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PROOF OF INSURANCE (2018 - 2018) CLOSED a I DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE � Os/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 cert'i'ficate holder is an ADDITIONAL IN'SU'RED,the policy(los)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), I PRODUCER CONTACTBrirettl?1, Brien, 6 Tina PHONE, ( .,,,. ) ... FAX, (3'10)832-8024 Harbor Insurance Agency AoriB•ss): 310 832-5311 I„( ,Na): 1622 S. Gaffe P.O. Box 671 INS INSURER(S)AFFORDING COVERAGE NAIC,0 . ....,,, 671 URERA:Colony Insurance Co . o CA INSURED INSURER B:California Auto Insurance 38342 Rojas Construction, DBA: Rojas Construction Entp. INSURERC: 13539 S Carolina St INSURER 0 INSURER E: San Pedro CA 90731-6829 INSURER F: 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 P'E'RIOD' 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. INSR• TYPE OF INSURANCE 'ADDL;'SUBRr POLICY EFP POLICY EXP LIMBS LTR 1 ,44'AfII POLIC'YN',UMSSR IMMtDD/Y'YYY1 ,1fiHD0NYY'Y1 X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 ..... CLAIMS-MADE x l OCCUR PR SESGE O'REN ED A .•..... a occunrurencal S 100,000 X Y 101 GL 0053319-02 4/28/2017 4/28/2018 MED EXP(Any one persont S 5,000 PERSONAL d ADV INJURY S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 3,000,000 �PRX POLICY J C �IL017 PRODUCTS-COMPIOP AGG.$ 3,000,000 OTHER? S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 (Ea accident) B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BA040000009864 10/10/2011 10/10/2018 BODILY INJURY(Per accident) S AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X_ HIRED AUTOS _ .AUTOS (Per accident)_ _ S Hurricane Catastrophe Fund 1 $ d UMBRELLA LIAR I OCCUR EACH OCCURRENCE S B EXCESS LIAR AGGREGATE $, ..... DED I RETENTIONS I 1 WORKERS COMPENSATION PER OTH. V STAT'UTE'I, 'ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S OFFICERIMEMBER EXCLUDED? II'I 1 A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If yyea deacrllae under DESC"RIPT"OF OPERATIONS Wow E.L.DtlSEASE»POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACOR 1101,Additional Remarks Schedule,may be attached H mon apace Is required) Certificate holder The City of E1 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 policy for terms and conditions. CERTIFICATE HOLDER CANCELLATION 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/BRIGIT ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 gowi) 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, B. 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 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 t 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 10days 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 poiicy' 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 poticy. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE„ ENDORSEMENT 00015 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 I5 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 A, WAIVER OF SUBROGATION 1904253-IV NEW sc 9-97-43- 51 HOME OFFICE SAN FRANCISCO EFFE�C'Tl VE MARCH 01, 2 017 AT 12. . 01 A .M. ALL EFFECTIVE DATESAPE AND EXPIRING MARCH 31, 201.8 XF .12 . 01 A. M. Al 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED Al PACIFIC STANDARD TIME k()Jlk�; CONSTRUCTION CIAROf (NA ST SA.bl LILI)Rlo, ANYTHING IN THIS PO[,lCY TO THE: CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF EL SEGUNDO, ITS OFF.,'ICIA1,S, EMPLOYEES, AGENTS AND VOLUNTEERS. WHICH MIGH'.1' ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION Wl.TH WORK PERFOFU4ED 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 03% . 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: OC'POBER 1.7, 201-1 2 57 0 AUTHOCOUT) PEPHE, PRESIDENT AND CEO OLD DP 217 SCIF FORM 10217 IREV 7 2014) 101 GL 0053319-02 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ' OWNERS, LESSEES OR CONTRACTORS - BLANKET COVERAGE INCLUDING PRIMARY / NON-CONTRIBUTORY AND WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person(s)or Organization(s) "or'i" Insured): _LPc.all2ri(s)of Covered'O"r !IqnL.. 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 11—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 assurnption of liability: we 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 additibnal insured(s). U156A-0313 Includes copyrighted material of ISO Properties, Inc., Page I of 2 with its permission.