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PROOF OF INSURANCE (2019 - 2019) CLOSED CERTIFICATE OF LIABILITY DATE(MMIDDIYYYY) INSURANCE 07/24/2018 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 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 not confer rights to the certificate holder in lieu of such endorsoment(s). PRODUCER C ON T ACT Kathy Macias-Ramirez Millennium Corporate Solutions P ( (818 638-7920 p kathlm)8mcs nsOcom......... ............................ PHONE FAX AIG" No,I°xtN: AdC,NAk. ) An ISU Network Member#01_12555 .m1 0. ADDRESS: Y @ _ ............w. 550 N Brand Blvd#1100 INSURER(S)AFFORDING COVERAGE NAIC# Glendale CA 91203 INSURER A: Mt Hawley Insurance Co 37974 INSURED INSURER B: Ohio Security Ins Company 24082 INSURER C: RSUI Indemnity Company 22314 ...... Trueline � INSURER D: Everest National Ins Co 10120 1651 Market St Ste B INSURER E Corona CA 92880-1710 INSURER F COVERAGES CERTIFICATE NUMBER: 2018-2019 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, •IRSWI .. 'A"DTI"V.5G�i�W ' POLICY EFF POLICY-ExP ._.. LTR TYPE OF INSURANCE LIMITS X COMMERCIAL GENERAL LIABILITY OCCUR ���EACH OCCURRENCE $ 1,000,000 �� (NSD WVD (MMIDDIYYYY) (MMIDDIYYYY) �. R -_...�.. ...WW.., CLAIMS- ADE PREMISES(Ea occurrence) $ 50,000 X $2,500 Ded-Per Occ MED EXP Any person)erson) $ 5,000 ...... A Y MGLO188847 07/25/2018 07/25/2019 PERSONAL a ADV INJURY $ 1,000,000 GEWL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POIL cy 0 PE F LOC PRODUCTS-COMP/OP AGG $ 2.000,000 OTHER: Employee Benefits $ 1,000,000 AUTOMOBILE LIABILITY CC.MQiBIC,*dEO�;SNrtJGLt:i NIR��tIT $ 1,000,000 ...._.., jXX _BO_"pira;.lt9tf�0 aANY AUTO DILY INJURY(Per person) $ BOWNED SCHEDULED BAS(19)56945605 07/25/2018 07/25/2019 BODILY INJURY(Per accident)AUTOS ONLY AUTOSHIRED X NON-OWNED AUTOS ONLY AUTOS ONLY f�du�sr fir=aplAtluRALE $ i COMP-$1K X COLL-$1K $ X UMBRELLA LIAB X�OCCUR EACH OCCURRENCE $ 4,000,000 CLAIMS-MADE EXCESS LIAB NHA245421 07/25/2018 07/25/2019 AGGREGATE $ 4,000,000 DED a XQ RETENTION$ -0- WORKERS COMPENSATION %A SPEk ERH AND EMPLOYERS'LIABILITY Y/N TATUTE D ANY PROPRIETOR/PARTNER/EXECUTIVE � E.L.EACH ACCIDENT $ 1,000,000 OF'FICEWMEMSFREXCLUDED? NIA 7600016618172 07/25/2018 07/25/2019 - ..... IMandatory In NH) E L,DISEASE- EA EMPLOYEE $ 1,000,000 Vg describe under -- GFI S(RI'P'l ON OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 .... - ----- ---- ---- -------- .. .... ............ ... .���.. ,......... ----- ..., I�.._ ..... ..,.._,..... DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES ACORD 101,Additional Re M ••••••••••••• ••••'�� ( marks Schedule,may be attached if more space is required) Re:350 Main Street.The City of EI Segundo,its officers,officials,employees,agents,and volunteers are included as additional insureds with for General Liability as respects to the insureds operations and only if required by written contract per the attached endorsement. Waiver of subrogation applies to the Workers Compensation. Should any of the above described policies be cancelled before the expiration date thereof,notice will be delivered in accordance with the policy provisions. 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 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Policy Number: MGL0188847 Mt Hawley Insurance Company II°IIIIIS 1ENDORSEMElY I"'Cl°IIIAINGES THE(POLICY,,, PI1 EASE IkEAD II"'T CAIIRPFLIULY. INSUREDADDITIONAL 1„,w,,,,,, OWNIERS, Illi,,,,,,,ESSIEES GIR ° F (III° SCI„„,I III,)Ul',,,,,,,EDI' 111' E IRSI�� N This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCl°IIII!!.:.D III,,,,,lE ..,.,..._.......... ..INa.me..Of Additional Insured ..,.,,�., .. . �,.....�...._.. ..�.._,. ... .._........... .................W.. .n�...ured Pemoin(s) Ororganization(s): II,,,.ocatlon(s) f Cover Olperatloins: All persons or organizations where required by written contract. 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 in- not be broader than that which you are required clude as an additional insured the person(s)or organi- by the contract or agreement to provide for such zation(s)shown in the Schedule, but only with respect additional insured. to liability for "bodily injury”, "property damage” or "personal and advertising injury" caused, in whole or B. With respect to the insurance afforded to these in part, by: additional insureds, the following additional exclusions apply: 1. Your acts or omissions; or This Insurance does not apply to "bodily injury" or 2. The acts or omissions of those acting on your "property damage"occurring after: behalf, 1. All work, including materials, parts or equipment in the performance of your ongoing operations for the fumished in connection with such work, on the additional, Insured(s) at the location(s) designated project (other than service, maintenance or, re- above. pairs)to be performed by or on behalf of the addi- tional insured(s) at the location of the covered However: operations has been completed; or 1. The insurance afforded to such additional insured 2. That portion of"your work"out of which the injury only applies to the extent permitted by law; and or damage arises has been put to its intended use by any person or organ¢ation other than another 2. If coverage provided to the additional insured is contractor or subcontractor engaged in performing required by a contract or agreement, the in- operations for a principal as a part of the some surance afforded to such additional Insured will project. CG 2010 04 13 ®Insurance Services Office, Inc.,2012 Page 1 of 1 Insured Policy Number MGLO188847 Mt Hawley Insurance Company 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 or Organkraftn(s) Completed Operations All persons or organizations where required by written oon#W. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. Section 11 — 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 is added to Section organization(s) shown in the Schedule, but only with III—Limits Of Insurance: respect to liability for"bodily injury' or"prop" dam- age"caused, in whole or in part, by"your worts"at the If coverage provided to the additional Insured is re- location designated and described in the Schedule of quired by a contract or agreement, the most we will this endorsement performed for that additional insured pay on behalf of the additional insured is the amount and included in the "products-completed operations of insurance: hazard". However. 1. Required by the contract or agreement;or 2. Available under the applicable Limits of Insurance 1. The insurance afforded to such additional insured shown in the Declarations;' only applies to the extent permitted by law, and whichever is less. 2. If coverage provided to the additional Insured is required by a contract or agreement the insur- This endorsement shall not increase the applicable ance afforded to such additional insured will not Limits of Insurance shown In the Declarations. not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 37 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 1 Insured 4 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - A 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 only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2%of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOM THE BLANKET WAIVER OF SUBROGATION NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER 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: 07/25/2018 Policy No. 7600016618172 Endorsement No. 001 Insured: Trueline Construction& Surfacing,Inc. Premium$INCL. Insurance Company: Everest National Insurance Company Countersigned By: -1998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved. From the WCIRB's California Workers'Compensation Insurance Forms Manual-1999.