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PROOF OF INSURANCE (2020) CLOSED I DATE(MM/DD/YYYY) ` CERTIFICATE OF LIABILITY INSURANCE D2/26/2D,9 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 v REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. C0 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 endorsement(s). c PRODUCER ...., ...., .CONTACT 01 Aon Risk Services Central, Inc. 'jF90-Iwc FAX Chicago IL Office (WC.No.Ext); C866) 283-7122 800-363-0105 d ,200 East Randolph E-MAIL 2 Chicago IL 60601 USA ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Everest National Insurance Co 10120 _ Surplus Insurance Co shelter Clean Services Inc. INSURER B: AXIS Sur p mpany 26620 11065 Penrose Street — ' sun valley CA 91352 USA INSURER C: INSURER D: INSURER E: ................ ..................... .,.,.,.,.,.,.,..., INSURER F: COVERAGES CERTIFICATE NUMBER: 570075174920 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. Limits shown are as requested INSPt AUDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSO a>OVO POLICY NUMBER (MMID MM/pD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY RM8GL00008191 021 /261 EACH OCCURRENCE $1,000,000 p� DAMAGE TO RENTED _--_.......,. CLAIMS-MADE II X u OCCUR PREMISES(Ea occurrence) $500,000 X Contractual Liability MED EXP(Any one person) $10,000 ............................. PERSONAL B ADV INJURY $1,000,000 N GEMLAGGREGA—TEry LIMITAPPLIES PER: I GENERAL AGGREGATE _w $3,000,000 r POLICY PE LOC I PRODUCTS-COMP/OP AGG $3,000,000 CT0 OTHER: r A AUTOMOBILE LIABILITY RM8CA00016-191 02/28/2019 02/28/2020 COMBINED SINGLE LIMIT $1,000,000 � A RM8CA00017-191 02/28/2019 02/28/2020 /Ea accident) X ANYAUTO BODILY INJURY(Per person) C .................... ...........Z ( OWNED SCHEDULED BODILY INJURY Per accident r AUTOS ONLY AUTOS HIRED AUTOS NON-OWNED I PROPERTYDAMAGE ONLY AUTOS ONLY (Per accident) w X Comp/Coll$2,000 _ d e P00100008343101 02/28/2019 02/28/2020 EACROC OCCURRENCE $5,000,000 5,000,000 L) UMBRELLA[IAB X OCCUR X EXCESS LIAB CLAIMS-MADE ,000'000 I ww,..�.m.,.......Y 1 N V A EMPLO ERS'LIABILITY I COMPENSATION RM8WC00031191 02/28/2019 02�28/2020 E L1EA STATUTE ACCIDENT $1,000,000 1 OED RE'T'ENTION x PER ANY PROPRIETOR I OFFICER/MEMBER EXCLUDED? N/A • • (Mandatory in NH) YYLL��..��---�lll ELDISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $1,000,000 ......... DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) "w...l RE: City of El Segundo. City of E1 Segundo, its officials, officers, agents and employees are included as Additional Insured in --� accordance with the policy provisions of the General Liability policy. A Waiver of Subrogation is granted in favor of e - Certificate Holder in accordancwith the policy provisions of the Workers' Compensation policy. I CERTIFICATE 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. City of El Segundo AUTHORIZED REPRESENTATIVE Attn: PW Dept. 350 Main Street E1 Segundo CA 90245 USA ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000003447 LOC#: ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY NAMED INSURED Aon Risk Services Central, Inc. Shelter Clean Services Inc. POLICY NUMBER see Certificate Number: 570075174920 CARRIER NAIC CODE see certificate Number: 570075174920 I EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Excess Liability Policies Excess Liability - 2nd Layer $10,000,000 Excess $5,000,000 Policy # 023627617 Term: 2/28/2019 to 2/28/2020 Carrier: Lexington Insurance Company Limits: $10,000,000 occurrence / $10,000,000 Aggregate Excess Liability - 3rd Layer $10,000,000 Excess $15,000,000 Policy # CCU3977337 Term: 2/28/2019 to 2/28/2020 Carrier: QBE Insurance Corporation Limits: $10,000,000 Occurrence / $10,000,000 Aggregate ACORD 1011(2008/01) 0 2008 ACORD CORPORATION,.All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: RM8GL00008-191 COMMERCIAL GENERAL LIABILITY EFFECTIVE DATE: 02/28/2019 CG 20 10 0413 NAMED INSURED: Triangle Services Inc. 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) Location(s) Of Covered Operations As Required by Written Contract or Agreement 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 these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury", "property This insurance does nota I to "bodilyinjury" or damage" or "personal and advertising injury" property damage occurring after: apply caused, in whole or in part, by: 1. All work, including materials, parts 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 performance 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 injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of the same project. 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 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 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—Limits 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 Page 2 of 2 ©Insurance Services Office, Inc., 2012 CG 2010 0413 POLICY NUMBER: RM8GL00008-191 COMMERCIAL GENERAL LIABILITY EFFECTIVE DATE: 02/28/2019 CG 20 37 04 13 NAMES INSURED: Triangle Services Inc. 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) Location And Description Of Completed Operations As Required by Written Contract or Agreement I 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 2. If coverage provided to the additional insured is include as an additional insured the person(s) or required by a contract or agreement, the organization(s) shown in the Schedule, but only insurance afforded to such additional insured will with respect to liability for "bodily injury" or not be broader than that which you are required "property damage" caused, in whole or in part, by by the contract or agreement to provide for such "your work" at the location designated and additional insured. described in the Schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and CG 20 37 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 B. 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 applicable Limits of Insurance shown in the Declarations. Page 2 of 2 © ISO Properties, Inc., 2004 CG 20 37 07 04 13 POLICY NUMBER: RM8GL00008-191 COMMERCIAL GENERAL LIABILITY EFFECTIVE DATE: 02/28/2019 NAMED INSURED: Triangle Services Inc. CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: As Required by Written Contract or Agreement Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions: 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 damage arising out of your ongoing operations or "your work" done under 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 04 05 09 0 Insurance Services Office, Inc., 2008 Page 1 of 1 ❑ POLICY NUMBER: RM8GL00008-191 COMMERCIAL GENERAL LIABILITY EFFECTIVE DATE: 02/28/2019 NAMED INSURED: Triangle Services Inc CG 20 26 04 13 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): As Required by Written Contract or Agreement 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 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 acts or will pay on behalf of the additional insured is the omissions or the acts or omissions of those acting amount of insurance: on your behalf: 1. Required by the contract or agreement; or 1. In the performance of your ongoing operations; or 2. Available under the applicable Limits of Insurance shown in the Declarations; 2. In connection with your premises owned by or whichever is less. rented to you. However: This endorsement shall not increase the applicable Limits of Insurance shown in the 1. The insurance afforded to such additional Declarations. insured only applies to the extent permitted by 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 04 13 ©Insurance Services Office, Inc., 2012 Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule Any person or organization for which you have agreed to waive your rights of recovery in a written contract, provided such contract was executed prior to date of loss. 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 02/28/2019 Policy No.WC8WC00031-191 Endorsement No. Insured Triangle Services Inc. Premium Incl Insurance Company: Everest National Ins Co Countersigned by mm WC 00 03 13 (Ed.4-84) ©1983 National Council on Compensation Insurance. This page intentionally left blank.