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PROOF OF INSURANCE (2019) CLOSED GOLFMAI-01 TDIELGADO "" "REX CERTIFICATE OF LIABILITY INSURANCE D 03 19/201 YY) ._.�.._._..... 03/19/2018 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. License#O'F09643 CCgAT-,ACT R _...@......�.._...rte P. PRODUCER PQM tor�a.de'I ado deserterrt rreins.com Desert Empire Ins Services,Inc. PHO E �);(760'j 360 700 FAX,N�,); 760) 360-4799 Sus e4 01untry Club Drive (AIE-MAAL Palm Desert,CA 92211 ADD ss. INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Wesco Insurance Company 125011 INSURED rStone National Insurance Company 25496 Golf Maintenance Solutions,LLC INSURER C:Capitol Specialtv Insurance Corporation 10328 Carefree,I22 NSURER D: AZ 85377 INSURER E: f i' INSURER F: �r011✓ERAGE''S ........._............CERTIFICATE NUMBER: REVISION,t°JITtdI�IBER: ._ 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 30LICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSO WM/n POLICY NUMBER IM LIMITS lPPff,y.yY1_IMM/DD/YYYYt A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 9DAMAGE SFa 100,000CLAIMS-MADE � X � OCCUR X WPP114348104 03/15/2018 03/15/201Ioccurrence) $ „ MED EXP(Any one person) $ 5,001) PERSONAL&ADV INJURY $ 1,000,000 GI N`L AGGREGATE LIMIT APPE.IES PER GENERAL AGGREGATE $ 2,000,000 POLICY N PRO- X JILOC 2,000,000 PRODUCTS- P A OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT kloa arclde'rii) $ ., ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident), $ HIRED NON-AWNED PROPERTY DAMAGE AUTOS ONLY (I AUTOS ONLY (Per accident) $ EXCESSLIALIAB X OCCUR ................ EACH CCU RENCE ...-m.1$ ww. B X UMBRELLA LIAB X ,OCCUR $ 1,00O,t)00 CLAIMS-MADE 71936X181ALI 03/15/2018 03/15/2019 $ 1,000,000 AGG... $ WORKERS COMPENSATION AND EMPLOYERS' .....�.............__............_ .---------------,,,--._ ..... ........ DED RETENTION$ ( rwrwra ( 0TH- AND LIABILITY Y I N� N/A A1CH N FLCCIDENT I-R, ..........� ANY PROPRIETOR/PARTNER/EXECUTIVE E L OFFICERIWEMBEREXCLUDED? A $ (Mandatory In NH) E L DISEASE-EA EMPI.OVEF. $ If yes,describe under DESCRIPTION OF OPERATIONS belowE L DISEASE-POLICY LIMIT $ A Equipment Floater _ WPP114348104 03/15/2019 'Died$1,000ITITITITmm 366,726 C Errors&Omissions _ SGCO2589-07 11/01/2017 11/01/2018 Deft$2500 1,000,0001 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of EI Segundo,its officials and employees are named as additional insured per attached form. This insurance Is primary and non contributory per attachedform. ..........-.......... _._.......... CERTIFICATE HOLDER ............... CANC"EtLATIO'N SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City CitMain Street ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo,CA 90245 •••••-•••---••••-• AUTHORIZED REPRESENTATIVE ......._._......... _._..... ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 20 38 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LEESSEES OR CONTRACTORS - AUTOMATIC STATUS FOR OTHER PARTIES WN N REQUIRED IN WRITTEN CONSTRUCTION AGREEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured: additional insureds, the following additional 1. Any person or organization for whom you are exclusions apply: performing operations when you and such This insurance does not apply to: person or organization have agreed in writing 1. "Bodily injury", "property damage" or "personal in a contract or agreement that such person or and advertising injury" arising out of the organization be added as an additional insured rendering of, or the failure to render, any on your policy; and professional architectural, engineering or 2. Any other person or organization you are surveying services, including: required to add as an additional insured under a. The preparing, approving, or failing to the contract or agreement described in prepare or approve, maps, shop drawings, Paragraph 1.above. opinions, reports, surveys, field orders, Such person(s) or organization(s) is an additional change orders or drawings and insured only with respect to liability for "bodily specifications; or injury", "property damage" or "personal and b. Supervisory, inspection, architectural or advertising injury"caused, in whole or in part, by: engineering activities. a. Your acts or omissions; or This exclusion applies even if the claims against b. The acts or omissions of those acting on any insured allege negligence or other wrongdoing your behalf; in the supervision, hiring, employment, training or in the performance of your ongoing operations for monitoring of others by that insured, if the the additional insured. "occurrence" which caused the "bodily injury" or However, the insurance afforded to such "property damage", or the offense which caused the "personal and advertising injury", involved the additional insured described above: rendering of, or the failure to render, any a. Only applies to the extent permitted by law; professional architectural, engineering or and surveying services. b. Will not be broader than that which you are 2. "Bodily injury" or "property damage" occurring required by the contract or agreement to after: provide for such additional insured. a. All work, including materials, parts or A person's or organization's status as an equipment furnished in connection with additional insured under this endorsement ends such work, on the project (other than when your operations for the person or service, maintenance or repairs) to be organization described in Paragraph 1. above are performed by or on behalf of the additional completed. insured(s) at the location of the covered operations has been completed; or CG 20 38 0413 ©Insurance Services Office, Inc., 2012 Page 1 of 2 b. That portion of "your work" out of which the 2. Available under the applicable Limits of injury or damage arises has been put to its Insurance shown in the Declarations; intended use by any person or organization whichever is less. other than another contractor or subcontractor engaged in performing This endorsement shall not increase the operations for a principal as a part of the applicable Limits of Insurance shown in the same project. Declarations. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III—Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement described in Paragraph A.1.; or Page 2 of 2 0 Insurance Services Office, Inc., 2012 CG 20 38 0413 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - 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 (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the additional insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and CG 20 01 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 1 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: (I (__) I have and will maintain a certificate of consent of self-insure for workers'compensation, issued by the Director (, of Industrial Relations as provided for by Labor Code§3700 for the performance of the work set forth the agreement with the City of EI Segundo. Policy No. (._J I have and will maintain workers'compensation insurance as required by Labor Code§3700 for the performance of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone# 6 (�} I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must Signature of Applicant immediately comply with thoseVision i'sion or the agre ent will automaticaily become void. 9 PP -�- Date 12-28-17 Print Name Wiliam Uawath Agreement for. �� I Dated: ., ... Reviewed by: