Loading...
PROOF OF INSURANCE (2019 - 2019) CLOSED a DATE(MM/DDNYYY) ACCM0 CERTIFICATE OF LIABILITY INSURANCE 3/6/2018 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 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). CONT'A'CT' PRODUCER NAME: Maile Jeppesen Brennan and Associates Risk Mgmt & Insurance Svc PHONE714-509-1073 FAX 714-975-8966 lMC,No,.Ext): ('A/C,No); License # 0649629 E-MAIL ADDRESS'.' 1551 N. Tustin Ave., Ste 500 INSURER(S)AFFORDING COVERAGE NAI'Cfd Santa Ana CA 92705 INSURERA:Colony Insurance Company INSURED INSURERB:Insurance Company of the West Krause ACT, Inc. INSURERC:Ohio Security Insurance Company DBA: Air Cleaning Technology INSURER D! 411 Rowland Ave INSURER E: Santa Ana CA 92707 INSURER F: COVERAGES CERTIFICATE NUMBER:2018-19 GL, Exc 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 PAID CLAIMS INSR AbDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE I„USD WVD POLICY NUMBER (MWDDIYYYYI IMMFDDPYYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE X OCCUR DAMAGE 0RENTF'D 300,000 PYt&'':EwflSk�$(k'.a c5rat;tmre^Ntt:y $ , X $2,500 Deductible X PACE308158 3/7/2018 3/7/2019 MED EXP(Aryone Per,on) $ 5,000 each occurence PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY I ��� II �.N CT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 I lIIl-l" Is AUTOMOBILE LIABILITY COMY3NED SINGLE I.IMI'f $ iFA acckdom) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS NON-OWNED PROPERTY'DAMAGE $ HIRED AUTOS AUTOS (Ptrra,rr.uG3erut) $ UMBRELLA LIAB X OCCUR EACH O'CCURRENCE $ 4,000,000 A X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4,000,000 DED RETENTION$ EXC308159 3/7/2018 3/7/2019 $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ''ANY PROPRIETOR,O'AR"Y'NER/EXECUTIVE r EL EACH ACCIDENT $ 11000,000 I(M(Mandatory In EXCLUDED? �L__, N/A WSD 5035621 01 1/1/2018 1/1/2019 E L DISEASE-EA EMPLOYEE $ 11000,000 B 'I(MandatorY In NH) If yes,describe under DESCRIPTION OF OPERATIONS below E L D'1SEASE•POL6Cv LIMIT $ 11000,000 C Contractors Equip/Tools BKS57761799 2/1/2018 2/1/2019 Limits $10,000/$1000 A Errors & Omissions PACE308158 3/7/2018 3/7/2019 Aggregate $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE: E1 Segundo Fire Department, 314 Main Street, E1 Segundo, CA 90245. The City of E1 Segundo is included as Additional Insured with regard to General Liability per attached forms EPACE100-0814 & EPACE101-0814. Waiver of Subrogation applies to Workers' Compensation per attached form WC990634. CERTIFICATE HOLDER CAN'CELLATIO'N SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of E1 Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: City Clerk ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE Greg Havill/TEMP .• ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) POLICY NUMBER:PACE308158 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL AL. INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED ETED P RAT'IOS This endorsement modifies insurance provided under the following: EnviroPACE Insurance Policy SCHEDULE Name Of Additional Insured Person(s) Location And Description Of Completed Or Organization(s) Operations Where Required By Written Contract Where Required By Written Contract A. Section XX. WHO IS AN INSURED, Coverage Part 1 and Part 2 is amended to include as an additional insured the person(s) or organization(s) shown in the SCHEDULE above, but only with respect to liability for bodily injury, property damage, environmental damage, or cleanup costs caused, in whole or in part, by your work at the location designated and described in the SCHEDULE of this endorsement performed for that additional insured and included in the products-completed operations hazard. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to section XXI. LIMITS OF LIABILITY AND DEDUCTIBLE: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Liability shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Liability shown in the Declarations. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. EPACE100-0814 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1 with its permission. POLICY NUMBER:PACE308158 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED ED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: EnviroPACE Insurance Policy SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations Where Required By Written Contract Where Required By Written Contract A. Section XX. WHO IS AN INSURED, Coverage Part 1 and Part 2 is amended to include as an additional insured the person(s) or organization(s) shown in the SCHEDULE above, but only with respect to liability for bodily injury, property damage, personal and advertising injury, environmental damage, or cleanup costs 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. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to bodily injury or property damage occurring after: 1. All work, including materials, parts 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 other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. EPACE101-0814 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 2 with its permission. C. With respect to the insurance afforded to these additional insureds, the following is added to section XXI. LIMITS OF LIABILITY AND DEDUCTIBLE: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Liability shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Liability shown in the Declarations. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED, EPACE101-0814 Includes copyrighted material of Insurance Services Office, Inc., Page 2 of 2 with its permission. ACC>R CERTIFICATE OF LIABILITY INSURANCE X12018 I TE IS ISSUED AS A MATTER OF w ONLY AND CONFERS NO RKWITS UPl THE COMMATE HOLDER.Tills CERT49CATE 00W iNOIT AFFIRMAl OR WEGATIA11MY AMEND, EXTEND OR AL.TIER THE COVERAGE AffORVIED BY THE POLICIES TM CVFMFOCATE OF l DOES IID? CONSTITUTE A COUIVACT GETWEEN THE ISSUING S), AuTHOR=D RE IC ATIK OR PRODLICEii.AM THE A IR',.. IMPORTANT;'l?'#w cedftift hokkv is sa ADOl MURED,i WINA be . .. . If SUaRlN' I r WAMD�...... 11 to...,, 11*Wfft OW a of iflaf PCOW, MW Ire an A stoteffMort on Eft 0"Wicalco does aot cAmlw 60ft to dw In In of eln 4 I Dan Ridcabus State Farm Irmranoe 949-.30-7100f ... � 1 I 30131 Town Center Drive,Suite 275 Laguna Niguel,CA 82677 A r Farm�Mtcl.WAAomcbft Imol Compmy 2117 .. iCr.9u, a!�C T DBA Air Cleaning Technology 411 Rol Ave Santa Ana,CA 927073445 _._...._... r: C4DVERAGES CETt'1 KATE NUMBER: REVISION NuMl THIS IS"TO "' 'Isr'Y THAT THE, POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED FC4t THE POLICY PEfilOD INDICATED NO Di ANY ENT, TERM OR OF ANY CONTRACT OR OTHER U :;TI'T"VKM RE'BPECT TO H THIS CERTIFICATE MAY BE ISS"OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES : %,nwc-HEREIN IS SLAB E(.T TO ALL THE TERMS, E KCLUSIONS AND CONDITIONSOF SUCH POLICES UNITS S"l MAY HAVE BEEN REDUCED BY PND CLAMS. K' I CQVUEKUL GENUIAL LNaLIIY EACHOCCURRENCE s V CLAffi i a�rNsoruLN:Awrulutr "� „finEW ' . a�� P'4'. CA UNIT Al WR mg �E y 4 Loc �dlPw r, rr, s AY ss58874-0M75 asm"0o�11 81MIvm16 „° ' POUE r $ IAaa.aau u"e"r �a , nI� . ., ANY AIJPosoolr wurtr VW .s S19IS394CM75 ocll VM$ oaolrMS X'ALL oaD* l� i Aurosr® SMUL ,� avow 56S 1763�C01 75 aalav�al s os1o1r1ots viva ItTr rte` ►.aEaalnos �',Auros 497109340175 01092MO 01M)IrMil t LVS _ N70Ca/Su srrL. oaaraa�r s, � � �� Al� � 'VAT AkY EL Ell Al II *u . g Fl artF .cw L ..�JI MIAIt s ( r pt';tre w F-L s Pm=LWT A Y 507 21524:M-75 03104=6 ' (111l sm Rq *m%x ens Gly of L9 Segu►do.M offidals and euwbyeft we nartledaddftml issued L.ota6m E1 Segundo Fire DoWnwrII r CERTIFIC-A i T"E HOLDEA CANCEI L ATI El Segundo Fire Department SHOULD ANY OF TIE ABOVE KSCRIBED POLICIES BE CANCELLED WORE 3SO ld',Tdin St TSE EXPIRATION nATE 7HIMEOF, NOTICE WILL BE DELMOM IN El Segundo,CA 90245 ACCORDANCE vrnH THE POLICY PATO "' AUTOOPAM '' o . 1' `11 4 A. IN.Ali teserrsd, ACORD 25{ CMM) Tlm ACORO ramm and logo an reqWbircoct maft of ACM 1001486M28499 02-04 f4 WORKERS COAWENSA71ON AND EMIPLOYERS UABIL17Y IN CE POLICY VIC 99 06 34 (Ed.8-00) WAIVIER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-BLANKET 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 orgy to the wdent that you perform work under a written contract that requires you to obtain this agreement from us). The additional premium for this endorsement shall be 3 %of the total California Workers'Compensation premium otherwise due. Schedule Person or Organization Job Description ANY PERSON / ORG ALL CA OPERATIONS WHEN 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 01/01/2018 Policy No.WS'D 5035621 01 Endorsement No. Insured KRAUSE A C T INC (CORP) Premium $ INCL. Insurance Company INSURANCE C' OF THE WEST Countersigned By VX 99 06 34 (E& INSURED