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PROOF OF INSURANCE (2018) CLOSED ATE AC . O CERTIFICATE OF LIABILITY INSURANCE D7/ 0/ n 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: It the certificate holder is an ADDITIONAL INSURED,the Is ol'"icy(les),must be endorsed. If SUBROGATION 16 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 PRODUCEte R lCo Inlieu of oratesuch rand'orBoment(s). Xa.. PRODUCER Solutions PHOpNE (626)275-300a _..,. 1.,FAX (626}275 0130 - ctapN7ACY mirez _ LiceMillnse # OC13480 ADDRESS:kathymarticsi IA mniJl�_. .mm. as.com 550 N Brand Blvd #1100 __ Rie'uRERC SSAFFORDING 1;,OVERAGP NAICs ._ INSURER A. Glendale CA 91203 m _. t tf�wf3.sy Insurance CO I'37974 _ INSURED INSURERa,Ohio SecurityIns Company 24082 i!iSutENc,RSO1 ndemnAt Compapy 22314 i ..�,.�___..._......._._..._t Na)rionaZI a Co Trueline INSURER D„,S erBa,. ._._ 1651 Market Street, Ste. S INsiJ ,ERE. Corona CA 92880 INSURER P e COVERAGES CERTIFICATE NUMBER: 2017 - 2010 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, AY ..... I Y v.,.,._._ -UCY E IIN ITA COMMERCIALE F I N URANCNS�OFTSUCHI POLICIES.LIMITS SHOWN POCYMUNBERVE BEEN REMOMC_Ya PAID l s N EACH OGCURRRI:;hiCE l I7S 'I EXCLUSIONS AND 01 u D $ 50,000 A CLAIMS-MADE �OCCUR L0186295 7/25/203.7 7/25/2018 PI IS6 iilop t�alz b $ 1,0 0,000 ...... XL 9dIISES ._.-..� 2 500 'ped - Per OccPERSONAL AD-oe ' .. _$ 5.000 I X blf3MED EXP tAnY one VINJURY $ 1,000,000 IGEiri Aa3GREI$ATELIMIT APPLIES PER: '9ENERALAGGREGgATE i 2,400.000 POCCY PrtO.. I�LOC 2,000.000 "O. L7 PRODUCTS $ O7NEfi Employee Benefits $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE OWr $ 1,000,000 X AUTO LY INJURY(Per person) $ALL OWNED - SCHEDULED EA91856945605 7/25/2017 7/25/2018 BODILY INJURY(Per accident) $ _ AUTOS AUTOS NON-OWNED TY DAMAGE $ X HIRED AUTOS X AUTOS II 4t 1I&)EI4I II _r, X COMP-$1,000 X (COLL-$1,000 I$ UMBRELLA LUU3 X I OCCUR EACH OCCURRENCE $ 21_000.r 0,00_ C X EXCESS LI IAR 1 CIAWS,-MADE AGGREiCAT'E $ 21000,000 p X V RETENTION$ -0- 2ZHA243D10 7/25/2017 7/25/2018 $, V OIR I I: -0- WORKERS COMPENSATION X I R OTH• MPLOYERS'LIABILITY N L TCdi CCIDENTm m AND E L ANY OFFICEFWA (Maf I lE � EMC6 U 1 L�"t f N!A 7600016618171 7/25/2017 7/25/2018 I,, L6SE 'a $ d8S 0 ,1300 La XCCUrIN![, C;Li'E3C r D 8L-EA d fi PLOY L:ESCdoscrONOdor Ek [TIS._A......-,...w......_._..................... .-..., .. ... air a n P OPERATIONS£e"pw E f 0LACY LINT $ 1,000,000 .. . . DESCRIPTION S I LOCATIONS I ,may be hed more sp2cs Is required) Rei City Segundo Hockey The Cit Remarks ElhSeeundo�ditsVofnficers,non-contributory employees, r Y egun Y Y 3 agents, and volunteers are included as additional insureds with primary & o c ry ording for General Liability as respects to the insureds operations and only if required by written contract per the attached endorsements. Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. aCERTIFICATE HOLDER CANCELLATION I` SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cit of El Segundo r THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Y 9 35a Main St. ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE Margaret Gilmore/NB Q 1980-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) Polley Number. MGL0186295 Mt.Hawley Insurance Company rill-118 iE111 l0ORSEI E'lll' T CHAT GES"1"Ill,,tE I,1OIi-ICY,IP1,,,,, &III!!!!! READ Iiir CARE IIFU''!LLY. SCHEDULED This endorsement modifies insurance provided under the foilowing: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Additional Insured P on(s) Or irgani tion(s)., Location(s) f Covered Operations: All persons or organiz0ons where required by written contract. p lnforrr° rtion required to complatethis fthudula, if not shown above,will be shown In the I:7r a„Par tirrrmr� A. Section Il —Who Is An Insured is amended to in- not be broader than that which you aro required dude as an additional insured the person(s)or organi- by the contract or agreement to provide for such tions)shorn in the Schedule,but only with respect additional Insured. to liability ibr "bodRy injuryw, `"property damage" or "personal and' advertising 'injury” caused, in whole or B. With respect to the insurance afforded to these in part, by; additional insureds,the following additional exclusions apply: i. Your acts or omissions;or This Insurance does not apply to 'bodily injury" or 2. The acts or omissions of those acting on your "property damagWoccurring air: behalf; i. All work., including materials, parts or equipment in the performance of your ongoing operations for the furnished In connection with such worts, on are additional Insureds) at the location(s) designated project (other than service, maintenance or rre- abova pairs)iDo be performed by or on behalf of the addi- tional Insured(s) at the location of the covered However; operations has been complet;or 1. The insurance afforded to such additional insured 2. That portion of"your wort' "out of which the Injury only applies to the extent permitted by law;and or damage arises has been put to Its Intended use by any person or organization other than another 2. if coverage provided to the additional insured is contractor or subcontractor engaged In performing required by a contract or agreement the in- operations for a principal as a part of the same surance afforded to such additional Insured will project. CG 2010 04 13 0 Insurance Services Office,Inc.,2012 Page 1 of 1 Insured Policy Number MGLO186295 Mt Hawley Insurance Company THIS ENDORSEMENT CHANGES THE POLICY.PLEASE WAD IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS COMPLETED OPERATIONS '17his andorsernent modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person(s) u and Description af or Organization(s) Completed Operations All persons or organizations where required by written contract. information required to oomplete Wa Schedule, if not shown above,will be shown in the Declarstion s. A. Secdon It Who lls 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 Section organization(s) shown In the,Schedule, but only with In—Llmft Of Insurance: respect to liability for "bodily injury"or"property dam- age caused, In whole or In part, by"your worm"`at the, If coverage provided to the additional Insured is re- location designated and doscribed In the Schedule of quired by a contract or agreement, the most we will this endorsement performed for that additional insured pay on behalf of the additional Insured is the amount and included in the "products-completed operations of Insurance: hazarxi". 1. Required by the contract or agreement;or However, 2. Available under the applicable Limits of Insurance 1. The insurance afforded to such additional Insured shown in the Declarations, only applies to the extent permitted by low,and whichever is low. 2. If coverage provided to the additional Insured is required by a contract or agreement the Insur- This endorsement shall not Increase the applicable arms aftrded to such additional Insured will not Limits of Insurance shown In the Declarations. not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 37 0413 0 Insurance Services Office, Inc.,2012 Page I of I Insured Policy Number. MGLO186295 Mt. Hawley Insurance Company " ENnOI SIEMENT CHANGES TH'iE;E POLICY"P1 EASE IREAO IT CAREFULLY. PRIMARY m roRy OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following,Is added to the Other Insurance Condition (2) You have agreed In writing In a contract or agree- and supersedes any provision to the contrary: anent that this Insurance would be primary and would not seek conbibution ft m any outer In- Primary And NoncorAribustory Insurance surence available to the additional Insured. This Insurance Is primary lo and will not seek con. tribution from any other Insurance available to an addltlonal Insured under your policy provided that (1) The additional Insured is a Named Insured under suchother Insurance;and CG 20 010413 0 Insurance Services Office, Inc,,2012 page 1 of 1 Insured 4 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2%of the California workers'compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOM THE BLANKET WAIVER OF SUBROGATION NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: 07/25/2017 Policy No. 7600016618171 Endorsement No. 001 Insured: Trueline Construction & Surfacing,Inc. Premium $INCL. Insurance Company: Everest National Insurance Company Countersigned By: -1998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved. From the VVCIRB's California Workers'Compensation Insurance Forms Manual-1999.