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PROOF OF INSURANCE (2019 - 2019) CLOSED
ALPIN'-2 OP ID:BF ACC�RE]" CERTIFICATE OF LIABILITY INSURANCE I D 0611 201 YYj D6114112016 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 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). North 907 Insurance NAMN,�'.., ....760 1 e) 760-745-9157. PRODUCER MJtilno.T#fl° rt... SS.bfarlt s45no5rthcOUrlt i165U'�tr1CL'. t71TU Escondido, Cy92033 0907 P.G?4�.F.i.-,Y_...' Rosalie Delaney ..................._..___. ........,..... _ _.......... __...INSURER A.:U.S•..Specialty..Ins.Co:._. _.-.,_..... _..-....,....,..,29599 ,......._.' INSURED Alpino Building INSURER 8: 14422 Pau maVista Drive iNSuaERc, Valley Center,CA 92082 _.... ... _._ _., _ INSURER�D..i...._.....,..........,.,..,,.,..........__. ..__._-.........._,w.,,.,,.....,.......-......,,,w......_.............__. INSURER E; y 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 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. p gr9SR'' AdDI iiaT&,...IT.. .. . . w. .,..,., POLICY EFF B04 ,. OR� TYPE OF INSURANCE jI I=_%na POLICY NUMBER 9PMWDO1YY'YYI) LAM1Lf )C MWYYYY1 LIMITS A I X.1 coMCLAIMS•MAOEGENERAL X�OCCUR 1 X X UIBAC105750.00 06/08/2018 06/08/2019v�nAnses ) s 1 100,000 J .,.... , . . ,.. M9eD EXP gArry one person) ..�.5 5,000. k .. ...., ....,„ ,. PERSONAL&ADV INJURY000,000.45.... „ .�!.... I GENJJ'LAi AGGREGATE E LIMIT AI1P6C?wPER: GENERAL AGGR_E._G_»ATE . .. 2,UDO.,_O.O. 0 PRO, LOC PRODUCTS c PfdP G� 5 000,000� CYJcw I 0114ER: Is .... C(EO;�a«AaEc..,B;Tnd Dru k)SIJG.L. LN.ITAUTOMOBILE LIABILITY �$ ............., .,........,.,,.......... ANY AUTO BODILY INJURY(Per person) ��5 - ALLOWNED SCHEDULED BODILY INJURY(Per aceidenl) S AUTOS AUTOS _ _ ........_,u_,._..W...._,_.._., _. AUTOS LPA! cCamirc s HIRED AUTOS ....._ NON-OWNED i r�ax9��wmrd��,�rs�:�A�E� .� _.__.,,._...,...._..,_......_„_... I is UMBRELLA LIAB X l ! „ OCCURRENCE Is A EXCESSLIAS ''CCAIMSMADE UIBAC105750-00 06/08/2018 06/0812019 AGGREGATE s 1,000,000 ^ N DED I RETENTION S WORKERS COMPENSATION STA UTE ANY PROPRIETOR/PARTNERIEXECUTNE �tl 9 EACH ACCIDENT I ER _.Im^___......,___............._.” OFF CERIME I ER EXCLUDED? N 1 A „E.L.E E H ACCIDENT 5...._..,..._ ..,....._.,.... (Mand tory In NH) E.L.DISEASE-EA EMPLOYEE DIf ESCRY ON OF OPERATIONS below HL DISEASE-POLICY LIMIT Idescribe under _s. 11111111e11.,_..._,.. k DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES(ACORD i09,Additional Remarks Schedule,may be attached if more space is required) 5t__ CERTIFICATE HOLDER CANCELLATION CITYELS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of EI Segundo, Its THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, officers,officials,employees agents and volunteers AUTHORIZED REPRESENTATIVE 350 Main Street El Segundo,CA 90245 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: U18AC105750-00 COMMERCIAL GENERAL LIABILITY CG 2010 07 04 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 Of Additional Insured Person(s) Or Organization(s): Location(s)Of Covered Operations Any person or organization for whom you are performing operations during the policy period when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. 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: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage" or "personal and advertising injury" "properly damage"occurring after.- caused,in whole or in part,by: 1. Your acts or omissions; or 1. All work, including materials, parts 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. CG 20 10 07 04 0 ISO Properties, Inc.,2004 Page 1 of 1 ❑ POLICY NUMBER: U18AC105750-00 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 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 ,+ SCHEDULE Name Of Additional Insured Person(s) Location And Description Of Completed Or Organization(s): Operations Any person or organization,when you and such parties have agreed in writing in a contract or agreement pertaining to"your work"performed during the policy period.This additional insured coverage does not apply to"excluded residential construction". "Excluded residential construction"means: a) the ground-up construction of any building whose units will be individually owned and titled; and, b) "your work"performed on the conversion of any building Into a condominium or townhome. 1 Information required to complete this Schedule, if not shown above,will be shown in the Declarations. Section 11 — 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 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". CG 20 37 07 04 ©ISO Properties, Inc.,2004 Page 1 of 1 13 POLICY NUMBER: U18AC105750-00 COMMERCIAL GENERAL LIABILITY HCS 040 06 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY AND BLANKET WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. PRIMARY AND NON-CONTRIBUTORY TO B. WAIVER OF SUBGROGRATION—BLANKET OTHER INSURANCE Under SECTION IV — COMMERCIAL GENERAL With respect to any person or organization that is LIABILITY CONDITIONS, The Transfer Of an additional insured under this Coverage Part, Rights Of Recovery Against Others To Us the following is added to paragraph 4, of Condition is amended by the addition of the SECTION IV — COMMERCIAL GENERAL following; LIABILITY CONDITIONS: We waive any right of recovery we may have If you have agreed in writing in a contract or against any person or organization because of agreement that this insurance is primary and non- payments we make for injury or damage arising contributory relative to an additional insured's own out of. insurance, then this insurance is primary and we a. Your ongoing operations; or will not seek contribution from that other insurance. For the purpose of this endorsement, b. "Your work" included in the "products- the additional insured's own insurance means completed operations hazard". insurance on which the additional insured is a However, this waiver applies only when you have Named Insured. agreed in writing to waive such rights of recovery When this endorsement is attached to the policy it in a contract or agreement, and only if the contract supersedes all other insurance conditions within. or agreement: a. Is in effect or becomes effective during the term of this policy;and b. Was executed prior to loss. HCS 040 06 10 13 Page 1 of 1 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 611412018 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 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 endorsement($). PRODUCER CONTACT Jennifer Rhodes Auto Insurance Specialists PHONE 800-498-3293 17785 Center Court Drive EWAIL cotylrnercial@aisinsurance.com INSGaRER s A m Suite 500 ��6Et9RDINOCOVE"R...E INSURER A:California Automobile Insurance CompanymW�-„ -.....„ Cerritos CA 90703 __..._�.. 3B342 INSVREO .. „ INSURER B: ............_._.„._. .......m_...,..-._,.........._p,_.wm.....,_......_ Intent Alpino INSURERC: DBA Alpino Building INSURER p; INS._ .W_J........„...., ,,...„._..„...__... ._._,_....-...............___ 4422 Palma Vista r URER E Valley Center CA 92082 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIEq DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES-LIMITS SHOWN MAY HAVE BEEN REDUCED BY 'AID CLAIMS. _,..'-..nf S S_.,.,..,..._,,,,,,,,,,,,,, IFSR PEFF PIA0IAYE LTR TYPE OF INSURANCE S POLICY NUMBER fMMIDDrY IMY1 LIMRSCOMMERCIALGENERALWABILITY _0RGE"(G” " _,..__,..-.._. .- ..... EACH OCCURRENCE CLAIMS-MADE FIOCCUR ..PREMISES IEs*Zuvrmr,.o! MED EXP(Anyone person) S PERSONAL&ADV INJURY S ENEREGATE GENT AGGREGATE LIMIT APPLIES PER: GRAL AGG _ � OTI ILI'i: ECT R LOCPOLICY 0 .,PRO,D,U,C,T5-COMPIOP AGG5......._ .. ... m _ .„ A AUTOMOBILE LIABILITY BA040000046197 06/14/2018 '0 611 4/2 01 9 CO&WINEDSINGLE L'IM11 S 1,000,000 _.IF c ent �~ANY AUTO I BODILY INJURY(Per person) S OWNED SCHEDULED �BODILY INJURY(Par accident) S AUTOS ONLY AUTOS 7 HIRED NON-OWNEp F'ROPEkfTYOA9�IAGE S AUTOS ONLY AUTOS ONLY 5 UMBRELLA LIABOCCUR EACH OCCURRENCE 5 EXCESS LIAR HCLAIMS-MADE AGGREGATE 5 DED [—I RETENTIONS WORKERS COMPENSATION S ATU7E ER „„„ AND EMPLOYERS'LIABILITY Y 1 N """""T ANYPROPRIETORfPARTNER/EXECUTIVE ❑ NIA A E.L.EACH ACCItlEN7 S OFFICERIMEMBEREXCLUDED7 ..E.L fACL "14T (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S Ifyyes,describe under DESCRIPTION OF OPERATIONS below � II E.L.DISEASE-POLICY LIMIT S t__J EDEl l ED L.-..3 DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more spats is required) Certificate holder is listed as additional insured, CERTIFICATE HOLDER CANCELLATION City of EI Segundo,it?s officers,officials,employees,agents and SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE volunteers THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. E!Segundo,CA 90245-3813 AUTHOR12EDRE'PRESEN'IATWV ; TAY �„ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Produced using Forms Boss Web Software.werw.FormsBoss,com(c)Impressive Publishing 800.208-1977 POLICY NUMBER: BA040000046197 COMMERCIAL AUTO CA 20 4810 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following; AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provide by this endorsement,the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s)or organization(s)who are"insureds"for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: VINCENT ALPINO DBA ALPINO BUILDING Endorsement Effective Date:6/14/2018 SCHEDULE Name of Person(s)Or Organization(s): CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS AND VOLUNTEERS 350 MAIN ST. EL SEGUNDO, CA 90245-3813. Information required to complete this Schedule,if not show above,will be shown in the Declarations. Each person or organization shown in the Schedule is an"insured"for Covered Autos Lability Coverage,but only to the extent that person or organization qualifies as an"insured" under the Who Is An Insured provision contained in Paragraph A.1.of Section Il—Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2.of Section I—Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 10 13 © Insurance Services Office, Inc.,2011 Page 1 of 1 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARMING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,0110), 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# j I certify that, in the performance of the work set forth in the agreement with the City of El 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 will automatically become void. ) Signature of Applicant l Datef fO $ Print Name t 1=t4e-e: Agreement for: Uirl Dated: t Reviewed by: