PROOF OF INSURANCE (2019) CLOSED E(MM1DDNYY'Y)
ARD CERTIFICATE OF LIABILITY INSURANCE DATE
09/18/2018
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 endorsementis).
PRODUCER III CONTACT NAME:
CANNON COCHRAN MANAGEMENT SERVICES,INC. PHONE(A/C No.Ext): [FAX(A/C No.Ext):
17015 N.SCOTTSDALE RD. E-MAIL ADDRESS:certificateteamOccrosLcom i
SCOTTSDALE,AZ 85255 INSURER(S)AFFORDING COVERAGE NAIC#
I INSURER A: ACE American Insurance Co, 22667
INSURED INSURER B: Indemnity Insurance Company of NA 43575
REPUBLIC SERVICES,INC, INSURER c: ACE Fire Underwriters 20702
18500 N.ALLIED WAY INSURER D: Illinois Union Insurance Company 27960
PHOENIX,AZ 85054 INSURER E:
INSURER F: )
COVERAGES CERTIFICATE NUMBER: 1444550 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.
INSR ADDL SUBR POLICY EFF POLICY EXP
TYPE OF INSURANCE POLICY NUMBER LIMITS
LTR INSD VdVD (MMIDDIYYYY) (MMIDDIYYYY)
A XII COMMERCIAL GENERAL LIABILITY HDO G71097171 06/30/2018 06/30/2019 EACH OCCURRENCE $5,000,000
J CLAIMS-MADE X OCCUR DAMAGE TO RENTED
$5,000,000
PREMISES(Ea occurrence)
MED EXP(Any one person)
PERSONAL&ADV INJURY $5,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $5,000,000
7 POLICY ❑PROJECT E-1 LOC
PRODUCTS-COMP/OP AGG $5,000,000
OTHER:
AUTOMOBILE
LY AUTO ABILITY /30/2018 06/30/2019 COMaccident)
INED SINGLE
LIMIT
A ISA H25159809 06 ci $5,000,000
OWNED AUTOS SCHEDULED I ( person)
ONLY AUTOS
� BODILY INJURY(Per accident)
HIRED AUTOS NV W
NON-ONED
ONLY - AUTOS ONLY PROPERTY DAMAGE
(Per accident)
UMBRELLA LIAB OCCUR (EACH OCCURRENCE
EXCESS LIAR' CLAIMS-MADE [AGGREGATE
DED RETENTION S I I
B WORKERS COMPENSATIONY/N NSA WLR C6522575A-AOS 06/30/2018 06/30/2019 ( X I PER u OTHER
AND EMPLOYERS'LIABILITY WLR 065225712-CA/MA/OR 06/30/2018 06/30/2019 r—J STATUTE
A .ANY PROPRIETOR/PARTNER/EXECUTIVE ® SCF 065225797-WI 06/30/2018 06/30/2019 IE•L.EACH ACCIDENT I$3.000.000
C OFFICER/MEMBER EXCLUDED? WCU C65225670-OH XS 06/30/2018 06/30/2019 IE.L.DISEASE-EA EMPLOYEE 1$3,000,000
A (Mandatory in NH) TNS C49167295-TX NSXS 06/30/2018 06/30/2019 [E,L.DISEASE-POLICY LIMIT 1$3„000,000
D If yes,describe under
DESCRIPTION OF OPERATIONS below
Contractor's Pollution Liability: See page 2 for details 06/30/2018 06/30/2019
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Division Number:3893-Named Insured Includes:Consolidated Disposal Service,L.L.C.-Dba:Republic Services of Southern California-Allied Waste Services-
American Waste
f
CE'RT'IFICATE HOLDER CANCELLATION'
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENTATIVE
City of EI Segundo _
350 Main Street
EI Segundo,CA 90245-3813'.
United States r
.................. ... w............ ........ ...........
............-...... ( 1988-2016 ACORD CORPORA'TI'ON.All rights reserved.................
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID:
LOC#:
ACORD ADDITIONAL REMARKS SCHEDULEAGEN
NAMED INSURED /
/ REPUBLIC SERVICES, INC.|rpuc,wumosR 18500 N.ALUWAY
| soeFi��Pog� m ' 4z85o54
\o«nn/�n /wxcoos PHOENIX,
y
See First Page Y EFFECTIVE DATE:
' - y
ADDITIONAL REMARKS '
'
THIS ADDITIONAL REMARKS FORM mA SCHEDULE roAconoFORM.
�
FORM NUMBER: 25_FORM TITLE:_CERTIFICATE OfLIABtLlTYINSURANCE
The following required by written contract.Amused below,the term certificate holder also includes any person u,organization that
the insured has become obligated to include as a result of an executed contract or agreement.
GENERAL LIABILITY:
� �
Certificate holder isAdditional Insured when required hywritten contract.
Coverage is primary andnun'onntnuutory when required bywritten contract.
Waiver ofSubrogation infavor n,the cortifinateholder ioincluded when required bywritten contract.
AUTO LIABILITY:
Certificate holder iaAdditional Insured when required by written contract.
Coverage is primary andnon-contributory when required bywritten contract.
Waiver of Subrogation in favor of the certificate holder is included when required by written contract.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY:
Waiver oxSubrogation infavor ofthe certificate holder ioincluded when required by written contract where allowed bystate|aw
Sm coverage for ND,VvAand VVY|scovered under policy nuWLR CO52o575Aand"topgap coverage�,OHiuxove�-'under policy nv CU
cnuz2os70.asnmeuonpage 1 ofthis cexmuote. �VV
TEXAS EXCESS INDEMNITY AND EMPLOYERS LIABILITY:
Insured|aoregistered nmn-smbachbertuthe Texas Workers Compensation Act. Insured has flied anapproved Indemnity Plan with the Texas
Department orInsurance which offers enalternative/nbenefits memployees rather than the traditional Workers Compensation Insurance mTrms Thr
�
excess policy(#TNSC^� 67295)shown pnthis mex>�cateprovides excess|ndrmn|�and Emp|oye�uobi|i�coverage for the approved Indemnity
—Plan.
Contractual Liability is included in the General Liability and Automobile Liability coverage forms.The General Liability and Automobile Liability policies du
not contain endorsements excluding Contractual Liability.
Separation vvInsured Liability)coverage|oprovided tnthe Additional Insured,when required hywritten momnactper the Cnnd�ionsoythe
Commercial General Lia�|i�Cmv�ageform and the aummobaeLio�otyCmve,ageform.
'
Insurer Affording Pollution Coverage-Tokio Marine Specialty Insurance Co.(NAIC#23850)Policy No.PPKI 830449
Contracting Operations Environmental Liability-$10,000,000 Per Contamination Incident/$1 0,000,000 General Aggregate
Professional Liability-$10,000,000 Per Incident/$10,000,000 General Aggregate
Additional Insured includes:City of El Segundo,when required by written contract.
�
^como1o1(mmom1) w1eox-201oxconoCORPORATION.All rights reserved.
The Acononame and logo are registered marks mxcoRo
4
POLICY NUMBER: HDO 671097171 Endorsement Number: 174
COMMERCIAL GENERAL LIABILITY
CG 20 26 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED
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): Any person or organization whom you have
agreed to include as an additional insured under a written contract or agreement,which include permits and
licenses,provided such contract or agreeement was executed prior to the date of loss.
Information required to complete this Schedule, if not shown above,will be shown in the Declaratvices.
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 is added to
organization(s) shown in the Schedule, but only Section III—Limits Of Insurance:
with respect to liability for"bodily injury", "property If coverage provided to the additional insured is
damage" or "personal and advertising injury" required by a contract or agreement, the most we
caused, in whole or in part, by your ads or will pay on behalf of the additional insured is the
omissions or the acts or ornissions of those acting amount of insurance:
on your behalf
1. In the performance of your ongoing operations; 1. Required by the contract or agreement;or
or 2. Available under the applicable Limits of
2. In connection with your premises owned by or Insurance shown in the Declarations;
rented to you. whichever is less.
However: This endorsement shall not increase the
1. The insurance afforded t4 such additional applicable Limits of Insurance shown in the
insured only applies to the extent permitted by Declarations.
law-,and
2. If coverage provided to the additional insured is
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 20 26 0413 m Insurance Services Office,Inc.,2012 Page 1 of 1