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PROOF OF INSURANCE (2017 - 2018) CLOSED ACC-MV� (MM(DDNYYY) k(i DATE .. CERTIFICATE OF LIABILITY INSURANCE DATE 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 endorsad. 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 endorrsernent(s)„ CON (310}832-5311 nor PRODUCER y NAPA"A .. .._ .._... „_...._ .., .... NAM[ B1xotte, Brien, & Ti Harbor Insurance enc FkI C7Nf: fA6 (31 0)83 9024 1522 S. Gaffey * P.O. Box 671 t;i�"��IJ,. �,(A•ICAh„I' _ .,w INSURER(S)AFFORDING COVERAGE NAIC#, ,San Pedro CA 90733-0671 INSURERA:Colony Insurance Co INSURED INSURERB:California Auto Insurance 38342 Rojas Construction, DBA: Rojas Construction Entp, INSURERC: 3539 S Carolina St _ INSURER D INSURER E: San Pedro CA 90731-6829 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1742503579 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. ItNTHt ----_--_TYPE OFiNSURANCE ---- ..A S POLICY NUMBER ffAM UWYYYYI (MMIDDffyyYExP. . .. ....� .... ----' o- - ,,,„ , - - -- lYYYYI J LIMITS AL RAL LIABILITY EACH OCCURRENCE 000, 0001, A ._X ...COI� CLAIMS-MADE X OCCUR L P-M&ESL"NIEU ..........a... .. ..2,'100,000. X Y 101 GL 0053319-02 4/28/2017 4/28/2016 MED EXP(Anyone person) $ 51000 PERSONAL&ADV INJURY $ 2,000,000 JTI°NF�R• ........ PRO- JECT _._._...D $ ,000 X r UCTS-COMPlOPAGG $ r GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 00 POLICY�� �LOC PROD $ 3,000,000 AUTOMOBILE LIABILITY dCOMBINED deyC�tKi'l E LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Pet person) $ B ALL OWNED SCHEDULED X.- AUTOS X AUTOS ) (Per accident) $ HIRED AUTOS X AUTOS HA0400000098fi4 10/10/2016 10/10/2017 BRO�IPL�IrIJN�URY DAMAGE $ PROPERTY DAM.........E _ Hurricane Catastrophe Fund 1 $ UMBRELLAL1AB M OCCUR E_g OCCURRENCE $ EXCE p.....�.,.,...TENTIO I 'AGGREGATE _ -- —DED SSLIARE CLAIMS-MADE p. .. �„ ...... _ NS Wq(ORI('ERS COMPENSATION 1ILITY YIN 4TATLITE�1OTH,� {� Mtln BL AND LJA TNL cXF.CVDTRWIF.. NIA E.L D SEASE ACCIDENT EA EMPLOYE : OFyyF6'C;�..ftIMOeMBUR F<,C'�LUD�G['1'N ... E S C7ESCRI'PTION OF OPERATION'S tolow i E DISEASE-POLICY LI ...MIT $ If rata.dosA:ba umfor DESCRIPTION OF OPERATIONS 1 LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may De attached If more space is required) Certificate holder The City of El Segundo, its officials, and employees are included as additional insured on general liability with liability limited to claims arising out of insured's operations only, with no assumption of liability to others. Operations for policy term 04-28-2017 to 04-28-2018. See 1policy for terms and conditions. CERTIFICATE HOLDER CA'NCELLAT'ION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE CITY OF EL SEGUNDO THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS, EL SEGUNDO, CA 90245 AUTHORIZED REPRESENTATIVE B Porter/BRIGITJ � ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS026(201401) 101 GL 0053319-02 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, L SSEES OR CONTRACTORS - BLANKET COVERAGE INCLUDING PRI A / NON-CONTRIBUTORY AND WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Additional Insured): Person(s)or Organization(s) f Covered Operations: Name of AdditionalInsured Pers Location s) „o All persons or organizations as required by a written Locations as required by a written contract or contract or agreement with the named insured. agreement with the named insured. A. SECTION II—WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability for"bodily injury", "property damage" or"personal and advertising injury"caused, in whole or in part, by: 1. your acts or omissions; or 2. the acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: Additional Insured Contractual Liability "bodily injury"or"property damage" for which the additional insured(s) are obligated to pay damages by reason of the assumption of liability in a contract or agreement. Finished Operations at Work "bodily injury"or"property damage"occurring after: 1. all work, including materials. Darts or equipment furnished in connection with such work; on the project(other than service, maintenance or repairs)to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. that portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization. Negligence of Additional Insured "bodily injury"or"property damage" arising directly or indirectly out of the negligence of the additional insured(s). U156A-0313 Includes copyrighted material of ISO Properties, Inc., Page 1 of 2 with its permission. 101 GL 0053319-02 C. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance is amended and the following added: The insurance afforded by this Coverage Part for the additional insured required by a written contract or agreement with the named insured is primary insurance and we will not seek contribution from any other insurance available to that additional insured. D. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 6. Transfer Of Rights Of Recovery Against Others To Us is amended and the following added: We waive any rights of recovery we may have against any person or organization because of payments we make for injury or damage resulting from your ongoing operations or"your work" done under a contract with that person or organization and included in the"products-completed operations hazard" if: a. you agreed to such waiver; b. the waiver is included as part of a written contract or lease; and c. such written contract or lease was executed prior to any loss to which this insurance applies. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. U156A-0313 Includes copyrighted material of ISO Properties, Inc., Page 2 of 2 with its permission. POLICYHOLDER COPY SC a. P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 09-12-2017 GROUP: POLICY NUMBER: 1904253-2017 CERTIFICATE ID: 8 CERTIFICATE EXPIRES: 03-01-2018 03-01-2017/03-01-2018 CITY OF EL SEGUNDO SC JOB:ALL CA OPERATIONS 350 MAIN ST EL SEGUNDO CA 90245-3813 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days .advance written notice to the employer, We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE, ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2017-09-12 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF EL SEGUNDO ENDORSEMENT #1600 - ROJAS, MARCO PRES SEC TRES - EXCLUDED. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2017-09-12 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO, ITS OFFICIALS, EMPLOYEES, AGENTS AND VOLUNTEERS. EMPLOYER ROJAS CONSTRUCTION DBA: ROJAS CONSTRUCTION SC 3539 S CAROLINA ST SAN PEDRO CA 90731 [ISS,CS) (REV 7-20141 PRINTED 09-12-2017 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION 1904253-17 NEW SC 9-97-43-49 PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE MARCH 01, 2017 AT 12 . 01 A.M. ALL EFFECTIVE DATESARE AND EXPIRING MARCH 31, 2017 AT 12 . 01 A.M, AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME ROJAS CONSTRUCTION 3539S CAROLINA ST SAN PEDRO, CA 90731 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF EL SEGUNDO, ITS OFFICIALS, EMPLOYEES, AGENTS AND VOLUNTEERS. WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, ROJAS CONSTRUCTION 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 030. 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: SEPTEMBER 12, 2017 2570 e P X . A�1R19C1ICIfg;:[') fig: "1"I'Sg'°N1" JV&' PRESIDENT AND CEO crir cnmo ino17 [Pr%/7.7nlAl nl n no 117