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PROOF OF INSURANCE (2018) CLOSED � � DATE(MM/DD/YYYY) A�!".^� EP CERTIFICATE OF LIABILITY INSURANCE I 10/24M17 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). CI PRODUCER EdmY�wood Partners Insurance Center(EPIC) I NAMIEa 19000 MacArthur Blvd. PH Floor PHONE FAX Irvine, CA 92612 E I"I"'Extl: (949)263-0606 �,(Arc,No): (949)263 0906 ADPREO$; ...., INSURER(S)AFFORDING COVERAGE MAIC# www.edgewoodins.com INSURER A: Travelers Property Casualty Company of America 25674 INSURED INSURER B: Travelers Casualty and Surety CO America 31194 JM Diaz, Inc. ity Com an DBA: JMD I p y of CT 25682 INSURER c: Travelers Indemnity 18645 E. Gale Ave., Ste#212 INSURER U:: City of Industry CA 91748 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 38494386 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 RAID CLAIMS. � SUER @ LIMITS... . ILTR II TYPE OF INSURANCE AlNn POLICY NUMBER dM0OJ4P�iD1YYVY (MM1OD1YYVY) COMMERCIAL GENERAL LIABILITY 680-2J330994 6/27/2017 6/27/2018 EACH CCUU-rdRi NN'kRRENCE $1,000,000 CLAIMS-MADE f l OCCUR ✓ ✓ PAEM1PSEra(r a rxcu rrsnrel� $1,000,000 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 JECT ,1'EGT ( ✓ LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER, Deductible $None C AUTOMOBILE LIABILITY ✓ ✓ BA-4J373941 6/27/2017 6/27/2018 �Ei( INx,LEI.uMnr $1,000,000 ANY AUTO BODILY INJURY(Per person) $ OWNEDSCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS �„ .. ., HIRED NON-OWNED Pi�&ER"ItY DAMAGE $ +, AUTOS ONLY ✓ AUTOS ONLY (Ppr ayK:OdoPdl A ✓ UMBRELLA AB ' I OCCUR Y/ CUP-7E606764 6/27/2017 6/27/2018 EACH OCCURRENCE $2,000,000 EXCESS,B `CLAIMS-MADE AGGREGATE $2,000000 DEC) I I RETENTION$0 Prod/Co-Ops $2,000,000 A WORKERS COMPENSATION ✓ UB-4288T923 6/27/2017 6/27/2018 ✓ STER ATUTE ORTH- AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE E EACH ACCIDENT $1,000,000 F_OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E DISEASE-FA EMPLOYEE $1,QQO.000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 B Professional Liability 105263164 6/27/2017 6/27/2018 $2,000,000 per Claim Claims Made Form $2,000,000 Aggregate Knowledge Date:4/8/2005 $10,000 Per Claim Deductible DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) RE:Rosecrans Avenue Striping Design-Project PW-17-41 Certificate holder(s)are named as Additional Insureds as respects General Liability per endorsement CG D3 81 09/15 and as respects Hired and Non-Owned Automobile Liability per endorsement CA T4 37 02/16,but only where required by written contract with the Named Insured prior to an occurrence and subject to all policy terms,conditions and exclusions. CERTIF'ICA'TEHOLDER CANCELLATION Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of EI b g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PU lic Works ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street EI Segundo CA 90220 AUTHORIZED REPRESENTATIVE Todd Holliday ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 2 (2016/03) The ACORD name and logo are registered marks of ACORD 38454366 117-18 GL, AU, w/Af, WC, Umb, Prof. Kim Pechar 1 10/24/2017 11:07:42 AM (PDT) I Page 1 of 4 umDiaz,Inc. COMMERCIAL GENERAL LIABILITY 680-2J3309e* THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, BLANKET ��U�� 8�� m�m�� u ADDITIONAL mm�� (ARCH��8�� V�� Q �� ITECTS, �~u�m��mv�� xnm�� m �� This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART --- 1. The following is added to SECTION 11 —WHO IS h. This insurance does not apply to "bodily AYAUydSWRED: injury' or '^propedydamnage" caused by "your work" and included in the "products- Any person or organization that you agree /n a °v*rA%encontract requiring insurance"Uoinclude as completed operations hazard" unless the anadditional insured onthis Coverage Part, but: "written contract requiring insurance" specifically requires you to provide such a. Only with respect to liability for"bodily injury", coverage for that additional insured, and then "property damage"or"persona|injury'; and the insurance provided to the additional b. If, and only to the extent that, the injury or insured applies only tosuch "bodily injury" or damage is caused by acts or omissions of "property damage"that occurs before the end you or your subcontractor in the performance of the period of time for which the "written of "your work" to which the."written contract contract requiring insurance" requires you to requiring insurance" applies, or in connection provide such coverage o/ the end of the with premises owned byorrented b»you. policy period,whichever isearlier. The person or organization does not qualify as an 2. The following is added to Paragraph 4.m' of additional insured: SECTION IV — COMMERCIAL GENERAL c. With respect to the independent acts CO&0��kTU��NS' s or ' omissions ofsuch person nrorganization; or The insurance provided tothe additional insured is excess over any valid and collectible other �, For "bodily injury', "property damage" or insurance, whether imary, excess, contingent or "personal injury" for which such person or �on any her basr, that is available to the organization hos assumed liability in � additional�insured for a loss we cover. Hom/ever, if contract oragreement. you specifically agree in the "written contract The insurance provided tosuch additional insured requiring insurance" that this insurance provided islimited osfollows: bmthe additional insured under this Coverage Part rmws1apply mm a primary basis, or a primary and m, Thi� inaucanc� doe� nota�p�onanybasia0m non-contributory basis, this insurance is ^�i ary any person or organization for which to other insurance available to the additionalcovarage as an additional insured sPecNficm|iY insured which covers that or organizations added by another endorsement to this as a named insured for such |oos, and m/ewill not Coverage Part. ' share with the other insurance, provided that: f. This insurance does not apply to the (1) The "bodily i '� O/' wr "property damage" for rendering of o, failure to render any which coverage issought occurs; and "professional services". (2) The "personal injury" for of whichwhichcoverage is |nthe event that the Limits ofInsurance ofthe sought arises out noffense committed; Coverage Part shown in the Declarations exceed the Urnhs of liability required by the after you, have signed that "written contract '\mr)8insurance",contract requiring �ur�nc�". the requiring msur� nce" But this insurance provided provided �u the additional 0uthe addiMmna! insured sh8isexcess over valid insu�an� additional insuved shall be r^~totbe |irnhsmfhabUbynequired and coUmct|b<eother insurance, m/heLher primary, by bytha "written contract requiring insurance'. �w�e$s' contingent or on any other basis, that is additional insured when that This endorsement does not increase the available to the additional person or organization is an additional insured limits ofinsurance �e�cribed in Section ||| — under anyother insurance. CG D3 81 09 15 Q 2n1sThe Travelers indemnity Company.All rights reserved. Page of includes the copyrighted material vfInsurance Services Office,|nc'with its permission COMMERCIAL GENERAL LIABILITY 3. The following is added to Paragraph 8., Transfer 4. The following definition is added to the Of Rights Of Recovery Against Others To Us, DEFINITIONS Section: of SECTION IV — COMMERCIAL GENERAL "Written contract requiring insurance" means that LIABILITY CONDITIONS: part of any written contract under which you are We waive any right of recovery we may have required to include a person or organization as an against any person or organization because of additional insured on this Coverage Part, payments we make for "'bodily injury', "'property provided that the "bodily injury" and "property damage" or "personal injury" arising out of "your damage" occurs and the "personal injury" is work" performed by you, or on your behalf, done caused by an offense committed: under a "written contract requiring insurance" with that person or organization. We waive this right a. After you have signed that written contract; only where you have agreed to do so as part of b. While that part of the written contract is in the "written contract requiring insurance" with effect; and such person or organization signed by you before, and in effect when, the "bodily injury" or c. Before the end of the policy period. "property damage" occurs, or the "personal injury, offense is committed. U Page 2 of 2 02015 The Travelers Indemnity Company,All rights reserved. CG D3 8109 15 Includes the copyrighted material of Insurance Services Office,Inc.,with its permission 014149 38494386 1 17 18 GL, AU, ./Al, WC, Ulnb, Prof I K" Pechar 1 10/24/2017 11:07:42 AM (PDT) I Page 3 of 4 JM Diaz, Inc. BA-4J373941 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM The following is added to Paragraph c. in A.1., Who between you and that person or organization, that is Is An Insured, of SECTION II — COVERED AUTOS signed by you before the "bodily injury" or "property LIABILITY COVERAGE in the BUSINESS AUTO damage" occurs and that is in effect during the policy COVERAGE FORM and Paragraph e. in A.1.,Who Is period, to name as an additional insured for Covered An Insured, of SECTION 11 — COVERED AUTOS Autos Liability Coverage, but only for damages to LIABILITY COVERAGE in the MOTOR CARRIER which this insurance applies and only to the extent of COVERAGE FORM, whichever Coverage Form is that person's or organization's liability for the conduct part of your policy: of another"insured". This includes any person or organization who you are required under a written contract or agreement CA T4 37 02 16 ©2016 The Travelers Indemnity Company.All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office,Inc,with its permission. trr 'rn3 t ( rr I i,, AlP, R. w, �i�nu�, r.roC. p a.run �ocaP�,.: I (.ra(�.-a(".ol't 11�(1'7�4.i AN( 4rm) I r;,,p, 4 A I WTRAVELERSJORKERS C��ONMPENSATION ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD, CT 06183 ENDORSEMENT WC 99 03 76 ( A) 001 POLICY NUMBER:UB-4288T923 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA (BLANKET RIVER) We have the right to recover our payments frorn anyone liable for an injury covered by this policy, We will not enforce our right against the person or organization named in the Schedule, The additional premium for this endorsement shall be % of the California workers' compensation pre- mium. Schedule Person or Organization Job Description ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER This endorsement changes the policy to which it is attached and is effective on the date issued unies.s Otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.). Endorsement Effective6/27/2017 Policy No, UB-4288T923 Endorsement No. Insured JM Diaz, Inc. Premium DBA: JMD Insurance Company Countersigned by DATE TE ISSUE:11/2/2017 ST ASSIPage 1 of 1 38687867 1 17-18 GL, AU, w/A1, WC, Umb, Prof. I Jun Schwaxt. 1 11/2/2017 2:23:38 PM (PUT) I Page 5 of 5