PROOF OF INSURANCE (2019 - 2019) CLOSED AC<>R CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDOPYYYY)
�,,,,, 1 I 5/7/2010
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 be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,csrhln policies may require an endorsement. A statement on this cortlflcste does not confer rights to the
certificate holder In lieu of such endorsement(s).
Wong
38 Executive Park Suits 320
CONT
Services, LLC O n49)679-37eom I r '1949)67111-3702
s .m. ,. oncrqt
Irvine, CA 92614 s A oRallocovEluoe,,,,,_, M!!!C.!......_.
INSURERAXinaale Insurance Company +38920
..W.............�....._.......... .......... _....,__.INO'URED INSURER 1174110 Lake F r�eandCasualty 684
CC LAYNE a SONS INC.
216 Btandard Street INSURut,p:........
El Segundo, CA 90245 1NIURE RE: _... ._
INSURFA p: 1
COVERAGES CERTIFICATE NUMBEWCLIS2103315 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.
wL AXP
TYPE OF INSU O. ,.. APC ...�
ComMEROALOENERAALUAWLITY I i vOLICYNUMImA PkXM4IC EFFI �r�1pC E y�FACFIOCC 1 00000
�S 00
A .. CLAIMS-MADE �'X]OCCUR 00
Y Y 010061552-0 2/1/2015 3/1/3019 �I" fl S.J.I W+ � fe 1r2..,._,6 ]Occluded
MED ...... ............- ...__1.0.. -........,._.0-
GEN'L AGGREGATE LIMB APPLIES.........._m..._... GENEONAL .00.000
PER .__..... ) S G .-�...
RAL AGGREGATE
El
00,000
POLICY
L J CST LOC PRODUCTS-COMPIOP AGG -,a................2...O.O..................0
JP
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AUTOMOBILE LIAaaJTY
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_ ANY ALTO BODILY INJURY(Par person) S
AALL UTOS ED SCHEDULED
BODILY INJURY(Per
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A _EXC 9 CLAIMrtMADE 0100061562-0 2/1 2015 I 3/1/2019 J IRENCE .m,m” y°S mm 2 00O O Y.
DEO RETENTIONS / S
WCjRXIRS
COMPENSATION
�I I
AND eMPLOYVW'UAIUUTYA
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-iDER
ANY
i 11000,000 000
C`HCERWEMBER EPCLUDED1 NIA'
a (MPlrldOM in NMI PLAGO8293-00 2/1/2015 2/1/3019 E.L.DISEASE.EA EMPLOYEE S 1.000.000
e SC.o bo U'B 6')rPE'P#N ri&.lies Ia�lwv (' E L INSEASE•POLICY LIMIT ITIT_�. .... ...._.. -.
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DESCRIPTION OP OPERATIONS I LOCATIONS I VEHICLE_(ACORD 101,Additional Remarks Schedule,may be attached K mon space h nqulled)
*10;Days Notice of Cancellation for Non-Payment of Premium.
The, City of E1 Segundo is named as Additional Insured per General Liability.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Sl Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS.
El Segundo, CA 90145
AUTHORIZED REPRESENTATIVE
Julie Wong/JULIE
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 26(2014101) The ACORD nems and logo are registered marks of ACORD
INS025(201401)
THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED- OWNERS, LESSEES OR CONTRACTORS
SCHEDULED PERSON OR ORGANIZATION
Attached To 0100061552-0 d FormingPart o Poli 02/01/2019
on the Declarations Named
Insured C C LayneI address &Sons Inc
Additional Premiu
m ....._ -.--. Return Premium:
SO s
This endorsement modifies Insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE p
Name of Additional Insured Person(s)or Organization(s): Locatlon(s)of Covered Operations I
Blanket,as 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 include B. With respect to the Insurance afforded to these
as an additional Insured the person(s) or additional insureds,the following additional exclusions
organlzation(s) shown In the Schedule, but only with apply:
respect to liability for "bodily Injury", "property This insurance does not apply to "bodily Injury" or
damage" or "personal and advertising Injury" caused, "property damage"occurring after:
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 work, on the
2. The acts or omissions of those acting on your project (other than service, maintenance or
behalf; repairs) to be performed by or on behalf of the
in the performance of your ongoing operations for the additional Insured(s) at the location of the covered
additional Insured(s) at the locatlon(s) designated operations has been completed;or
above. 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.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
CG 2010 07 04 0 ISO Properties,Inc.,2004 Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED.OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
Attached To 'and Forming Part of Policy Effective D f
ate o Endorsement Named Insured
0100061552-0 02/01/201812:01AM at the Named Insured C C Layne&Sons Inc
address shown on the Declarations
Additional Premium: Return Premium:
$0 $0
This endorsement modifies Insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE `f
u Name of Additional Insured Person(s)or Organlzatlon(s) Location and Description of Completed Operations
Blanket,as required by written contract. EXCLUDES ALL NEW RESIDENTIAL CONSTRUCTION
"Your work"does not include"new residential
construction",which means any building or structure not
previously occupied,and designed or Intended for
occupancy in whole or in part as a residence by any person
or persons."New residential construction"does not include
apartments or apartment buildings or assisted living
facilities.
A Information required to complete this'Schedule.,if not shown above,will be shown in the Declarations.
Section II—Who Is An Insured Is amended to include as
an additional insured the person(s) or organizatlon(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 desig-
nated and described in the schedule of this endorse-
ment performed for that additional insured and in-
cluded In the"products-completed operations hazard
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
CG 20 37 07 D4 m ISO Properties,Inc.,2004 Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY,PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED- PRIMARY AND NON-CONTRIBUTORY ENDORSEMENT
Attached To and Forming Port of PolicyI Effective Date of Endorsement Named Insured
0100061552-0 G 02/01/201812:01AM at the Named Insured C C Layne&Sons Inc
address shown on the Declarations
lum: Return Premium:
S
A ditlnOPremium.,
Soo Prem ... .,.� _...... . ....
This endorsement modifies Insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE
ENVIRONMENTAL CONTRACTING AND PROFESSIONAL SERVICES LIABILITY COVERAGE
PRODUCTS POLLUTION LIABILITY COVERAGE
The Insurance provided to Additional Insureds shall be excess with respect to any other valid and collectible insurance
available to the Additional Insured unless the written contract specifically requires that this insurance apply on a primary
and non-contrlbutory basis,in which case this insurance shall be primary and non-contributory.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
CAS5003 0717 Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US-BLANKET
Attached To and Forming Part of Policy Effective Date of Endorsement Named Insured
0100061552-0 02/01/2018 12:01AM at the Named Insured C C Layne&Sons Inc V
address shown on the Declarations
Additional Premium: Return Premium;
so $0
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE
SECTION IV—CONDITIONS,8.Transfer of Rights of Recovery against Others to Us is amended by the addition of the
following:
We waive any right of recovery we may have against persons or organizations because of payments we make for injury or
damage arising out of"your work"done under a written contract with that person or organization wherein you have agreed
to provide this waiver.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
CAS4002 0110 Page 1 of 1
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06
(F-d,4-841
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_5% of the California workers' compensation premium
otherwise due on such remuneration.
Schedule
Person or Organization Job Description
Blanket Waiver of Subrogation As respects to all CA jobs performed by the named insured
during the policy period where by written contract a waiver
of subrogation is required prior to the commencement of
work.
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:05/22/2018 Policy No.FLA008293-00 Endorsement No.
Insurance Company: Falls Lake Fire&Casualty
Company Insured:CC LAYNE&SONS INC.(A Corp)
Countersigned By
01998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved.
A " CERTIFICATE OF LIABILITY INSURANCE °�'�`MwD°"'�"'
I4�,, 09/27/2018
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(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(a).
PRODUCER ... .. CONTACT
I'w� _.__ ..
YA
ADDRESS:
......... 6 Najc_"....a322-0831
tam, Tom Brundi a License 0479986 Es Ie Hernandez 1
214 Standard St. Ste B es ranza®tombrundidg e.com w A
............_... URFJt(SIAFFORDING COVERAGE ..................MAIC/
EI Segundo CA 90245 INSURER A. State Farm Mutual Automobile Insurance Company 25178
INSURED INSURER a
C C LAYNE&SONS INC ..INSURER.C„......................___._..._..._ ._........_,,..........
216 STANDARD ST INSURER 01;-11111111111111
EL SEGUNDO CA 90245 I,INSURER INSURER F.. ....._,_, .... .L........ ... I
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 'ERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH 'OLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR .. .. IDOL SUeR POLICY F»FF' I'
LTR' TYPE OF INSURANCE POUCY NUMBER POLICY EXP _ LIMnS
COMMERCIAL GENERAL
LIABILITY EACH OCCURRENCE $
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GLN'L AGGREGATE...................�..._............r..,............................ .......
PERSONAL IL ADV INJURY S
UM(T APPLIES PER: GENERAL AGGREGATE f _
POLICm' O ❑LOC PRODUCTS-COMPIOPAGG S
E.,,,,,,,.,. GT S
OTHER'
AUTOMOBILE LIABILITY Y Y 499 1658-C26-75C 09/26/2018 03!28/2019 tOUM DIED StNGLE LIMIT' $ 1,000,000
ANY AUTO BODILY INJURY(Par S ..... " .
A X OIRVMJEDONLY SCHEDULED BODILY INJURY(Par accident) S � ~~
OS
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ARTNERIEXECUTIVE E. EACH ,., .www,...,..
( ry i DISEASE-EA EMPLOYEE S """""" ...
It
M.oeserbe under
L}�XhP",ION OF OP'NAT40045 LW.W ., E.L.DISEASE-POLICY LIMIT i
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD JIM,AMNImW Remarks Sehaduk.may M attached N mon spew Is requlnd) .
2006 FORD F350 SD CREW CAB VIN 1 FTWW31 P46EA08216
Job site:Vista Park
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 PROVISION&
350 Main St
Au E
FJ Segundo
CA 90245
NTATIi/
01988'2015 A RO CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACO
100140 132819.12 MIS-2016