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PROOF OF INSURANCE (2019) CLOSED CERTIFICATE OF LIABILITY INSURANCE DATE(MMJDDlYYYY) 6/26/2018 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(les)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). PRODUCER CONTACT had H Y PAOC.NoI� _ MAIL (5 Lake urance.c FAX (509)697-4600 410tSaFiYsahsgton Insurance Inc. chadl@centralwains EMAIL A,PI�tiL�9:, om P.O. BOX 100 .... .... .. INS..... _ COVERAGE NAIC# y Insurance Company 29424 SELAH, WA 98942 INSURERA:Hartford Casualt INSURED INSURER 13: Richard J Andring Dba: Wiland Associates INSURER C: 1651 Collins Rd INSURER D: INSURER E; Selah WA 98942 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1753002649 REWSION',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. �. ..,,, ADDL'$UBR POLICY Err POLICY EXP TYPE OF INSURANCE 1=.,MVr) POLICY NUMBER fMhh0yMY lMMfDDNYYYYI LIMITS X COMMERCIAL GENERAL LIABILITY Y EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE ❑K OCCUR UAIeMAGE"10ICU411.D 300 PREMISE CEa ooc arrelrcrr� .,..$ 300,000 X Y 52SRAVW2897 1/12/2019 1/12/2019 MED XP(Any oeperson) �00 PEEnINJURY 1,000C) m GEN'L AGGREGAI E LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,0 00 X I PRO- POLICY _. ��.J JECT �LOC PRODUCTS-COMNOPAGG S 2,000,000 OTH ; Stopgap $ 1,000,000 AUTOMOBILE LIABILITY COIVOINED Slh<t,�L'c LiM17' (FaarxWenl'1 $ 1,000,000 ANY AUTO BODILY INJURY(Per AUTOS I SCHEDULED X Y 52SBAVW2897 1/12/2018 1/12/2019 ODILYINJURY(Peraccd)t) $ A ... ALL L............... NON-O X HIRED AUTOS X AUTOS WNED LPOa,_OQ IiYI�_ki1a",t �,$............................. . ...................... X UMBRELLA LIAR Z C , ,0 00 . A ATE EX �^ .. ..CLAIMS MADE AGGREGATE $ ,..2 000 ..... $ 2,0,00,000 • DED F RETENTION$ X Y 52SBAVW2B97 1/12/2016 1/12/2019 $ WORKER'S COMPENSATION HER 01'H- AND EMPLOYERS'LIABILITY y N N , - J STAT TF].............1 F ....."... ANY PROPRIETORIPARTNER/EXECUTIVE SC?aRt" '!:'i A"1`iC,3NS'beluuw p � ELEACH ACCIDENT PFjCt-R1 FMBFKEXCLUDED7 NIA (mandatory N ) UEM PLOYEE,.$ describeindorE.L.DISEASE POLICY LIMIT ",. .,. . $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space Is required) City of Elsugundo, its officers,• officials, employees and volunteers are named as additionlas insureds. Coverage is Primary and Non-Contributory with waiver of subrogation. CE'RT111CATE HOLDER /wa CANCELLATION p•/� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. E1 Segundo, CA 90245 0 � AUTHORIZED REPRESENTATIVE ✓I�� � .: X Chad Lakey/CDL ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) POLICY NUMBER: 52 SBA VW2897 ENDT 001 EFF 06/26/2015 it THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR O ORGANIZATION This endorsement modifies Insurance provided under the following: BUSINESS LIABILITY COVERAGE FORM1� SCHEDULE P Name Of Additional Insured Person(s)Or Organization(s): CITY OF EL SEGUNDO Location(s)Of Covered Operations: 350 MAIN ST EL SEGUNDO, CA 90245 Information required to complete this Schedule,if not shown above,will be shown in the Declarations. A. Section C. —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 organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury", "property This insurance does nota injury" or ' damage" or "personal and advertising injury" apply to bodily m'u property damage occurring after: caused,in whole or in part, by: 1. All work, including materials, parts or 1. Your acts or omissions;or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. 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. Form SS 4170 06 11 Page 1 of 1 Process Date: 06/27/18 Policy Expiration Date: 01/12/19 © 2011,The Hartford (Includes copyrighted material of Insurance Services Office, Inc.,with its permission) POLICY NUMBER: 52 SSA VW2897 ENDT 001 EFF 06/26/2018 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS 'b This endorsement modifies insurance provided under the following: '' BUSINESS LIABILITY COVERAGE FORM 9 8" SCHEDULE Name Of Additional Insured Person(s)Or Organization(s): ,�Ws^ CITY OF EL SEGUNDO 0Location And Description Of Completed Operations: 350 MAIN ST EL SEGUNDO, CA 90245 RE: FIRE TRAINING Information required to complete this Schedule,if not shown above,will be shown in the Declarations. Section C. — 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 p damage"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". Form SS 41 7106 11 Page 1 of 1 Process Date: 06/27/18 Policy Expiration Date: 01/12/19 © 2011,The Hartford (Includes copyrighted material of Insurance Services Office,Inc.,with its permission) DATE(MMIDDIYYYY) AC'P )F�'L;� ' CERTIFICATE OF LIABILITY INSURANCE 1 06/2912018 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOTAFFIRMATIVELYOR NEGATIVELY AMEND, EXTEND ORA LTER THE COVERAGE A F FORDED 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(les)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 endorsementqs), PRODUCER WN TALI NAME: Central Wash. Ins.Agency, Inc PHONE I FAX (AIC No.Ext): m, I (AIC,No° PO Box 100 ADDRESS INSURER(S)AFFORDING COVERAGE NAIC it Selah WA 98942-010 INSURERA: Underwriters at Lloyds, London-CFC 100001 INSURED INSURER B: Wiland Associates LLC INSURER C 1651 Collins Road INSURERD: INSURERE Selah WA 98942 INSURER F: COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR" A9.FULY $U3..W POLICY EFF POLICY EXP LTR TYPE OF INSURANCE igNSD YYMrI POLICY NUMBER (MMIODNYYY) (MMIDDIYYYYI LIMITS COMMERCIAL GENERAL LIABILITY FACH CI RRFNC'F $ UHC I I - CLAIMS-MADE [7 OCCUR "HIII .4.i - MFD FXP(Ana on-narcnn) $ PF..RSONAI.RADV IN,,II,IRY $ - LIMITAPPLIESPER GENERAL AGGR EGAT E $ II tl0,+F] PRO-SECT ❑LOC PRODI HTS-C'OMPlCP Ai;r; $ - -- CTIIEUR $ AUTOMOBILE LIABILITY FOWBIN)-,r,'.'' �Jkbd;LE II,00E $ - F„i<iC.h,7¢4rI1 ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS - HIREDAUTOS NON-OWNED NI,I;P1,17'P'd r'WIrRrN o'.N: $ - AUTOS 0P!"„r,,,;.ronl �I UMBRELLA LIAB [,,[OCCUR EACH OCCURRENCE $ EXCESS LIAR IM-1 I40ADE AGGREGATE $ DFD I U RETENTION$ $ WORKERS COMPENSATION I PER 9. 'OTH- AND EMPLOYERS'LIABILITY YIN ,„, ,,, `;TAT'ITF R FR AW1 PROPRIETOR/PARTNER/EXECUTIVE� E L EACH ACCIDENT OFFICER/MEMBER EXCLUDED? r •- rv� NIA $ (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ Il a,.",,, describe under C'dC"la':Vwlrl'x"PIr;req"vP>I'I";�y��,1'Iallld!i•Irt�i^„,r EL DISEASE-POLICY LIMIT $ Errors&Omissions ”' $1 M/$1 M-Each Claim/Aggregate A PSG02506374 02/15/2018 02/15/2019 DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLE, (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance 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 AUTHORIZED REPRESENTATIVE EI Segundo CA 90245 , + ,y ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 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: U 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. (_)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 EI Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone# %6 1 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 1mu t- immediately comply with th Ions or the agreement will automatically become void. Signature of Applicant Date Print Name Agreement for: 14ry Dated: I- o2- Reviewed by:..A°