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PROOF OF INSURANCE (2018 - 2019) CLOSED Client#: 25181 PSOMAS
ACORDTM CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY)
03/27/2018
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 have ADDITIONAL INSUREDrovistons or
p 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 any rights to the certificate holder in lieu of such endorsement(s).
PRODUCER NAMEACT Katie Kresner
Greyling Ins. Brokerage/EPIC PHONE
'
J FAC
(A1C NoEn770.552.4225 q!c,,No):
866.550.4082
3780 Mansell Road,Suite 370 ��
Alpharetta,GA 30022 n .�.ss: Katie.Kresner gre N'ing.com
WSURERIS)AFF'ORDINGCOVERAG..............
INSURER A::Naalionaal A,,0-rk.h,%Cay. 19445
INSURED INSURER B:
Psomas
555 S. Flower Street INSURER C
Suite 4300 INSURER D:
INS
Los Angeles, CA 90071 INSURER E i
URER F:
COVERAGES CERTIFICATE NUMBER: 18-19 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 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 BEE REDUCED BY PAID CLAIMS.
LICY
FF
LTR �( COMMERCIALOGENERALNIAB ADDLSV GL5268212 POLICY NUMBER 04/01/2Y18 POLICYE7GPI OCCURRENCE LIMIT
TYPE UBft .. MMIDMYYYY
�, E l,l
A M ,i^.. S
CLAIMS-MADE X,OCCUR 0 Y 04/01/2019 EACH�AOCrr $1,000,000
i RPNv11S fLMd11;ID .."
LIABILITY
_ (�Ep o< ,i.or erc,ea), $500,000
YED XP(Any one person) $25,000
PERSONAL&ADV INJURY $1,000,000
00,000
--GN'LAGGRE ,IMITAPPLIES PER GENER..A....L.....A....G.....G.....R....E....G
.ATE $2,000,000
ko
POLICY�PECT X I LOC � PRODUCTS-COMP/oPAGG
$2,000,000
OTHER $
A AUTOMOBILE LIABILITY CA4489706
0410112018 04/0112019,COMBINED f IM""
(La arcidf1,000,000
...,
X ANY AUTO BODILY INJURY(Per person) $
OWNED X SCHEDULED BODILY INJURY Per accident) $
AUTOS ONLY AUTOS _
HIRED NON-OWNED
PROPERTY DAMAGE
AUTOS ONLY Po lde'1t
$
UMBRELLA.
AB OCCUR
R- EACH OCCURRENCE $
EXCESS
XCESLIAR
MADE AGGREGATE $
! A WORKERS coeNSHa noN XEcuTIVE Y I" WC015893764(AOS) 04101/2018 0410112019 e L EACH ACCIDENT ®STH- $
RETENTION $
(Mandatory h BE F.,l.CLUDED'7 ® NIA E L DISEASE- 1,000,000
EA EMPLOYEE $1,000,000
If be under },
DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $1,000,00
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
1AFB010101; Project#PW 18-09-EI Segundo Blvd. Rehabilitation&Improvements Pre-Design Engineering
Support Services.The City, its officials&employees are named as Additional Insureds with respects to
General Liability where required by written contract.The above referenced liability policies with the
exception of workers compensation are primary&non-contributory where required by written contract.Should
any of the above described policies be cancelled by the issuing insurer before the expiration date thereof,
(See Attached Descriptions)
CERTIFICATE HOLDER CANCELLATION
City of EI Segundo Public Works SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Arianne Bola ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street I
EI Segundo,CA 90245-0000 AUTHORIZED REPRESENTATIVE
©1988-2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2016/03) 1 of 2 The ACORD name and logo are registered marks of ACORD
#S1032878/M1032607 KKRE1
DESCRIPTIONS (Continued from Page 1)
30 days'written notice(except 10 days for nonpayment of premium)will be provided to the Certificate
Holder.Waiver of Subrogation is applicable where required by written contract&allowed by law.
SAGITTA 25.3(2016/03) 2 of 2
#S1032878/M1032607
POLICY NUMBER: GL5268212 COMMERCIAL GENERAL LIABILITY
CG 20 37 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) Location And Description Of Completed Operations'
Or Organizationisl
AW'WERWN 00114ORGAN'I ZATIOI UHO-XOU PER THE CONTRACT OR AGREEMENT
OR B TEDY,TO''0'IWCi UCW,l,AS 4
LTBq.O RSO O ''l X'iRIESULT,:OF
. Off PIOREIENE n'YOU
EVENTEEE ,41 KTO
T.p,lar,°,'•h'^I,Fh Sw�Y'noY�H(„"P�,,i^"N,•,.,;r,; . :,7,•,''i".. ry.ti'^ti:!'iv,. .%:dw i";
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 which you are required by the contract or
include as an additional insured the person(s) or agreement to provide for such additional
organizationfs) shown in the Schedule, but only insured.
with respect to liability for "bodily injury" or B. With respect to the insurance afforded to these
"property damage" caused, in whole or in part, additional insureds, the following is added to
by "your work" at the location designated and Section III - Limits Of Insurance:
described in the Schedule of this endorsement If coverage provided to the additional insured is
performed for that additional insured and required by a contract or agreement, the most
included in the "products-completed operations we will pay on behalf of the additional insured
hazard". is the amount of insurance:
However: 1. Required by the contract or agreement; or
1. The insurance afforded to such additional 2. Available under the applicable Limits of Insu-
insured only applies to the extent permitted rance shown in the Declarations;
by law; and
whichever is less.
2. If coverage provided to the additional
insured is required by a contract or agree- This endorsement shall not increase the appli-
ment, the insurance afforded to such addi- cable Limits of Insurance shown in the Decla-
tional insured will not be broader than that rations.
CG 20 37 04 13 ff Insurance Services Office, Inc., 2012 Page 1 of 1 0
POLICY NUMBER:GL5268212 COMMERCIAL GENERAL LIABILITY
CG 20 10 04 13
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 Oi...._.-•. __...__._..._..... .........._..............._..._. . ......._......._..._
Additional Insured Personis)
Operations
Or Organization(s) tl „ . _. Locationls)Of Covered
ANY PERSON OR ORGANIZATION WHOM YOU PER THE CONTRACT OR AGREEMENT,
BECOME OBLIGATED TO INCLUDE AS AN
ADDITIONAL INSURED AS A RESULT OF ANY
CONTRACT OR AGREEMENT YOU HAVE
ENTERED INTO.
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 that which you are required by the contract
include as an additional insured the personis) or or agreement to provide for such additional
organization(s) shown in the Schedule, but only insured.
with respect to liability for "bodily injury", B. With respect to the insurance afforded to these
"property damage" or "personal and advertising additional insureds, the following additional
injury" caused, in whole or in part, by: exclusions apply:
1. Your acts or omissions; or This insurance does not apply to "bodily injury"
2. The acts or omissions of those acting on or "property damage" occurring after:
your behalf; 1. All' work, including materials, parts or
in the performance of your ongoing operations equipment furnished in connection with such
for the additional insured(s) at the location(s) work, on the project (other than service,
designated above. maintenance or repairs) to be performed by
or on behalf of the additional insured(s) at
However: the location of the covered operations has
1. The insurance afforded to such additional been completed; or
insured only applies to the extent permitted 2. That portion of "your work" out of which
by law; and the injury or damage arises has been put to
2. If coverage provided to the additional its intended use by any person or
insured is required by a contract or organization other than another contractor or
agreement, the insurance afforded to such subcontractor engaged in performing
additional insured will not be broader than operations for a principal as a part of the
same project.
CG 20 10 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 2 ❑
BLANKET WAIVER OF DLR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different
date is indicated below.
(The following"attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy).
This endorsement, effective 12:01 AM 4/1/2017 forms a part of Policy No. IWC015893765
Issued to PSOMAS
By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA.
We have a right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce
our right against any person or organization with whom you have a written contract that requires you to obtain this
agreement from us, as regards any work you perform for such person or organization.
The additional premium for this endorsement shall be 2.00 % of the total estimated workers compensation premium
for this policy.
WC 04 03 61 Countersigned by..
(Ed, 11190)
Authorized Representative
CCERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
I 1/24/2018
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 c'ortificato 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 endorse'm'ent(s).
PRODUCER CONTACT
lolb'
n Lee
Deale Renton&Associates PHONE � 1t ( -427-68180039 EM nr1 [(Arc t�f:714
P.O. 0X -Pf
(r(rgapll.a:Drr1
Santa Ana CA 92711-0550
„INSURERj3)AFFORDING COVERAGENAIL#
.
INSURER A:XL Specialty Insurance Co. 37885
INSURED PSOMAS INSURER P:
PSOMAS
555 South Flower Street, Suite 4300 !NsuRER c: „
INSURER Dt
INSURER E:
OSAngeles iii IN
SURER F:
COVERAGES CERTIFICATE NUMBER: 11620682001 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 BYPAIDCLAIMS_
IL TR — TYPE OF INSURANCE )N$'D W Vn POLICY NUMBER AMM POLICY
EFf II((d'M DDY"Y't LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s
CLAIMS-MADE 6I OCCUR
mm PFfMId SESft",,saLrcwllrence) $
MED EXP(Any one person) $
PERSONAL&ADV INJURY $
GEN'L AG'GREGA"I'ELIMIT APPLIES PER. GENERAL AGGREGATE $
l .,..... RO
CLk O
LOC _ PRODUCTS-COMP/OP AGG ,
$
. $
....................
AUTOMOBILE LIABILITY WNED SINGLE Lft r
ANY AUTO BODILY INJURY(Per person) s
ALL OWNED ""-"' SCHEDULED
AUTOS AUTOS BODILY INJURY(Per accident)
$
NON-OWNED PrdrlPf',rk1'4"Y"74o Ad:ar -,. ..
HIREDAUTOS AUTOS fl"+arrec,;lrpih;ll $
UMBRELLA LIAB
SS LIAR
DOCCUR
EXCEMS-MADE AGGREGATERRENCE $
ry
FD WC RETENTION$
WORKERS COMPENSATION PER OIH-
AND
I.STATUTE. I,,,,--,,,,1FR
ANY PRtOoP01n O IP RBTNERIEXECUTIVE N/A E,LEACH ACCIDENT $
YIN
(Ma
OFFICERIMEMBER EXCLUDED?
yy
If es,describe
scrON under OPERATIONS below ,EDISEASE-EA EMPLOYEE $
D L DISEASE-POLICY LIMIT $
A Pn9axcionalLiability DPR9917719 10/15/2017 10/15/2018 Per Claim $1,000,000
CWrnL Made Annual Aggregate $1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space Is required)
1AFB010101.Project#PW 18-09,EI Segundo Blvd.Rehabilitation And Improvements Pre-Design Engineering Support Services.SEE CANCELLATION
SECTION of Certificate for 30 Days Notice of Cancellation.
CERTIFICATE HOLDER CANCELLATION 30 Day Notice of Cailcollalion
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.
Public Works
Attn:Arianne Bola
350 Main Street AU HDRIZED REPRESENTATIVE
EI Segundo CA 90245 �e
I �d01
©1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD