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PROOF OF INSURANCE (2018 - 2018) CLOSED
.q1 DATE IYYYY) a�CCERTIFICATE OF LIABILITY INSURANCE 10/03/20173/203r2o17 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder,Is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsament(9. PRODUCER Gleason Insurance Brokers LLC CONTACT DAVID GLEASO'N NArAIE'. 9477 Greenback Lane PHONE 916-542.7093 1 FAX 855-543.4948 EMAIL INSURANCEBROKERS.CO'M FolsoUnit m CA 95630 A90t 945.....�.�. R 8' ..................................................-..._w................._w_w_w_w_w_w_w -- NSU A AFFORDING COVERAGE MAIC 4 INSURER A:"'SPECIALTY INSURANCE COMPANY 29599 .............................................................................................................................................................................. .r_w_w....................................__....... INSURED AYUS 8r CO INC INSURER B 1511 N KENMORE AVE NATIONAL UNION FIRE INSURANCE CO LOS ANGELES CA 90027 INSUR[ItC INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:014 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 )OLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY )AID CLAIMS. PoNSR TYPE OF INSURANCE POLICY LIMITS LTR ✓ COMMERCIAL GENERAL LIABILITY SUSR POLICY'NUM'BER r1rONli YYI rY �O[BYAYEYXiY9 EACH OCCURRENCE $1,000,000 CLAIMS-MADE ❑✓ OCCUR U16AC91867-00 wR1 $(L=aEom aem o) $100,000 A 415.12017 415!2018 1 MED EXP(Any one porson) $5,000 ✓ BVPD DED$2000,00 PE'R'SONAL A ADV INJURY $1,000,000 GEN"L AGGRE,GAIE LIMIT APPLIES PER GENERAL AGGREGATE $2,000,000 POLICY 1:1JECT ❑Loc PRODUCrs.COMPOOP AGG $2,000,000 OTHER: $ I AUTOMOBILE LIABILITY COMBINED SINGLE UMI(1' $ . .. ... W w (Ea ov*108 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY 0 AUTOS HIRED %AUTOS N-OWNED PROPERTY DAMAGE $ -- AUTOS ONLY ONLY (Per accident) .. $ UMBRELLA LIAROCCUR EACH OCCURRENCE $2,000,000 C ✓ EXCES�SS LIIARCLAIMS-MADE� EBU 020689752 21V2017 416@018 AGGREGATE $2,000,000 DED i I R'EEN,,.N, $ WORKERS COMPENSATION PER Li STATUTE E HEMI� EXCLUDE EV WE ECUTIVE AND EMPLOYERS'LIASILITY YIN El N l� E.L.EACH ACCIDENT ERH $ OFFIC(Mandstory Ili NR) E.L.DISEASE-EA EMPLOYEE $ Ud yrws,dN:aryt)o umu9ar DE'SCRIP'TION OF OPLRA1"IONS below � ryI T E DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Addhtonel Remarks Schedule,may be attached It more spate In required) General Contractor doing REMODELS-TENANT IMPROVEMENTS CERTIFICATE HOLDER CANCELLATION Mf EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ain'St„ THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EI Segundo,Ca 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE DAVID GLEASON ®1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Produced wing Forme Bou Web Software,www.FormeBosa,com(c)Impressive Publishing 500.208.1977 POLICY NUMBER: XN107266700 COMMERCIAL GENERAL LIABILITY NX GL 189 0511 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSUREDS - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Policy Number: XN107266700 Endorsement Effective: 4/5/2017 12:01 a.m. Named Insured: Counter Signed By: AYUS&CO INC, DBA:AYUS&CO INC SCHEDULE Name of Person or Organization: Any person or organization that the named Insured is obligated by virtue of a written contract or agreement to provide insurance such as Is afforded by this policy. Location: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section II—Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization shown in the Schedule is held liable for your acts or omissions arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds,the following exclusion is added: 2. Exclusions This insurance does not apply to"bodily injury"or"property damage"occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project(other than services, maintenance or repairs)to be performed by or on behalf of the additional insured(s)at the site 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 other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. The words"you"and"your"refer to the Named Insured shown in the Declarations. NX GL 189 0511 Page 1 of 2 Includes copyrighted material of Insurance Services Office, Inc.,with its permission POLICY NUMBER: COMMERCIAL GENERAL LIABILITY NX GL 189 05 11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. D. The following are added to SECTION V—DEFINITIONS: "Your work"means work or operations performed by you or on your behalf; and materials, parts or equipment furnished in connection with such work or operations. E. The following additional provisions apply to any entity that is an insured by the terms of this endorsement: 1, Primary Wording With respect to the Third Party shown above,this insurance is primary and non-contributing.Any and all other valid and collectable insurance available to such Third Party in respect of work performed by you under written contractual agreements with said Third Party for loss covered by this policy, shall in no instance be considered as primary, co-insurance, or contributing insurance. Rather, any such other insurance shall be considered excess over and above the insurance provided by this policy. Z If required by written contract or agreement:We waive any right of recovery we may have against an entity that is an additional insured per the terms of this endorsement because of payments we make for injury or damage arising out of"you work"done under a contract with that person or organization. NX GL 189 05 11 Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission j ru ' H, CC Named Insured:AYUS&CO INC Policy Number: U16AC91867-00 Insurer U.S.Specialty Ins Co—Admitted Carrier Endorsement Effective Date:02/15/2017 Change Endorsement Number:4 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY GENERAL CHANGE ENDORSEMENT The following endorsement modifies policy terms provided by the above listed policy number. Form CG 20 10 07 04 -Additional Insured- Owners, Lessees or Contractors— Scheduled Person or Organization is added to the policy with the following scheduled information: Nasse ol`Additionaal Insured Person(s) or Organization(s): City ol"111 Segundo 350 Maaira St.., El S'egundaa, Ca 90245 Location(s) of Covered Operations: 350 Main St., El Segundo, Ca 90245 Lkscri patia.ara of Operations: COMMERCIAL WORK-NON - STRUCTURAL REMODEL - KITCHEN AND I3ATl-lROOM IMPROVEMENTS Form CG 20 37 07 04 -Additional Insured - Owners, Lessees or Contractors - Completed Operations is added to the policy with the following scheduled information: Name ol`I'crson or Organization(s): City ol°Fl Segundo 356 Main St., I:16 Segundo, Ca 90245 Location: 350 Main St., El Segundo, Ca 90245 Description cal"Coma feted Operations: COMMERCIAL WORK -NON - STRUCTURAL REMODEL - KITCHEN AND BATHROOM IMPROVEMENTS ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED By lhBkN,'�'R8"M'M�"iR'Si Xf1�;'?GMMY4 'P'M'M�'R'w"'M" HCS 060 08 11 12 Page 1 of 1 POLICY NUMBER: U16AC91867-00 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEE'S OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location And Description Of Completed Or Organization(s): Operations City of EI Segundo 350 Main St., EI Segundo, Ca 90245 350 Main St., EI Segundo, Ca 90245 COMMERCIAL WORK-NON -STRUCTURAL REMODEL- KITCHEN AND BATHROOM IMPROVEMENTS Information required to complete this Schedule„ if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for"bodily injury" or"property dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sched- ule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". CG 20 37 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 IJ POLICY NUMBER: U16AC91867-00 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR 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 City of EI Segundo Location(s)of Covered Operations: 350 Main St., EI Segundo, Ca 90245 350 Main St., EI Segundo,Ca 90245 Description of Operations: COMMERCIAL WORK - NON -STRUCTURAL REMODEL-KITCHEN AND BATHROOM IMPROVEMENTS 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 exclu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage or personal and advertising injury "property damage"occurring after: caused, in whole or in part, by: 1. All work, including materials, parts or equip- 1. Your acts or omissions; or ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project (other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) desig- covered operations has been completed; or nated above. 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 CERTHOLDER COPY SC STATE P.O. BOX 8192, PLEASANTON, CA 94588 INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 04-08-2017 GROUP: POLICY NUMBER: 9167666-2017 CERTIFICATE ID: 2 CERTIFICATE EXPIRES: 04-08-2018 04-08-2017/04-08-2018 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 2017-02-15 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF EL SEGUNDO ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2017-04-08 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO EMPLOYER AYUS & CO, INC DBA: AYUS & CO, INC SC 1511 N KENMORE AVE LOS ANGELES CA 90027 M0408 PRINTED 03-17-2017 (REV.7-2014) STATE COMPENSATION' IN REPLY REFER TO: MAY 4, 2017 CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO CA 90245-3813 CERTIFICATE OF WORKERS' ----------------------- COMPENSATION INSURANCE ---------------------- CANCELLATION WITHDRAWAL NOTICE ------------------------------ RE: CERTIFICATE DATED APRIL 8, 2017 THE CANCELLATION HAS BEEN WITHDRAWN FOR THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW. THIS LETTER SUPERSEDES THE NOTICE OF CANCELLATION SENT TO YOU ON APRIL 28, 2017 . THIS EMPLOYER' S WORKERS' COMPENSATION INSURANCE COVERAGE CONTINUED UNINTERRUPTED. EMPLOYER: AYUS & CO, INC 1511 N KENMORE AVE LOS ANGELES, CA 90027 POLICY 9167666-17 CUSTOMER SERVICE REPRESENTATIVE CUSTOMER SERVICE CENTER (888) 782-8338 5860 Owens Dr Pleasanton, CA 94588-3900 Mailing Address: P.O. Box 8192 • Pleasanton, CA 94588-9682 SCIF 19102