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PROOF OF INSURANCE (2019 - 2019) CLOSED 'a DATE(MMMD/YYYY)
" °" CERTIFICATE OF LIABILITY INSURANCE N 02/04/2019
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 riahts to the certificate holder in lieu of such endarsement(s).
PRODUCER
F COMPANY NAM_, _ T.... .?.l 5117.-44,6�F64............------ .........
HOME OFFICE:DMUTUAL
BOX 328ANCE
CONTACT
C.ENo.Ext 88 333-4949 ,.,..C.E„r`!.ZE.R,.. (A/acs N........................................................_. ......
ONE FAX
OWATONNA,MN 55060 E MAPL
a.Dgp tEss„"CLIE,NTCONTACTC,EN,TERd,I=EQINS,CQM
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935
...... .....,,,,,,, - ..... .... ......
INSURED 308-577-6 INSURER B:
WATERLINE TECHNOLOGIES INC INSURER C:
620 N SANTIAGO ST '""'""`"""
SANTA ANA,CA 92701-3942 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:217 REVISION NUMBER:0
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 INSR WVD POLICY NUMBER (MM/DDIYYYYI (MMIDOIYYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000
CLAIMS-MADE X OCCUR PRE MAMAGE ( RENTED a $100,000
MED EXP(Any one person) EXCLUDED
A Y N 0623485 08/15/2018 08/15/2019 PERSONAL&ADV INJURY $1,000,000
.m_ ❑ ❑ ......
C PL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE
�l@V $2,000,000
OLICY LOC PRODUCTS-COMP/OP AGG $2,000,000
OTHER: IV
AUTOMOBILE LIABILITY V,COMBINED SINGLE LIMIT $1,000,000
— (Ea accidents
X ANY AUTO _ SCHEDULED BODILY INJURY(Per person)
�- "
A OWNED AUTOS ONLY autos Y N 0623485 08/15/2018 08/15/2019 BODILY INJURY(Per accident)
NON•OWNED ___.,.,.,.,_,.....
HIRED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE
P F?,&SISI,S^,t�„ ...�...._..................-.,..�.
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $8,000,000
A EXCESS LIAR CLAIMS-MADE. N N 0623486 08/15/2018 08/15/2019 AGGREGATE $8,000,000
,.,DED_. R.,",.ETENT..ION ....................
_.----------
WORKERS COMPENSATION YIYI 11 OTH-
AND EMPLOYERS'LIABILITY Y/ry
.w...............1.PER„"S,TAT.u"TE.1._............E.R......................._.....
.,.,.,.....,.,.
ANY PROPRIETORIPARTNERIEXECUTIVE ❑
(Mandatory
inOFFICERIMEMNH EXCLUDED? N I'0' E.L.DISEASE E.L.EACH CEA EMPLOYEE
(Mandatory in NH)
If yes,describe under - ......._._._._._._._..._...-.'.,..._
E.L DISEASE•POLICY LIMIT
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
SEE ATTACHED PAGE
CERTIFICATE HOLDER CANCELLATION
308-577-6 2170
CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
350 MAIN ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
EL SEGUNDO,CA 90245-3813 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
O 1988-2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: 308-577-6
LOC#:
ADDITIONAL REMARKS SCHEDULE Page Of
AGENCY NAMEDINSURED
FEDERATED MUTUAL INSURANCE COMPANY WATERLINE TECHNOLOGIES INC
................_.._......... ....................._-. 620 N SANTIAGO ST
POLICY NUMBER SANTA ANA,CA 92701-3942
SEE CERTIFICATE#217.0
w-.�. ......................._....m._.M..............._.._........_.
CARRIER NAIC CODE
SEE CERTIFICATE#217.0 EFFECTIVE DATE: _................
SEE CERTIFICATE#217.0
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: cR,T,IFICAT„EOF LIABILITY INSURANCE _,,,,,,,,,,,,,...,,,,,
ALL OPERATIONS TO VARIOUS LOCATIONS IN CA.
CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSURED UNDER THE
GENERAL LIABILITY ON A PRIMARY AND NON-CONTRIBUTORY BASIS.
THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED ON GENERAL LIABILITY SUBJECT TO THE CONDITIONS OF THE ADDITIONAL
INSURED - OWNERS, LESSEES, OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION ENDORSEMENT.
THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED ON BUSINESS AUTO LIABILITY.
.........................
ACORD 101 (2008101) © 2008 ACORD CORPORATION.All rights reserved.
The ACORD name and logo are registered marks of ACORD
i91 sa tt,,
POLICY NUMBER:0623485 COMMERCIAL GENERAL L.IABIL"
CG 2010 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 tinder the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
_..Name Ot Additional insured
nsur d( sj
Person ....._........... .....................Location(s)Of Covered Oiler..,.......-..........,.........x
Or
atiOns
l'f'Y'OF t L Sf Gt3NOfl :ANY COVERAGE PROVIDED BY THIS
3FCE MAIN 5T &,,NDOFt�rr:Irl EN I`
APPLIES 5 ONLY kli€TE E RESPECT TO
L SEGUNDO CA 90245 ;NAMED INSURED'$DELIVERY OF PRODUCTS TO
XR1`IFJCATE HOLDER.ADDITIONAL INSUREDS
At SO INCLUDE:CITY OF EL SEGUNDO,ITS
OFRCE'RS,OFFICIALS,E=MPLOYEES AND
VOLUNTEERS,
L......................................... .................................. .................... ....... . ...._... __.......................................................................... -
prEfnsan aEiara rer}�it R*d to complete this Schr-dole.if not shown above,will be shown in the€pec€arations_
A. Section 11 - Who 1s An Insured Is amended to 8, With respect to the insurance afforded to these
include as an additional insured the person(s) or additional insureds, the following additional
organixalion(s) shown in the Schedule, but only exclusions apply:
with respect to livability for 'bodily injury", This insurance does not apply to "bodily injury"or
"property damage" or 'personal and advertising "property damage'occurring after
injury"caused,.In whole or in part,by: 1. All work, including materials, pails or
1. Your acts or omissions: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 performartce 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
However: 2. That portion of "your work" out of which the
1. The insurance afforded to such additional injury or damage arises has been put to its
insured only applies to the extent permitted by intended use by any person or organization
law;and other than another contractor or subcontractor
engaged in perforating operations for a
2. If coverage provided to the additional insured principal as a part of the sante project.
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 ar)reernent to
provide for such additional insured.
WATERLINE TECHNOLOGIES INC
620 N SANTIAGO ST
SANTA ANA CA q2701
0 Insurance Services Office,Inc.,2012 Page 1 of 2
DO 2010 0413 Policy Plumber:0623485 Transaction Effective Date:02.04-2013
Office coI:
r ',
C, With respect to the insurance afforded to these 2, Available under the applicable Limits of
additional insureds, the following is added to Insurance shown in the Declarations;
Section III-Umlts Of Insurance: whichever Is less.
If coverage provided to the additional insured is This endorsement shall not increase the
required by a contract or agreement,the most we applicable Limits of Insurance shown In the
will pay on behalf of the additional insured is the Declarations.
amount of insurance,
1. Required by the contract or agreement;or
Pais,,2 of 2 O Insurance Services Office,Inc.,2012
CG 2010 0413 policy Plumber;01§23485 Transaction Effective Date:02.04-2019
u le 111
FEDERATED INSURANCE COMPANIES
THIS ENDORSEMENT CHANGES THE POLICY,PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE PART
INSURED:
WATERLINE TECHNOLOGIES INC
620 N SANTIAGO ST
SANTA ANA CA 927€31
1. 4`VFIO IS AN INSURED for 'bodily injury"and "property damage" liability is amended to include the Additiona€
Insured specified below but only with respect to liability arising out of your operations or premises owned by
or rented to you.
2. The insurance does not apply to 'bodily injury" or "property dar%tge' liability arising out of the sale
negligence of the Additional insured named below.
3. We agree to notify the Additional Insured named below at the address stated below of any cancellation of, or
material change to,this policy.
Relationship of the Additional Insured to the insured:
See IL-F-40-0028
Additional Insured Name and Address;
C.fTY OF EL SEGUN€O
3.%MAIN ST
EL SEGUNDO CA 90245
Includes copyrighted material of Insurance Services Office,Inc.with its permission.
CA-F-7;(10-13) Policy Number: 0023485 Transaction Effective Date:02-04-2019
EXTENSION ENDORSEMENT
Extension-CA-F-75-CITY OF EL SEC311NDO
ANY COVERAGE PROVIDED BY THIS ENDORSEMENT APPLIES ONLY WITH RESPECT TO
NAMED INSURED'S DELIVERY OF PRODUCTS TO CERTIFICATE HOLDER,ADDITIONAL
INSUREDS ALSO INCLUDE:CITY OF EL SEGUNDO,ITS OFFICERS,OFFICIALS,
E"MPLOYE"ES AND VOLUNTEERS,
IL-P-40-0029 (05-10) Policy Number:0623485 Transaction Effective Dale:02-04-2019
WATETEC-01 N'PILIPOSYAN
ACORN DATE(MMIDD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 113112019
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(s).
PRODUCER CONTACT
Paramount Exclusive Insurance Services,Inc. Pvc"r Ext):(818)986-7283 (A/C Na):(818)986-4949
---
15760 Ventura Blvd.Suite 500
Encino,CA 91436fsss:
................................ . .,NGCPVERAGE ................ NAIC#
INSURER(S)„A,F,F,O,RDI,,,,,,,,,,,,,,,,,,,,
INSURER A:Bench- .... 41394
Benchmark Insurance Co
INSURED INSURER R., ,....................... . ..................... ... .,....__,
Waterline Technologies,Inc. JN RER C:
620 N.Santiago St. inlsu,RER.P:
Santa Ana,CA 92701
INSURE,R..„E„..:............................ ......,............................. .....................,,...... ...........
INSURER F
.............
__. .....__ .........
COVERAGES CERTIFICATE NUMBER: R'EVIS'ION 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 3OLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSR IADDL SUER 'POLICY EFF ��PeOLICY EXP
LTR TYPE OF INSURANCE INSD WVp ICY NUMBER IMIMIpD/YYYYI_yxee•IDDIYVYYI •LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
_
.... CLAIMS-MADE I --- OCCUR ^DA_MAG I"'r—OREI+I"I'rO .N....... ................I
�"RIrvML��.�IFJI_la:�t al
—
„MED..E XP(Anv one person) $ ...
PERS,O•,,,NAL&,ADV INJURY $
GEN1 AGGREGATE LIMIT APPLIES PER: GE,N,ERA,I,,AGGREGATE $..................................__...
....... POLICY EJ%s F] LOC ..,PRODUCTS-COMPIOPAGG _$ ............................... __
OTHER.
AUTOMOBILE LIABILITY COMBINED��'INGLE LIMIT
$
ANY AUTO 060115
y a BODILY INJURY•IP,„e„r,parsonl $
LED
ALS ONLY ....•., AUTO(3N.Y pbPEcRdTYYUDDAAMAGEacpident $
AAUTOS ONLY NUGTOSU O I I $
p
_......._
. UMBRELLA LIAB N I�II OCCUR EACH OCCURRENCE $ .................... ....
�,,,,....Y......... A
G ,FCATE $.............................
A WORKERS COMPENSATION
CLAIMS-MADE......................_ IIII
.A • . ... STR UT.E .L.•, tl...ERH
DED RETENTION$ _ —
D�_._..m.._ -- - 1,000.
IC EMOPROIEOTOR/PIABILI REXECUTIVE X EACH
,000
q,MandE ,00 ,000
IN
ANY PR� �II”" mm ...
If yes,describe MBER EXCLUDED? f YY NIA X CST5013027 7/1/2018 7/1/2019 DISEASECEDA EMPLOYEE, 1,000,000
DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Waiver of.subrogation in favor of City of Segundo
_.. .............
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE City of Segundo ACCORDANCE WITH THE POLICY PROVISIONS. WILL BE DELIVERED IN
401 Sheldon St
EI Segundo,CA 90245 ”
AUTHORIZED REPRESENTATIVE
I ..............
ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06
(ed. 4-84)
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 2.0 % 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 Date: 7/1/2018 Policy No. CST5013027 Endorsement No.
Policy Effective Dates: 07/01/2018-07/01/2019 Premium $
Insured: Waterline Technologies Inc
Carrier Name/Code: Benchmark Insurance Company
WC 04 03 06
(Ed. 4-84) Countersigned by
Page 1 of 1