PROOF OF INSURANCE (2019) CLOSED ACCORL> DATE( 11OVrrYY)
CERTIFICATE OF LIABILITY INSURANCE
', ..,. 12/1 11!22018..
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFOR'M'ATION 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 provision's 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{{endorsendent'(s).
.PRODUCER 9 CONTAC1" Julie Ryba'k
Kellogg$Moreland Agency,Inc DBA [�IP 0 N.,Exfs: (909)7'92.8950 �F� �ol, (909)'.792'-2'030
Arroyo Insurance Services Ao r� Ss, iulper arroyoins.00rn
1654 Plum Lane 'INSIURER(SI AFFORDING COVERAGE NAIL p
Redlands CA 92374-4532 INSURER A; Berkley Assurance Company 39462
INSURED INSURER B! United Financial Casualty Cc 11770
California Street Lighting,A California Corp INSURER C r State Compensafien Ins Fund 35076
3200 Guasti Road#100 INSURER D
!L@'SL9RE�R E
Ontario CA 91761 INSURER F:
COVERAGE-2 GERsi?SCATS,NUMSER: REVISIONNUP'RE`R'
THIS IS TO'CERTIFY"T HAT THE POLICt'ES CSF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REOUI'REMENI,TERM OR CONDITION OF ANY CONTRACT OR O'TH'ER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAINTHE 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. AUUL'SUHH POLICY EFF POLICY EXP
k.TR TYPE OF INSURANCE k>NSD Wvo POLICY'NUMBER (MWOD(Y`YYY'l'CMMMONYYY)� LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE q`,� 1,000,000
�UAMAUM. I C KcN i t"ta �q 100,000
CLAIMS-MADE OCCUR F'Iult ES'- E.XP fAaayr arae pur'son) Y.SExcluded
A Y VUMB0162531 12/0112018 12/01/2019 y�PERSONAL s ADV INJURY s 1,000,000
GEhs't..AGGREGA'TE LINHI APPLIES PER. I ENSEFtAt AGGREGATE: $ 2,000,000
POLICYPRO- 2,000,000
UEC;T ❑LOC PRODUCTS CUMIPrOP AGG. $
_ �C77'9ER'
AUTOMOBILE LIABILITY GO",.E,D'SINGL,E',Ltba'AIT 1"000,0,00
IES mCcacrentd
ANY AUTO BODILY INJURY(Per person) ��S
B OWNED SCHEDULED 06588638-0 02/23/2018 02/23/2019 BODILY INJURY(Per accident) S
AUTOS ONLY AU"aO$
HIRED NGNI .)WN6D PROPER'Y CAaMAGE
" AUTOS ONLY X AAUTOS ONL`✓ Per awc�dmnll
UMBRELLA LIA6 ,""JK" OCCUR EACH OCCIARItEP7,CE �S 2,000,000
A EXCESS LIAB CLAIMS 11DE VUMB0162551 12101/2018 12/01/2019 AGGREGATE, s 2,000,000
UE 1 1 RETENTION 5 S
'WORKERSCOMPENSA'"ON PER f N OTH"
1 AND EMPLOYERS'LIABILITY
STATUTE P I ER
Y/N 1,000,000
AtwYrPFtOPirM1ETt7taY*nAR1'Na;:BtfEXEC.tI,t"I'apE 'E,1,. EACwiACCdUIEV�aT S
C �;p;�,;,y.���,IMA,;r�k_�I„y ,;,tl�., n NtA 9222151-18 12!0112018 12/01/2019
(M.tenaawry u,NH) E.�. utrlEAaa: VA�fVdLOYEE S 1,000,000
If yr.s,describe under ��_mm 1,000,000
17ES�CRIP'IION OF OPERATIONS btrimv El DtSIFASE-POUC:Y LIMIT $
DESCRIP71ON OF OP'ERA'TIONS r LOCATIONS,VUMLES (ACORO 101,Additional Rornark's Schedule,may be attached if more space Is required)
"City of Et Segundo,its officials,and employees are additional insureds per attached forms#CG2033&#CG2037” Such insurance is primary per attached
form ff'VCAS2035, Waiver of Subrogation applies Ices'attached forms#CG2404⟩. 30 days written notice of cancellation applies.
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 City Clerk A'CCORDANC'E WITH THE POLICY PROVISIONS.
350 Main Street,Room 5
AUTHORIZED REPRESENTATIVE
EI Segundo CA 90245-3813 (""``
-
I
031988-2015 ACORD CORPORATION. All rights reserve
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
COMMERCIAL GENERAL LIABILITY
CG 20 33 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - AUTOMATIC STATUS WHEN
REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A, Section If — Who Is An Insured is amended to B. With respect to the insurance afforded to these
include as an additional insured any person or additional insureds, the following additional
organization for whom you are performing exclusions apply.
operations when you and such person or This insurance does not apply to:
organization have agreed in writing in a contract or
agreement that such person or organization be 1, "Bodily injury", "property damage" or "personal
added as an additional insured on your policy. and advertising injury" arising out of the
Such person or organization is an additional rendering of, or the failure to render, any
insured only with respect to liability for "bodily professional architectural, engineering or
injury", "property damage" or "personal and surveying services,including.-
advertising Injury"caused, in whole or in part, by: a. The preparing, approving, or failing to
1. Your acts or omissions; or prepare or approve, maps, shop drawings,
opinions, reports, surveys, field orders,
2, The acts or omissions of those acting on your change orders or drawings and
behalf-, specifications;or
in the performance Of Your ongoing operations for b. Supervisory, inspection, architectural or
the additional insured. engineering activities.
A person's or organization's status as an 2, "Bodily injury"' or "property damage" occurring
additional insured tinder this endorsement ends after:
when your operations for that additional insured
are completed, a. All work, including materials, parts or
equipment furnished in connection with
such work, on the project (other than
service, maintenance or repairs) to be
performed by or on behalf of the additional
insured(s) at the locallon of the covered
operations has been completed,or
b, 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
sarne project.
CG 20 33 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
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Cir Orqaniza Location And Dost.iPtion 0.1 ComOAed Onerations
As required by written contract executed prior Construction project sites at which you performed work
to the date of occurrence but only to the extent for such additional Insured,
permitted by law and 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.
Information required to complete this Schedule, if not shown above,will be shown in:the Declarations.
Section It - 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 "properly
damage"caused, in whole or in part, by "your work"
at the location designated and described in the
schedule of this endorsement performed fof that
additional insured and included in the "products-
completed operations hazard".
CG 20 37 07 44 0 ISO Properties,Inc.,2004 Page 1 of 1 II
THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY.
PRIMARY AND NONCONTRIBUTORY WORDING
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE
With respect to coverage provided to an additional insured via attachment of an Additional Insured endorsement to
this policy, such coverage is primary insurance and we will not seek contribution from any other insurance available
to thai adddional iosured.
ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED
VCAS2035 11 10 Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
To any person or organization provided you entered into the contract with that person or organization prior to any
claim or loss to which this insurance applies,
(If no entry appears above, information required to comptete this endorsement will be shown in the Declarations
as applicable to this endorsement,)
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV—
COMMERCIAL GENERAL LIABILITY CONDITIONS)is amended by the addition,of the following:
We waive any right of recovery we may have against the person or organization shown in the Schedule above
because of payments we make for injury or darnage arising out of your ongoing operations or "your work" done
Linder a contract with that person or organization and included in the "products-completed operations hazard".
This waiver applies only to the person or organization shown in the Schedule above.
CG 24 0410 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 M
ENDORSEMENT AGREEMENT BROKER COPY
WAIVER OF SUBROGAT'ION
BLANKET BASIS 9222151-18
RENEWAL
SP
HOME OFFICE 9-60-1$-14
SAN FRANCISCO EFFECTIVE DECEMBER 1, 2018 AT 12.01 A.M. PAGE 1 OF 1
ALLEFFECTIVE DATESARE AND EXPIRING DECEMBER 1, 2019 AT 12.01 A.M.
AT 12:01 AM PACIFIC
STANDARD TIME OR THE
TIME INDICATED AT
PACIFIC STANDARD TIME
CALIFORNIA STREET LIGHTING
3200 E GUASTI RD STE 100
ONTARIO, CA 91761
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.
THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE
2.00% OF THE TOTAL POLICY PREMIUM.
SCHEDULE
PERSON OR ORGANIZAT'I'ON JOB DESCRIPTION
ANY PERSON OR ORGANIZATION BLANKET WAIVER OF
FOR WHOM THE NMIED INSURED SUBROGATION
HAS AGREED BY WRITTEN
CONTRACT TO FURNISH THIS
WAIVER
NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE
OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS
POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE
HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR
LIMITATIONS OF THIS ENDORSEMENT.
COUNTERSRGNED AND ISSUED AT SAN FRANCISCO° NOVEMBER 8, 2018
2572
AUTI,uUIRIZED REFRE xENT hVE PRESIDENT AND CEO
MF FORM 10217 IREV,7°2014) OLD DP 217