PROOF OF INSURANCE (2019) CLOSED ACC>Re' DATA(MM120`1 YY)
CERTIFICATE OF LIABILITY INSURANCE 08/1412018
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.
I IMPORTANT: If the certificate holder Is an ADDITIONAL 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
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this ceftlficab dose not confer rights to the certificate holder In lieu of such endorsement(a).
PRODUCER P&.11ROSe''Smlth
Jacobs-Weber,Inc.
P.O.Box 87 3,81-648-4209 " 381-2'93 3074
, 1a,.Not:
Yoakum,TX 77995 ADORE s: rsmith llacobs-weber.com
INS'URERIJ)AFFORDING COVERAGE MAIC N
INSURER A: Arch Insurance Company 11150
INJURED � _..., „.. .... „., .,.,.
Firs Service Specification and Supply dbe FS3 `
Frank Lane INSURER C
18582 Bea'chmont Avenue I INSURER D:
Santa Ana,California 92705 1::$U:FR;;
SUER ;
COVERAGE'S CERTIFICATE NUMBER: REVISION NU'MBE'R:
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.
IN ADOL _ ._.._.�.... .�.....
POLICY EP'F POLICY
TYPE OF INSURANCE eel Ode POLICX NUMBER /'�N2203M N_.1 LIMITS
A COMMERCIAL GENERALLIABIUTY Y Y MFPK08563002 05/23/2018 05/23/2019 EACH OCCURRENCE $ 11000,000
CLAIMS-MADE 12OCCUR UAMAGEAORENNED = 100,000
MED!REXP one person) Is 5,000
PERSONAL&ADV INJURYI$ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE lis 2,000,000
POLICY [:]JECT F7 LOC PRODUCTS.COMPMP AGG s 2.000,000
' OTHER; s
A AuroMoelLE unelurY Y Y MFPK08583002 05/23/2018 L
0$/23/2019DILY INJURY(Par Person) s 1,000,000
Ik'UINL�'SNNd'�LE LIMO
o�radents �
ANY AUTO BO s
OWNED SCHEDULED I BODILY INJURY(Per soddeM) s
AUTOS ONLY AUTOS
HIRED NON-OWNED P'RCPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY (Per NN
. II Is
EXCESS LJAB E7CLAIMSMADE I Y V I'AGGREGATE OCCURRENCE I S
UMBRELLA LIAROCCUR VI
... AGGREGATE s
WO JMP EMPLOYERS'N COMPENSATION S O pp s
I`
WORKERS EMPLOY RS'LAA n T YIN
.I STATUTE � O�
PLOYERJ'LU1BIUTY I$
OFFICERIWNEMSE XCLUDED ANY ECUTNVE ❑ NIA E.L.EACH ACCIDENT
(Mendm"In NH) I E.L.DISEASE-EA EMPLOYEE I s
II IaCRIP f0 NOF OOPERATIONS bW*wr I El,DISEASE-POLICY LIMIT 1$
1
DEACWPTN)N OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Addltlonel Remerke SeMdule,may be etteehed If mon spew le nqulnd)
The certificate holder is listed as an additional Insured.Coverage Is primary and non-contributory under the endorsement CG2001. A notice of cancellation is
Included per form ML0086.
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,Its offloers,officials,employees, ACCORDANCE WITH THE POLICY PROVISIONS.
agents and volunteers
350 Main Street AUTHORIZED REPRESENTATIVE
EI Segundo,TX 902453813 i
I � I
+1988.2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo aro registered marks of ACORD
POLICY NUMBER:MFPK08583002 COMMERCIAL GENERAL LIABILITY
CO 2010 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL, INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON O
ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Pemon(s)
Or Organization(s) Location(s)Of Covered Operations
City of EI Segundo IAII Contracted Locations
Its officers,officials,employees,agents and volunteers
350 Main Street
EI Segundo,CA 90245
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 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:
dwith amage" to��li liability "bodily vjury", Of
fpr pmThis insurance does not apply to "bodily injury" or
g p 9 injury" 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
However. 2. That portion of "your work" out of which the
1. The insurance afforded to such additional injury or damage arises has been put to its
insured insurance
applies to the extent permitted b intended use by any person or organization
ry pp p y other than another contractor or subcontractor
law;and engaged in performing operations for a
2. If coverage provided to the additional insured is principal as a part of the same project.
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.
CG 2010 0413 0 Insurance Services Office, Inc.,2012 Page 1 of 2
C. With respect to the insurance afforded to these 2. Available under the applicable Limits of
additional insureds, the following Is added to Insurance shown in the Declarations;
Section III—Limits Of Insurance: whichever is less.
If coverage provided to the additional insured is This endorsement shall not increase the
required by a contract or agreement, the most we applicable Limits of Insurance shown In the
will pay on behalf of the additional insured is the Declarations.
amount of insurance:
1. Required by the contract or agreement; or
p
Page 2 of 2 0 Insurance Services Office, Inc.,2012 CG 2010 0413
POLICY NUMBER:MFPK08563002 COMMERCIAL GENERAL LIABILITY
CO 20 0104 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY AND ILIO C NTRIBUTORY -
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
This insurance is primary to and will not seek additional insured.
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 0104 13 0 Insurance Services Office, Inc.,2012 Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
NOTICE OF CANCELLATION-CERTIFICATE HOLDERS
The person(s) or organization(s) listed or described in the Schedule below have requested that they
receive written notice of cancellation when this policy is cancelled by us. We will endeavor to mail or
deliver to the Person(s) or Organization(s) listed or described in the Schedule a copy of the written notice
of cancellation that we sent to you. Such copies of the notice will be mailed as soon as practicable to the
address or addresses provided by your broker or agent.
This notification of cancellation of the policy is intended as a courtesy only. Our failure to provide such
notification to the person(s) or organization(s) shown in the Schedule will not extend any policy
cancellation date or impact or negate any cancellation of the policy. This endorsement does not entitle
the person(s) or organization(s) listed or described in the Schedule below to any benefit, rights or
protection under this policy.
Any provision of this endorsement that Is in conflict with a statute or rule is hereby amended to conform to
that statute or rule.
Schedule
Person(s)or Organization(s) including mailing address:
City of El Segundo
350 Main Street
EI Segundo, CA 90245
All other terms and conditions of this policy remain unchanged.
Endorsement Number.
Policy Number:MFPK08563002
Named Insured:Fire Service Specifications&Supply
This endorsement is effective on the inception date of this Policy unless otherwise stated herein:
Endorsement Effective Date: May 23,2018
00 ML0086 00 11 10 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 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#
( 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
immediately comply with the rovasions the agre nt will automatically become void.
Signature of Applicant �'• Date ��
Agreement for:4,1 { .� ° ji Y f
Dated:
Reviewed by: � � ! '
1