Loading...
PROOF OF INSURANCE (2018) CLOSED DATE(MM/DD/YYYY) APw C>R" CERTIFICATE OF LIABILITY INSURANCE 12/21/2017 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 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). PRODUCER CONTACT NAME, Trudy Polito CA License#OK26631 Hall&Company' PHONE FAX A/E Insurance services (AOC,No,E:rtk 360.626.2'964 WC„No);360-598-3703 19660 10th Ave NE AD(�DRrSS tpolito@hallandcompany.com Poulsbo WA 98370 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:EVEREST INDEMNITY INSURANCE COMPANY 10851 INSURED 12329 INSURER B Tom Salas dba Breathe Safe Environmental 3010 Wilshire Blvd#260 INSURER C: Los Angeles CA 90010 INSURER D INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:1434323440 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 'AID CLAIMS INSR TYPE ADDL''SUDR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DDIYYYY) (MM IDD(Y1/YY!_ A X COMMERCIAL GENERAL LIABILITY EF4ML02150-171 12/16/2017 12/16/2018 EACH OCCURRENCE $1.000.000 DAMCLAIMS-MADE X OCCUR PRE t0 RLNtLD ,PREMISSES(Ea occurrence,) $50,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000.000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $1.000.000 X POLICY F J' LOC PRODUCTS-COMP/OP AGG $1.000.000 OTHER $ A AUTOMOBILE LIABILITY EF4ML02150-171 12/16/2017 12/16/2018 COMBINED SWGI.F I,IM11" $ (,Era accident) 1.000„000 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) AUTOS ONLY AUTOS $ X HIRED AUTOS ONLY XAUTOS ONLY (Pta v)aA%, dtrj G)AMIAf..F $ (' iranl) .., $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ 1 EXCESS LIAB CLAIMS-MADE AGGREGATE $ V DED I RETENTION$ .... .. $ WORKERS COMPENSATION PER 0TH AND EMPLOYERS'LIABILITY Y/N STATUTE ` ER, „ ANYPROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ OFFICER/MEM BER EXCLUDED? NIA (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE•POLICY I IMIT” $ A Professional Liab;Claims Made EF4ML02150-171 12/16/2017 12/16/2018 $1,000,000 Per Claim Contractors Pollution Liab. $1,000,000 Aggregate DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The certificate holder is an additional insured per the attached. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of EI Segundo 350 Main Street wRig� EI Segundo CA 90245 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: EF4ML02150-161 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 Orgianization(s): Location(s) Of Covered Operations Blanket where required by written contract. 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 Yinjury""bodil u or damage" or "personal and advertising injury" "property damage" occurring after: caused, in whole or in part, by: 1. Your acts or omissions; or 7. Al work, including materials, parts or equip- 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 ©ISO Properties, Inc., 2004 Page 1 of 1 ❑ POLICY NUMBER: EF4ML02150-161 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS,S, LESSEES O CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operations Blanket where required by written contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. 1 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 POLICY NUMBER: EF4ML02150-161 COMMERCIAL GENERAL LIABILITY ECG 20 557 06 08 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - LESSON OF LEASED EQUIPMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE � � Name Of Additional Insured Persons Or Or anization(s) Blanket where required by written contract. Information required to complete this Schedule, if not shown above„ will be shown in the Declarations. A Section II — Who Is An Insured under the Com- D. With respect to the insurance afforded to these mercial General Liability Coverage Part is amend- additional insureds„ this insurance does not apply ed to include as an insured the person(s) or organ- to any "occurrence" which tames place after the ization(s) shown in the Schedule, only with respect equipment lease expires. to liability for "bodily injury", "property damage" or E. For the purposes of this endorsement, paragraph "personal and advertising injury" but only to the ex- 4. Other Insurance under SECTION IV — tent caused, in whole or in part, by your mainte- COMMERCIAL GENERAL LIABILITY Hance, operation or use of equipment ,leased to CONDITIONS of the Commercial General Liability you by such person(s) or organization(s). Coverage Part is replaced by the following: B. The insurance afforded to these additional in- 4. Other Insurance sureds shall only include the insurance required by the terms of the written agreement and only to the The insurance afforded to these additional in- extent that coverage is provided within the terms of sureds is excess over any other insurance this Coverage Part. naming an insured whether such insurance is C. The Limits of Insurance afforded to these addition- primary, excess, contingent or contributing.This insurance may not be used to satisfy any al insureds shall be the lesser of the following: deductible or self-insured retention amounts an 1. The Limits of Insurance required by the written insured may owe as a result of this loss, dam- agreement between the parties; or age or injury. 2. The Limits of Insurance provided by this Cov- erage Part. ECG 20 557 06 08 C Everest Reinsurance Company, 2008 Page 1 of 1 ❑ Includes copyrighted material of ISO Properties, Inc. used with permission ECG 24 506 06 15 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVED OF TRANSFER OF RIGHTS OF' RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILTY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART MOTOR VEHICLE POLLUTION LIABILITY COVERGE PART SCHEDULE Name of Person or Organization: Blanket where required by written contract. Any person or organization that is: 1. An owner of real or personal property on which you are performing operations, but only at the specific writ- ten request by that person or organization to you, and only if that request is made prior to the date your operations for that person or organization commenced; or 2. A contractor on whose behalf you are performing operations, but only at the specific written request by that person or organization to you, and only if that request is made prior to the date your operations for that person or organization commenced. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work"done under a contract with that person or organization and.included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. ECG 24 506 06 15 Copyright, Everest Reinsurance Company, 2015 Page 1 of 1 ❑ Includes copyrighted material of Insurance Services Office, Inc., with its permission ECG 24 588 12 15 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY UTOPY PROVISIO I - YOUR ONGOING AND/OR COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTOR'S POLLUTION LIABILITY COVERAGE PART MOTOR VEHICLES POLLUTION LIABILITY COVERAGE PART Paragraph 4., Other Insurance of Conditions(Section IV) is amended by the addition of the following: If other liability insurance similar to this insurance listing as a Named Insured a person or organization that is: a. An owner of real or personal property on which you are performing operations; or b. A contractor on whose behalf you are performing operations, and this policy names those persons or organizations as additional insureds for those operations, then this insur- ance is primary to that other insurance, and that other insurance shall not contribute to amounts payable under this insurance, for liability arising out of your ongoing and/or completed operations performed for that person or organization under a written contract which requires that this insurance be primary. However, this does not apply if the written contract was not executed prior to the date that your operations for Oiat person or organization corn- rnenced. ECG 24 588 12 15 Copyright Everest Reinsurance Company, 2015 Page 1 of 1 0 Includes copyrighted material of Insurance Services Office, Inc., with its permission. CONTRACTOR'S POLLUTION LIABILITY ECG 20 532 04 12 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION - ONGOING AND COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: CONTRACTOR'S POLLUTION LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Blanket where required by written contract. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured under the D. For the purposes of this endorsement, paragraph Contractor's Pollution Liability Coverage Part is 4. Other Insurance under SECTION IV — amended to include as an insured the person(s) CONDITIONS of the Contractor's Pollution or organization(s) shown in the Schedule, only Liability Coverage Part is replaced by the with respect to liability for "bodily injury" or following: "property damage" but only to the extent caused, 4. Other Insurance in whole or in part, by: The insurance afforded to these additional (1) Your acts or omissions; or insureds is excess over any other insurance (2) The acts or omissions of those acting on your naming an insured whether such insurance is behalf; primary, excess, contingent or contributing. in the performance of your operations for the This insurance may not be used to satisfy any additional insured. deductible or self-insured retention amounts an insured may owe as a result of this loss, B. The insurance afforded to these additional damage or injury. insureds shall only include the insurance required by the terms of the written agreement and only to the extent that coverage is provided within the terms of this Coverage Part. C. The Limits of Insurance afforded to these additional insureds shall be the lesser of the following: 1. The Limits of Insurance required by the written agreement between the parties; or 2. The Limits of Insurance provided by this Coverage Part. ECG 20 532 04 12 Copyright, Everest Reinsurance Company, 2012 Page 1 of 1 13 Includes copyrighted material of ISO Properties, Inc., with its permission. ECG 24 506 0615 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILTY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART MOTOR VEHICLE POLLUTION LIABILITY COVERGE PART SCHEDULE Name of Person or Organization: Blanket where required by written contract. Any person or organization that is: 1. An owner of real or personal property on which you are performing operations, but only at the specific writ- ten request by that person or organization to you, and only if that request is made prior to the date your operations for that person or organization commenced; or 2. A contractor on whose behalf you are performing operations, but only at the specific written request by that person or organization to you, and only if that request is made prior to the date your operations for that person or organization commenced. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. ECG 24 506 06 15 Copyright, Everest Reinsurance Company, 2015 Page 1 of 1 ❑ Includes copyrighted material of Insurance Services Office, Inc., with its permission POLICY NUMBER: EF4ML02150-161 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. FIRED AUTO AND NON-OWNED AUTO LIABILITY This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Insurance is provided only with respect to those coverages for which a specific premium charge is shown: Coverage Premium Hired Auto Liability $Included Non-Owned Auto Liability $Included (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. HIRED AUTO LIABILITY agreement. This exclusion does not apply to If a specific premium charge is shown above for Hired liability for damages: Auto Liability, the insurance provided in Section I — (1)That the insured would have in the absence of Coverages, under Coverage A — Bodily Injury And the contract or agreement; or Property Damage Liability, applies to "bodily injury" or (2)Assumed in a contract or agreement that is an "property damage" arising out of the maintenance or "insured contract", provided the "bodily injury" or use of a "hired auto" by you or your "employees" in the "propertydamage" u course of your business. 9 occurs subsequent ent to B. NON-OWNED AUTO LIABILITY the execution of the contract or agreement. b. "Bodily injury"to: If a specific premium charge is shown above for Non- Owned Auto Liability, the insurance provided in Section (1)An "employee"of the insured arising out of — Coverages, under Coverage A — Bodily Injury And and in the course of: Property Damage Liability, applies to "bodily injury" or (a) Employment by the insured; or "property damage" arising out of the use of a "non- owned auto" by any person other than you in the course (b) Performing duties related to the conduct of of your business. the insured's business; or C. EXCLUSIONS (2) The spouse, child, parent, brother or sister of the "employee" as a consequence of Only with respect to the insurance provided by this paragraph (1) above. endorsement: 1. Subparagraphs b., c., e., g., h.,j., k., I., m. and n. of This exclusion applies: paragraph 2. Exclusions in Section I — Coverages, (1) Whether the insured may be liable as an under Coverage A — Bodily Injury And Property employer or in any other capacity; and Damage Liability, do not apply. (2)To any obligation to share damages with or 2. The following exclusions are added to paragraph 2. repay someone else who must pay the Exclusions in Section I — Coverages, under damages because of the injury. Coverage A — Bodily Injury And Property Damage This exclusion does not apply to: Liability: (1) Liability assumed by the insured under an This insurance does not apply to: "insured contract", or a. "Bodily injury" or "property damage" for which the (2)"Bodily injury" to domestic "employees" not insured is obligated to pay damages by reason of entitled to workers compensation benefits. the assumption of liability in a contract or c. "Property damage"to: ECG 04 528 0114 Copyright,Everest Reinsurance Company,2014 Page 1 of 3 Includes copyrighted material of Insurance Services Office,Inc., with its permission. (1) Property owned or being transported by, or a.The Limit of Insurance provided in paragraph rented or loaned to the insured; or b. below, and the rules below fix the most we (2)Property in the care, custody or control of the will pay regardless of the number of: insured. (1) Insureds; D. WHO IS AN INSURED (2) Claims made or"suits" brought; or (3)Persons or organizations making claims or Section II —Who Is An Insured is deleted with respect bringing "suits". to Coverages provided under this endorsement and replaced by the following: b.The General Aggregate Limit of one million 1. Each of the following is an insured under this dollars($1,000,000) is the most we will pay for insurance to the extent set forth below: the sum of: (1) Medical expenses under Coverage C of a. You. the Coverage General Liability Coverage b. Any other person using a "hired auto" with your Part;and (2) Damages under the Hired Auto Liability permission. And Non-Owned Auto Liability coverage c. With respect to a "non-owned auto", any partner provisions described in paragraphs A. and or"executive officer"of yours, but only while such B. of this endorsement. "non-owned auto" is being used in your business. 2. For the purposes of the coverage provided by d. Any other person or organization, but only with this endorsement and subject to paragraph E.1. respect to their liability because of acts or of this endorsement, paragraphs 5. and 7.under omissions of an insured under paragraphs a, b., Section III—Limits of Insurance in the or c.above. Commercial General Liability Coverage Form 2. None of the following is an insured: will continue to apply with respect to Medical Expenses under Coverage C. a. Any person engaged in the business of his or her employer with respect to "bodily injury" to any The Limits of Insurance provided under this co-employee of such person injured in the endorsement apply separately to each consecutive course of employment; annual period and to any remaining period of less b. Any partner or "executive officer" with respect to than 12 months, starting with the beginning of the any "auto" owned by such partner or officer or a this endorsement's inception date, unless this endorsements extended after issuance for an member of his or her household; additional period of less than 12 months. In that c. Any person while employed in or otherwise case, the additional period will be deemed part of engaged in performing duties related to the the last preceding period for purposes of conduct of an "auto business", other than an determining the Limits of Insurance. "auto business"you operate; d. The owner or lessee (of whom you are a F. DEFINITIONS sublessee) of a "hired auto" or the owner of a "non-owned auto" or any agent or "employee" of 1. For the purposes of this endorsement only, the any such owner or lessee; definition of "insured contract" in the Definitions e. Any person or organization with respect to the Section is amended by the addition of the following: conduct of any current or past partnership or 9."Insured contract' means: joint venture that is not shown as a Named g. That part of any contract or agreement Insured in the Declarations. entered into, as part of your business, E LIMITS OF LIABILITY pertaining to the rental or lease, by you or any of your "employees", of any "auto". However, 1. Except with respect to Medical Expenses under such contract or agreement shall not be Coverage C as described in paragraph 2. below, considered an "insured contract" to the extent for the purposes of the coverage provided by this that it obligates you or any of your endorsement, Section III — Limits of Insurance "employees" to pay for "property damage" to is deleted and replaced by the following: any "auto"l rented or leased by you or any of your"employees". ECG 04 528 0114 Copyright,Everest Reinsurance Company,2014 Page 2 of 3 Includes copyrighted material of Insurance Services Office,Inc., with its permission. 2. Only with respect to the insurance provided by this (3) Any "auto" that you insure as an owned endorsement,the following definitions are added: "auto" under any other auto liability a. "Auto business" means the business or insurance policy; or A temporary substitute for an "auto"you own occupation of selling, repairing, servicing, that is out of service because of its storing, or parking "autos". breakdown, repair, servicing or destruction. b. "Hired auto" means any "auto" you lease, hire, c. "Non-owned auto" means any "auto" you do not rent or borrow on an occasional or infrequent own, lease, hire, rent or borrow which is used in basis.This does not include: connection with your business. This includes (1) Any "auto" you lease, hire, rent or borrow "autos" owned by your "employees", your from any of your "employees", your partners partners or your executive officers", or or your "executive officers", or members of members of their households, but only while their households; used in your business or your personal affairs. (2) A long-term leased "auto"; ECG 04 528 0114 Copyright,Everest Reinsurance Company,2014 Page 3 of 3 Includes copyrighted material of Insurance Services Office,Inc., with its permission. AC"RDr CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) •.---' 11110/2017' 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 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). PRODUCER CONTACT 800-881-341lliams Freedom Insurance Services,Inc. PHONE FAX NAME: I a a insuref' Anaheim, CA 92801 AcFsXt} commercial@���urefis.com I�caak� 844-881 3419 700 N Valle Street Suite B E-MAIL. License#: 01 123461 INSURER(S)AFFORDING COVERAGE NAIL N .....,DINS,,, INSURER A: Amtrust 42376- .., INSURED INSURER B: Breathe Safe Environmental,LLC 3010 Wilshire BlvdD INS RER Ste 260 INSURER D ------ Los Angeles, CA 90010 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 2 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 CONTRACTOR 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 1REDUCED BY PAID CLAIMS ,NSA TYPE OF INSURANCE INS 5.W POLICY NUMBER rMMIDD/VYYYI (POOCY EFF MO,,, OP�YI, LIMITS 4 RAL LIABILITY PR MI $ COMMERCIAL GENE EACH OCCURRENCE DAMAGE TO RENTED li MED EXP(Any one son) $_ CLAIMS-MADE f OCCUR PW1ERSO'NA�.B AD;VINJURY $ GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY El LOC PRODUCTS,;COMPIOP AGG $ JST",fi OTHER $ AUTOMOBILE LIABILITY COIF BiNED SIINiGLF'N.IMI'T' S BODILY arc damp ANY AUTO INJURY(Per person) S OWNED SCHEDULED AUTOS ONLY 5 BODILY INJURY(Per er accntnt} HIRED NON--OWNED I r p DAMAGE .. S AUTOS ONLY AUTOS ONLY r�aa.u�gettd'p S UMBRELLA LIAR OCC11UR EACH OCCURRENCE 5 EXCESS LIAR S-MADE f AGGREGATE S OED V RETENTIONS ! C S $TAT ER A WORKERS CO07 H- MPENSATION �,IN TWC3594945 01/01/2017 01/01/2018 X ATF,,,,, ER, 1,000,000 ANY(Mandatory ry in NH)EXCLUDED?PROPRIETOR/PARTNER/EXECUTIVE �I NIA E L DISEASE ACCIDENT $ 1,000,000 (yes,describe under �.W A EMPLOYEE,$ 1,000,000 DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street EI Segundo, CA 90245 A'U'THORIZED REPRESENTATIVE ©1 8 2015 RD�CORPO TION. All rights roserved, ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by MMW on November 10,2017 at 12:32PM WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) 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 as required by written contract. 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 1/1/2017 Policy No. TWC3594945 Endorsement No. 3 Insured BREATHE SAFE ENVIRONMENTAL,LLC Premium$ 3303 Insurance Company Technology Insurance Company,Inc. Countersigned by................. ..m .......... ................................ WC 04 03 06 (Ed.04-84)