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PROOF OF INSURANCE (2019) CLOSED DATE(MMIDD/YYYY) AC" >R0 CERTIFICATE OF LIABILITY INSURANCE �. 9/20/2018 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 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). PRODUCER CONTACTDebra Barnes ____AE Conrey Ins Brokers &Risk Managers Lic#0543173 PHONE (7 14)838-5835 .(.7.1.4..)..e39-81.6.6 F IAIP.Aq,Ext): d N . _)E. .......................... 17821 East 17th Street #100 EDMAtl- debrab@conrey.1.ns...'..°.om „ .........................!.N.S.R.R.E.R(S).A.F.F.O.R.O.�.N.G..C,O,VERAGENAIC#............ Tustin CA 92780mm, INSURERA:Oh10 Security Insurance Comp ................................... 4082...2..............,__...._�._. IN INSURER Fire And Casualty INSURED INS 4 Q 6.... J K Miklin, Inc. INSURERC:Sequoia Insurance Company 2298..5...... dba Yamada Enterprises INSURER D: 16552 Burke Ln INSURER. E..'.................................................... Huntington Beach CA 92647 INSURER F; COVERAGES CERTIFICATE NUMBER:18-19 GL AU WC UM 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. .. ............ (J� ..,.,.,. POLICY NUMBER IMOLICYEFF P�INPINOILfYC XP..............................................................................LIMITS....... ,. ....................LTR TYPE OF �ObL... �INSR INSURANCE YYYt X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 50..................... A CLAIMS-MADE MALL t CMdfLD 0 000 X .. ...........� .� OCCUR X Deductible/SIR = $0.00 X Y BKW55667154 8/21/2018 8/21/2019 M,ED EXP(Anp one person) $ 15,000 (NoM. ._....... . Deductible/SIR).................. --- ....................... ..PERSONAL 8..ADV.......,.,. $ 1,000,000 , GENI AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 ...................................................................... POO LLICY D I ECT 2:0 LOC PRODUCTS-COMP/OP AGG $ 0 HER� .,. .0..0'..0..0........ ernoe outss'ide?, limits- $ AUTOMOBILE LIABILITY COMBIiNED SINGLE LIMYT $ 1,000,000 (Ea�ce�enl,9 X ANY AUTO $ U (Per person) ALL OWNED SCHEDULED BAS55667154 8/21/2018 8/21/2019 BODILY INJURY NON-OWNED X Y .�. AUTOS AUTOS (Per accident) $ HIRED AUTOS I AUTOS �"'.... .5....�W DA ASE.................... $ X Same as above Medical payments $ 5,000 UMBRELLA OCCUR E��H X EXCESS AB.A.B.......H CLAIMS-MADE AGGREGATE RRENGE ...., _ $ ..._r'.:.Q.0.0^, 000.^ DEO X NRETENTION$ 10,000 X Y USA55667154 8/21/2018 8/21/2019 $ WORKERS COMPENSATION - X STATUTE G ORTH- AND EMPLOYERS'LIABILITY YIN '-'"""-'- ANY OFFICER/MEIMBER/EXCLUDED?ECUTIVE """Y"""� NIA E L EACH ACCIDENT EA EMPLOYEE $ 1,000,000 C (Mandatory in NH) y QWC1063133 8/21/2018 8/21/2019 E L DISEASE O O O,D.R.Q.. If ydescribe underes, OF OPERATIONS below E DISEASE-POLICY LIMIT $ 1,000,000 A Builders Risk / Inland BKW55667154 8/21/2018 8/21/2019 PerJobsite/Catastrophe Limit $100,000 Marine Installation Floater Deductible $1,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) AS RESPECTS GENERAL LIABILITY: CERTIFICATE HOLDERS ARE NAMED AS ADDITIONAL INSUREDS WHEN REQUIRED BY WRITTEN CONTRACT PER BLANKET FORMS CG2037(04/13) & CG2010(04/13) . ADDITIONAL INSURED APPLIES ON A PRIMARY AND NON-CONTRIBUTORY BASIS PER GENERAL LIABILITY EXTENSION CG88100413 AS RESPECTS THE OPERATIONS OF THE NAMED INSURED AS COVERED UNDER THIS POLICY. TRANSFER OF RIGHTS TO RECOVERY AGAINST OTHERS (WAIVER OF SUBROGATION) APPLIES. WITH RESPECTS TO AUTO LIABILITY, BLANKET AUTO COVERAGE EXTENSION APPLIES, INCLUDING ADDITIONAL INSURED AND WAIVER OF SUBROGATION, PER ENHANCEMENT ENDORSEMENT CA88100113. AS RESPECTS WORKERS' COMPENSATION: BLANKET WAIVER OF SUBROGATION INCLUDED OFFICERS EXCLUDED - LINDA BRAVERMAN POLICY CERTIFICATE MOLDER CANCELLATION f SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of E1 Segundo ✓" THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street. ACCORDANCE WITH THE POLICY PROVISIONS. E1 Segundo, CA 90245 AUTHORIZED REPRESENTATIVE Debra Barnes/LKW ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I NS025(201401) POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 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): City of El Segundo 350 Main Street EL SEGUNDO, CA 90245 Location(s) Of Covered Operations Any location(s) when You have agreed in a written contract, agreement or permit 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 include as an additional insured the person(s) these additional insureds, the following addi- or organization(s) shown in the Schedule, but tional exclusions apply: only with respect to liability for "bodily in- This insurance does not apply to "bodily in- jury", "property damage" or "personal and jury" or" property damage" occurring after: advertising injury" caused, in whole or in 1. All work, including materials, parts or part, by: equipment furnished in connection with 1. Your acts or omissions; or such work, on the project (other than ser- 2. The acts or omissions of those acting on vice, maintenance or repairs) to be per- your behalf; formed by or on behalf of the additional in the performance of your ongoing insured(s) at the location of the covered operatons for the additional insured(s) at the operations has been completed; or location(s) designated above. 2. That portion of "your work" out of which However: the injury or damage arises has been put 1. The insurance afforded to such additional to its intended use by any person or or- insured only applies to the extent permit- ganization other than another contractor ted by law; and or subcontractor engaged in performing operations for a principal as a part of the 2. If coverage provided to the additional in- same project. sured is required by a contract or agree- ment, 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 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 C. With respect to the insurance afforded to these additional insureds, the following is added to Section III -Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the ap- plicable Limits of Insurance shown in the Dec- larations. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 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) Or Organization(s) City of E1 Segundo 350 Main Street EL SEGUNDO, CA 90245 Location And Description Of Completed Operations Work described in writing in the contract, agreement or permit. " Location(s) at which at which You performed work described in written contract, agreement or permit 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 include as an additional insured the person(s) these additional insureds, the following is or organization(s) shown in the Schedule, but added to Section III -Limits Of Insurance: only with respect to liability for "bodily in- If coverage provided to the additional insured jury" or "property damage" caused, in whole is required by a contract or agreement, the or in part, by "your work" at the location des- most we will pay on behalf of the additional ignated and described in the Schedule of this insured is the amount of insurance: endorsement performed for that additional 1. Required by the contract or agreement; insured and included in the "products-com- or pleted operations hazard". However: 2. Available under the applicable Limits of Insurance shown in the Declarations; 1. The insurance afforded to such additional whichever is less. insured only applies to the extent permit- ted by law; and This endorsement shall not increase the ap- 2. If coverage provided to the additional in- plicable Limits of Insurance shown in the Dec- sured is required by a contract or agree- larations. ment, 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 37 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed.04.84) WAIVER Of OUR RIGHT To RECOVER FROM OTHERS ENDORSEMENT -CALIFORNIA 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 as required by written contract. 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 8/21/2018 Policy No. QWC1063133 Endorsement No. 0 Insured J K Mildin Inc.(a Corp) Premium$ 2354 Insurance Company Sequoia Insurance Company Countersigned by .......................................................... WC 04 03 06 (Ed.04-84)