PROOF OF INSURANCE (2018) CLOSED CERTIFICATE OF LIABILITY DATE(MMIDDIYYYY)
6/2212018
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: lithe certificate holder Is an ADDITIONAL INSURED,the polic
th sUBRROGaATeIO is not WAIVED,
Dr subject
is to the theterms
and
holder In Sea of such must have ADDITIONAL INSURED en o rlvl ant. A be statement
on
les
policy,of the certain policies may require an endorsement. A statement on
g endorsement(s),
PRODUCER NAME: FAX
130
0 j'o Insurance
9250
6 6s PHONE rr,t x,a), 840.297 5962 (Arc„neo), 949-297-5960
r MAIL
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INSU0%8)AFFORDING COVERAGE NAIC k
www.loausa.com CA License#OE67768 INSURER A: Travelers Property Casualty Company of America 25674
INSURED ECompany 13056
Lund and Associates Engineering, Inc.
23138 Galva Avenue lNsURR c
R B Insurance .... ... .. .
Torrance CA 90505 INSURER D:
INSURER r-:
.., INSURER F
COVERAGES CERTIFICATE NUMBER: 42696280 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 'AID CLAIMS.
INS. POLICY EFF POLICY E-XI,
8URANCE f L�lawletit POLICY 47 BER r10/1D/2017 1 10/1/2FI
LAR TYPEOFIN
w ✓ ✓ EACH OCCURRENCE $2,000,000
LIMITS
CLAIMS-MADE ( ✓ OCCUR ''Scheduled Al ndt DAMAO OAw ITIEh near) $1,00
LIABILITY
0,000
u COMMERCIALGENERAL
Professional Services MED EXP(Any one person) $10,000
Waiver Of ubrog a lOUwc�ry performed by the Insured IPERSONAL 8 ADV INJURY $ 6)00,000
GEN
't,l. sa 1 G, AE LIMIT APPLIES PER: are Excluded GENERAL AGGREGATE TE $4,000,000 4 000,000
PRO-
POLICY IP JECT ❑✓ LOC PRODUCTS COMP OP AGG $4Q00000
O cri�Desifinated
Proluct„,899_ „ ,_I
$
A
AUTOMOBILE UTOBODILYINJURY
BAIABaIrY 6806H7591181747 10/112017 10/1/2018 a �(Perperaon) Included in GL
OWNED SCHEDULED
CHEDULED BODI
AUTOS ONLY ALY INJURY(Per accident) $
PRR71 GgTY r714M1# I
HIRED NON-OWNED✓, $AUTOS ONLY ✓(AUTOS ONLY (Par rrrislaraaj
$
UMBRELLA LIAS OCCUR EACHOCGUNRENCE $
EXCESS LIAR „CLAIMS-MADE AGGREGATE $
DED RETENTION$
AND EMPLOYRKERS ERSEL ABILITY YIN NSATION STA UTE .. ERH
ANYPROPRIETOR/PARTNER/EXECUTIVE
(MandaN/A E.L.EACH ACCIDENT
$
OFFICER/MEMBER
tory In NHE.L.DISEASE-EA EMPLOYEE $
Ed0sc4bo under
DSCRIaION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT
$
B 1,Professional Liability RDP0030397 10/1/2017 10/1/2018 $1,000,000 Each Claim
Claims-Made $2,000,000 Aggregate
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If mora space Is required)
Certificate Holder is an Additional Insured With respect to General Liability(CSL),but only as required by wriltera contract,sk ned by 010 Insurer/
prior to an occurrence as per Endorsement noted above. GL Includes Soparaati'on of Insureds and Conlractual Liability perliniflatlons In the Liability
Coverage form, Coverage is subject to ali policy terms,conditions,limitations and exclusions.30 Day Notice of Cancellation/10 Days for
Nora-Payment In accordance with policy provisions.
CERTIFICATE HOLDER CANCELLATION
PW 18-20:California Street Storm Design
City OF EI Segundo ld0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Cl Main SegoTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
EI Segundo Street 90245 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
(AVC)Alicia K.(gram lip
988-2015 C CORPORATION. All rights reserved.
ACORD 25( ) The ACORD namelogo are registered mark$of ACORD
42696280 110/17-10 GL/PL I Pam Prieto 16/22/2010 4:55:50 AM (PDT) Page 1 of 3
Lund and Associates Engineering, Inc.
COMMERCIAL GENERAL LIABILITY
POLICY NUMBER: 68061-17591181747 ISSUE DATE: 6/22/2018
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
SCHEDULED L INSURED
(ARCH C SURVEYORS)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
NAME OF PERSONS OR ORGANIZATIONS:
City of EI Segundo
PROJECT/LOCATION OF COVERED OPERATIONS: ,
PW 18-20: California Street Storm Design
PROVISIONS
1. The following is added to SECTION II —WHO IS e. This insurance does not apply to the
AN INSURED: rendering of or failure to render any
The person or organization shown in the "professional services".
Schedule above is an additional insured on this If. In the event that the Limits of Insurance of the
Coverage Part, but: Coverage Part shown in the Declarations
exceed the limits of liability required by the
a. Only with respect to liability for"bodily injury", "written contract requiring insurance", the
"property damage" or"personal injury"; and insurance provided to the additional insured
b. If, and only to the extent that, the injury or shall be limited to the limits of liability required
damage is caused by acts or omissions of by that "written contract requiring insurance".
you or your subcontractor in the performance This endorsement does not increase the
of "your work" to which the "written contract limits of insurance described in Section III —
requiring insurance" applies, or in connection Limits Of Insurance.
with premises owned by or rented to you. g. This insurance does not apply to "bodily
The person or organization does not qualify as an injury" or"property damage" caused by "your
additional insured. work" and included in the "products-
completed operations hazard" unless the
c. With respect to the independent acts or "written contract requiring insurance"
omissions of such person or organization; or specifically requires you to provide such
d. For "bodily injury", "property damage" or coverage for that additional insured, and then
"personal injury" for which such person or the insurance provided to that additional
organization has assumed liability in a insured applies only to such "bodily injury" or
,property damage that occurs before the end
contract or agreement. of the period of time for which the "written
The insurance provided to such additional insured contract requiring insurance" requires you to
is limited as follows: provide such coverage or the end of the
policy period,whichever is earlier.
CG D3 82 091 S ®2015 The Travelers Indemnity Company. All rights reserved. Page 1 of 2
Includes the copyrighted material of Insurance Services Office,Inc.,with its permission
42696280 10/17-18 GL/PL I Pam Prieto 1 6/22/2018 9:55:50 AM (PDT) I Page 2 of 3
COMMERCIAL GENERAL LIABILITY
2. The following is added to Paragraph 4.a. of 3. The following is added to Paragraph 8., Transfer
SECTION IV — COMMERCIAL GENERAL Of Rights Of Recovery Against Others To Us,
LIABILITY CONDITIONS: of SECTION IV — COMMERCIAL GENERAL
The insurance provided to the additional insured LIABILITY CONDITIONS:
shown in the Schedule above is excess over any We waive any right of recovery we may have
valid and collectible other insurance, whether against the additional insured shown in the
primary, excess, contingent or on any other basis, Schedule above because of payments we make
that is available to the additional insured for a loss for"bodily injury", "property damage" or"personal
we cover. However, if you specifically agree in the injury" arising out of "your work" on or for the
"written contract requiring insurance" that this above,, or at the pert performed by you, shown in the Schedule
or on your behalf, done
insurance provided to the additional insured under a "written contract requiring insurance" with
under this Coverage Part must apply on a primary that person or organization. We waive this right
basis or a primary and non-contributory basis, this only where you have agreed to do so as part of
insurance is primary to other insurance available the "written contract requiring insurance" with
to the additional insured which covers that person such person or organization signed by you
or organization as a named insured for such loss, before, and in effect when, the "bodily injury" or
and we will not share with the other insurance, "property damage" occurs, or the"personal injury'
provided that: offense is committed.
(1) The "bodily injury" or "property damage" for 4. The following definition is added to the
which coverage is sought occurs; and DEFINITIONS Section:
(2) The "personal injury" for which coverage is "Written contract requiring insurance" means that
sought arises out of an offense committed; part of any written contract with the person or
after you have signed that "written contract organizations shown in the Schedule above,under which you are required to include that
requiring insurance". But this insurance provided
to the additional insured still is excess over valid Person or organization as an additional insured
on this Coverage Part, provided that the "bodily
and collectible other insurance, whether
primary, injuryand property damage occurs and the
excess, contingent or on any other basis, that is "personal injury" is caused by an offense
available to the additional insured when that committed:
person or organization is an additional insured a. After you have signed that written contract;
under any other insurance. b. While that part of the written contract is in
effect; and
c. Before the end of the policy period.
Page 2 of 2 ®2015 The Travelers Indemnity Company.All rights reserved. CG D3 82 09 15
Includes the copyrighted material of Insurance Services Office, Inc.,with its permission
47.696280 19/17-18 GL/PL I Pam Prieto 1 6/27/20:1.8 9:55e50 AM (PDT) I 'Page 3 of 3
CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGEAND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS II
IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES
($100,000),
IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN LABOR CODE § ' INTEREST,
AND ATTORNEY'S FEES.
I affirm under penalty of perjury under the laws of California one of the following declarations:
(_J 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#
(,ZJ 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 those provisions or the agreement ill automatically become void. 7h
Signature of Applicant Date -7-/-7- I g
Agreement r: LWA 4 k :, ct '� ° ' i" r 1 i _
Dated: ` 6
Reviewed by: .
717
�_
1