Loading...
PROOF OF INSURANCE (2019 - 2020) CLOSEDA �'' CERTIFICATE OF LIABILITY INSURANCE DATE (MM/°°/YYY) 3/6/2019 THIS CERTIFICATE IS ISSUED ASA 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, 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 J B N United Insurance Services IWAME:... Greg Smith PHONE(805)418-1788 FAX N le051918-1789 ADDRESS! CA License No. OG19748 INSURERS AFFORDING COVERAGE NAIC# 270 Conejo Ridge Ave. Ste 205 INSURER A: Kinsale Insurance Com an __ Thousand Oaks CA 91361 INSURED '... INSURER B: American Fire & CasualtyCo INSURER C: Insurance Co of the West G 2 K Construction, Inc. INSURERD;Ohio SecuritV Insurance Com an 28348 Roadside Drive, Suite 205 INSURER .E : INSURER F: Agoura Hills CA 91301 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. YLTR LTR. TYPE OF INSURANCE ADOL SUBR POLICY NUMBER. POLICY EFF MM DDNYVV POLICY EXP MM DDIY Y LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGET6REN'T95 50,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea 4ccurcence $ MED EXP (Any one person) $ 5,000 A CLAIMS -MADE OCCUR X Y 100033795-3 11/20/2018 11/20/2019 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OPAGG $ 1,000,000 GENLAGG tGATE:LIMITAPPLIESPER: POLICY X PROJFCT LOC $ AUTOMOBILE LIABILITY CO' fiBINED 51NGLE� UMIT Era ae�;4dq�nl $ 1,000,000 ANYAUTO BODILY INJURY (Per person) $ ALL OWNED X 'SCHEDULED Xi BODILY INJURY (Per accident) $ B AUTOS '.. AUTOS XX NON -OWNED SAS55738783 /31/2018 /31/2019 PROPERTY DAMAGE $ Peke rcldsanl HIREDAUTOS AUTOS Medical payments $ B X UMBRELLA LIA13 X OCCUR EACH OCCURRENCE $ 4,000,000 A EXCESS LIAB CLAIMS -MADE AGGREGATE $ 4,000,000 100033750-23 11/20/2018 11/20/2019 DED RETENTION $ $ C WORKERS COMPENSATION Y X I WC STATU- OTH- IQ13Y LIMITS ER LIABILITY Y/N - ANY PROPRIETOR/PARTNER/EXECUTIVE (ND ROPRIIE ID E L EACH ACCIDENT $ -.... 1,000 000 E.L. DISEASE- EMPLOYEE $ 1000 000 ER EXCLUDED? Mandato NH) (Mandatory NIA 503998901 1/16/2019 1/16/2020 E..L. DISEASE- POLICY LIMIT $ 11000,000 If yes describe under DESCRIPTIONOF OPERATIONS below D Inland Marine — KS55738783 /24/2018 /24/2019 RentedlLEased Equipment 100,000 Equipment Floater Scheduled Equipment 72,854 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) 10 day notice of cancellation for non-payment of premium and 30 day notice for all other cancellations. The City of E1 Segundo, its officers, officials, employees, agents, and volunteers are hereby named as Additional Insureds in regards to the Named Insured's operations on behalf of the Certificate Holders per the attached endorsement. Waivers of subrogation have been issued in their favor. RE: PW 18-28 - Campus E1 Segundo Shade Structure Project 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 E1 Segundo 350 Main Street AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 Greg Smith/GES Cer&sx% I ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. Ail rights reserved. INS025 (201005),01 The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS SCHEDULED PERSON OR ORGANIZATION Attached To and Forming Part of Policy Effective Date of Endorsement Named Insured 0100033745-3 11/20/2018 12:01AM at the Named Insured G 2 K Construction 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 A. Section II — Who Is An Insured is amended to include B as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf, in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. 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 location of the covered operations has been completed; or 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 20 10 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 Date of Endorsement Named Insured 0100033745-3 11/20/2018 12:01AM at the Named Insured G 2 K Construction 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 Section II — 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 "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 04 © 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 Part of Policy Effective Date of Endorsement Named Insured 0100033745-3 11/20/201812:01AM at the Named Insured G 2 K Construction Inc address shown on the Declarations Additional Premium: Return Premium: $0 $0 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE ENVIRONMENTAL CONTRACTING AND PROFESSIONAL SERVICES LIABILITY COVERAGE The insurance provided to Additional Insureds shall be primary and non-contributory with respect to any other valid and collectible insurance available to the Additional Insured, provided that the written contract specifically requires that this insurance apply on a primary and noncontributory basis. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. CAS5003 0110 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHER TO US -BLANKET Attached To and Forming Part of Policy Effective Date of Endorsement Named Insured 0100033745-3 11/20/2018 12:01AM at the Named Insured G 2 K Construction Inc address shown on the Declarations Additional Premium: Return Premium: $0 1 $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 99 06 34 (Ed. 8-00) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - BLANKET 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 otherwise due. Person or Organization ANY PERSON / ORG WHEN REQUIRED BY WRITTEN CONTRACT 3 % of the total California Workers' Compensation premium Schedule Job Description ALL CA OPERATIONS 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 01/16/2019 Policy No. WVE 5039489 01 Endorsement No. Insured G 2 K CONSTRUCTION INC Premium $ INCL. Insurance Company INSURANCE COMPANY OF THE WEST WC 99 06 34 (Ed. 8-00) Countersigned By INSURED