears above, Information required to complete this endorsement will he shown In the Declarations as applicable to the en dors-ernent.) E person or organ ion shown in the Schedule is an 'Insured"for Liability Covercige, but only to the extent that person or organization qMlffieS as an 'insured" under the Nie,Is An Insured Provision contained in Secdon 11 of the Coverage Form. CA 2048 42 99 Copyright, lnsuraix�e Services Office, Inc., 199, Page 1 of 1 13 4885 POLICY NUMBER BAP557108805 COMMERCIAL AUTO CA 04 44 03 10 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance proeided under the following: BUSINESS AUTO CGVERAGE FORM BUSINESS AIJT0 PHYSICAL DAMAGE CO)wERAGE FORM GARAr,E COVERAGE FORM MOTOR CARRIER COVERAGE FOMI TRUCKERS COVERAGE FORM Vvqth respect to coverage provided by this endorsement,the provisions of the Coverage Form apply unless modi- fied by the endorsement. This endorsement changes the policy effa.I[ve on the inception date of the polky unless another dAe is indirsted below. Namad I nsumd: All American Asphalt Endorsee ientEflective Dab: 8/l/17 SCHEDULE Narna(s)Of Person(s)Or Organization(s): ALL PERSOUS AND/OR ORGANIZATIONS THAT ARE REQUIPED BY WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PR13VIDED UNDER THIS POLICY not wri above. will be sho^.N-n in the D arc-13rations. The Transfer Of Rights Of Recovery Against Others To Us Condition does not apply to the personf.,$) or organIzation(s) sho,wn in the Schedule. but only to the extent that subrogetion is waived prior to the`w- Project cident"or the'loss" under acontract with that person o r o rg an iz,110 n. Schedule Project#17-27/RE: East of Sepulveda Boulevard City of El Segundo, it's officers, officials, employees, agents, Pavement Rehabilitation and volunteers 4885 CA 04"0310 Q Insurarre Services Office, Inc.,2009 Page 1 of 1 0 WORKERS!COMPENSATION AND EMPLOYERS'LIABILITY INSURANCE POLICY WC 04 03 06 (Ed.4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- CALIFORNIA We fta�)e the right to recover our payments from anyone liable for an injury covered by this policy. 'Ilk will not enforce our right against the person or organization nand in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreernent from us.) You must maintain payroll records accurntely o*�grjating the remuneration of your empV)yE*is while engaged in the work described in the Schedule. The additional pren-dum for this endorsetont shah be 0.00 % of the California 'workers'compensation pre- mium otherwise due on such remuneration. Schedule Person or Organtzation Job Description ALL PERSONS AND/OR ALL CA OPERATION ORGANIZATIONS THAT: ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY FOR WORK PERFORMED BY YOU FOR THAT PERSON AND/OR ORGANIZATION City of El Segundo, it's officers, officials, employees, Project#17-27 RE: East of Sepulveda Boulevard agents, and volunteers Pavement Rehabilitation All American Asphalt Policy #WC593205704 8/1/17 Zurich American Ins. Co. WC 252(4-84) 4885 WO 04 03 06(Ed.4.84) Page 9 of 1