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PROOF OF INSURANCE (2019) CLOSED ACCOR DATE(MMIDDIYYYY) 7L.�74.,./'I1k" CERTIFICATE OF LIABILITY INSURANCE I 319/2 018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS W CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ELOW. 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 r)ot confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Ed t�eWoo'd Partners Insurance Center(EPIC) CONTACT 19t�00 MacArthur Blvd. PH Floor PHONE FAX Irvine, CA 92612 pmt.. . )., 9 ..p, q 161Ne (949)263-09'06 INSUREAS.),AFFORD INGCOVERAGE N'AM0 www.edgewoodins.com INSURER A: GuideOne National Insurance Companv 14167 INSURED -INSURE a Robert's Liquid Dis osal SURERD 1401'6 Carmenita Rd. — Santa Fe Springs CA 90670 INSURERRD INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 40766530 REVI'SIO'N 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 PAID CLAIMS, AR COMMS ✓ ENV562000053-00 BER r LIMITS 1 TYPE,OF INSURANCE COMMERCIAL A L 3-00 3/5/2018 R 3/5/2019XP CH OCCURRENCE 5'4 000,0'00 'NSR: � POLICY rAMIt11�)CY'YYYY(dMMdDDVY'YY'Y4 10'itt�AGd .TI„)A("fv 10 I ir'. L�0 IA CLAIMS—MADE ,/{OCCUR rrl'yr,;,l.tpM,t, mei ty�rC�ri, ,. 50„()' 1'ED'EXP(Aw.yy one Pwswia S 5,00'0 II ... . I rt,�A(av INJURY x 1 00aT!„000 I ,P�Rs�IN ,— GE'N'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s 2000,000 r OLtCY PEC LOC p PRODUCTS-COMP/OP AGG S 2„OOOgOQO. OTHERS AUTOMOBILE LIABILITY COMBINED SINGLC LIMIT' c d9o) BODILY S ANY AUTO Y INJURY(Per person) S OWNEDSCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) S HIRED NON-OWNED ”PROPERTY DQAAGE AUTOS ONLY AUTOS ONLY Ipmr asrr e,ml;p dl �S A UMBRELLA UAM ENV562000054-00 _ 3/5/2018 3/5/2019 mm* y ✓ OCCUR EACH OCCURRENCE t 4 0'0'0 000 EXCESS IAB „IBL CLAIMS-MADE AGGREGATE D 4 OOfs,ttrtr ✓I RETENTION s 10,000 S ---- ,,,,$TATIITE OT'H. WORKERS COMPENSATION B PER I I ER AND EMPLOYERS'LIABILITY I S ANYPROPRIETORIPARTNERIEXECUTIVE —1 E.LEACH ACCIDENT 0 FFICER/M EMS E R E XCLUDED? NIA (Mandatory In NH) E-L.DISEASE-EA EMPLOYEE.' S If ies dounbe under Transportation iao l Pollution Liability d b 018 $5 00 000 per Ll ce/ �„ w DSGtRp rION OF tOYPERATIONS below _ E A Pollution Liability ENV562000053-00 3/512018 3/5/2�� w 5 ccurrencelAggregate Limit 000,000 Occurrence/Aggregate Limit I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached_ u I1 more apace Is requlrad) Cerlifocale holder is named as addiltonat insured as respects the general liability',but only if required by written contract with the named insured,prior to an occurrence,per form CG 2010 07104&CG203707104 subject to all policy terms and conditions. CE'RTIFI'CATE HOLDER CANCELLATION City Of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE C ity ofrrten't OC ndoPubWorks THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 116 Illinois Street I Segundo CA 902463613 AUTHORIZED REPRESENTATIVE Tony D”Asaro 0 1966-2015 ACORD CORPORATION, All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 06F5.6 1 19—Ia GLIUK5 Al RA[N: HASTE'F• , J”, Zlhc tx , b V2019 2:0'x:77 P14 flPSTI I Pn9& o of 4 AGENCY CUSTOMER ID: LOC 4CC>R0 ADDITIONAL REMARKS SCHEDULE Page of . .................... GIENCY NAMEDINSURED Edgewood Partners Insurance Center(EPIC) Robert's Liquid Disposal 14018Carmenila%d. POUCYNUMBER Santa Fe Springs CA 90670 ................. CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER. 25 FORM TITLE:Certificate of Liability(03/16) HOLDER: City of El Segundo Department of Public Works ADDRESS:150 Illinois Street El Segundo CA 902453813 City of El Segundo, its officials, and employee as "additional insureds" with respects to general liability ACORD 101 (2006101) 0 2008 ACORD CORPORATION. Ali rights reserved. The ACORD name and logo are registered marks of ACORD ADDENDUM 407W,10 1 16-15 61./UMB Al "M MA✓TEI Yhh SeJ.—t. 1 3'9rd01h 2;02z20 PH (FST! I E'.q. 2 of 4 Robert's Liquid Disposal POLICY NUMBER'ENV562000053-00 COMMERCIAL GENERAL LIABILITY CG 2010 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED - OWNERS, .ESS S O CONTRACTORS - SCHEDULED SO OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Orvanlzation(s): Location(s)_Of Covered Operations Any person or organization for whom you are performing In respect to any location where the named insured is operations when you and such person or organization have performing"your work". agreed in writing in a contract or agreement,effected prior to the date your operations for that person or organization commenced,that such person or organization be added as an additional insured on your policy. Information required to complete thlse Schedule,If n—of shown,will be shown in the Declarations. A. Section II—Who Is An Insured is amended to include B. With respect to the insurance afforded to these as an additional insured the person(s)or additional insureds,the following additional exclu- organization(s)shown in the Schedule,but only with sions apply. respect to liability for"bodily injury","property damage" This insurance does not apply to"bodily injury"or or"personal and advertising injury"caused,in whole or "property damage"occurring after: in part,by: 1. All work,including materials, parts or equip- 1. Your acts or omissions;or 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 the additional insured(s)at the location of the in the performance of your ongoing operations for the covered operations has been completed;or additional insured(s)at the location(s)designated 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 2010 07 04 m ISO Properties,Inc., 2004 Page 1 of 1 10^^p.'fN �L A^W IVa Wl'!N meMI'V•, � Ja,c S14i�wnr x i 0:;,,',"r eo i W".tr •,y� of 4 Roberts Liquid Disposal POLICY NUMBER: ENV562000053-00 COMMERCIAL GENERAL LIABILRY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASER IT CAREFULLY. ADDITIONALINSURED - OWNERS, LESSEES OR CONTRACTORS -" COMPLETED 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 Any person or organization for whom you are performing In re.weet to any location where the Named Insured is operations when you and such person or organization have perforating"your worse." agreed in writing in a contract or agreement,effected prior to the date your operations for that person or organization commenced,that such person or organization be added as an additional insured on your policy I" w Information required to complete this Schedule,if not shown above, will be shown in the Declarations. Section 11-Who Is An Insured is amended to Include as an additional insured the person(s)or organiation(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 O ISO Properties, Inc., 2004 Page 1 of 1 mid ;d ua :J9.,d9 L,rB,^Rw'P NH Illm'+x IN N w'i;CFA 1 ;NV II :ll /,.1I:,k6 PP:�:H Ih APs� I9nop'N 4 � ACC>R� CERTIFICATE OF LIABILITY INSURANCE DATE(MMtPO1_YYY_)_-1 ih. ,.. 1 04/19/2018 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. IIWtPORTANT'. If the certificate holderis an ADDITIO'N'AL INSURED,the policy(les)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 orrdorsement(s). PRODUCER CONTACT LANA N,,,,,Mtl�l'E; AGENCY CUSTOMER ID: LOC ADDITIONAL REMARKS SCHEDULE Page 2 Of 2 AGENCY NAMEDINSURFD BETH BETTGER INSURANCE AGENCY INC ROBERT&PEGGY HERRICKS POLICY NUMBER DBA ROBERTS LIQUID DISPOSAL 14018 CARMENITA RD CARMER MAIC CODE SANTA FE SPRINGS CA 90670 Stale Farm Mutual Aulwnobife Insurance Comparly 125178 EFFECTIVE DATE: 04119/2018 -ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIAMUTY INSURANCE AUTOMOBILE LIABILITY: COMBINED SINGLE LIMIT$2,000,000 ADDITIONAL INSURED:YES 1.244 3054-B01-75 02101/2018-08/01/2018 2,296 5SWE20-75 05120/2018-11120/2018 3.413 850"03-75 02103/2018-08/03t2018 ACORD 101(20,08101) @ 2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD 1004362 142991.1 01-21-2013 CERTHOLDER COPY Sc STATE COMPFNSATION P.O. BOX 8192, PLEASANTON, CA 94588 FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 04-19-2018 GROUP: POLICY NUMBER: 1446891-2017 CERTIFICATE ID: 325 CERTIFICATE EXPIRES: 12-31-2018 12-31-2017/12-31-2018 CITY OF EL SEGUNDO SC DEPT OF PUBLIC WORKS 150 ILLINOIS ST EL SEGUNDO CA 90245-4311 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 30 days advance written notice to the employer. We will also give you 30 days 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 policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may bre 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 policy. Authorized Representative President and CEO UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' COMPENSATION LAW. EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #2085 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 12-31-1998 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER HERRICKS, ROBERT LEE (II) AND HERRICKS, PEGGY LEE DBA: ROBERT'S LIQUID DISPOSAL 14018 CARMENITA RD SANTA FE SPRINGS CA 90670 [VR1,CN] (REV.7-2014) PRINTED : 04-19-2018 \I' ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION REP 02 1446891-17 RENEWAL SC HOME OFFICE 1-37-56-44 SAN FRANCISCO PAGE 1 OF 1 ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC EFFECTIVE APRIL 25 , 2018 AT 12.01 A.M. STANDARD TIME OR THE TIME INDICATED AT AND EXPIRING DECEMBER 31 ; 2018 AT 12.01 A.M. PACIFIC STANDARD TIME ROBERT' S LIQUID DISPOSAL 14018 CARMENITA RD SANTA FE SPRINGS, CA 90670 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF EL SEGUNDO WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, ROBERT'S LIQUID DISPOSAL 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: APRIL 27, 2018 2570 APRESIDENT AND CEO SCIF FORM 70217 ;REV/7-20:4) OLD DP 217