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PROOF OF INSURANCE (2019 - 2020) CLOSED.✓"""" POLAELE-01 'DONMOI A<:X ,?L> CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 4/18/2019 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(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). PRODUCER License # OL48969aPCT Carrie Conejo 135 ( Noy ....... C3 Risk &Insurance Services PHOS 404 Camino Del Rio S. STE 410 No„ Ezty (619 385 San Diego, CA 92108p,'". carrfeiRc3%ns'urance.com ..........................................................INSLlfiE.���LAFFORDING„COyE,Rl1GE.................................................L............NAI,C #.............. INSURER A : Middlesex Insurance Co an 23434 - �..... P . Y ....... INSURED INSURER B: Security National Insurance Company 19879 POLARIS ELECTRIC CO INC INSURER C: 1216 E IMPERIAL AVE INSURER D: EISegundo, CA 90245................................................................................................ INSURER E : ....................... INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: n 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 DOLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBRM POLICY NUMBER POLICY EFF POLICY EXP LIMITS I.TR INSD WVD WMIDDIYYYYI IMM/DDIYYYYI A X COMMERCIAL GENERAL LIABILITY OCCUR A0122519 3/18/2019 3l18/20205000 µ gFPP 00 CLAIMS-MADE X I EACH _ OCCURRENCE 1,000,000 ........ ... . � ! P... �E Fid RENTED �.................................................'............... nE,QEXP.(?.x ane..aarsa...........$.................................................5,000 PER3QNAL&,ALV INJ,URY,_,,,_ „S1,000,000 .. GEN'L AGGREGA'P "LIMIT APPLIES PER: _GENERAL AGCRE ATE $ 3,000,000 POLICY �_7a F] LOC PRODUCTS - COMP/OP AGG $ 2,000,000 OTHER:$ ....... .a....m__.._......m.... .................... A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 X ANY AUTO A0122519 3/18/2019 3/18/2020 gpplLVrINJURV (Per.Aerson),....- ,$, � �y+� PRIUP $ OWNED SCHEDULED P AUTOS ONLY AUTOS Y INJURY Per accdenl $ HIRED X. A%.ITNO'"z01�4k E'R YDAMAGE X AUTOS ONLY ...�,...er,,,succi,_e.EwL.......................................................................................................................... II $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ EXCESS LIAB CLAIMS-MADE A0122519 3/18/2019 3/18/2020 5,000,066 DED I X I RETENTION $ 0 $ q PER B WORKERS COMPENSATION �Y I N� NIA A SWC1196823 6/1/2018 6/1/2019 E D OR 1,000,000 ANY PER/MEn NH /PARTNER/EXECUTIVE E'mW......_.-"".�""'" 'm'.....'-..'..... 11000000 CYF Dti R ryEMBE j EXCLUDED? Y,,. E L DISEASE EA EM PLOYEE .........................................................'............ �(NMtl L EACH ACCIDENT . .._...............�...........- �....._ , .........,..EE,, $ YYY If yes, describe under 1,000,000 DESCRIPTION OF OPERATIONS below E L. DISEASE - POLICY LIMIT $ A RentedlLeased Equip A0122619 3/18/2019 3/18/2020 Limit 100,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Additional Insureds are included as, where re Iu red by written contract as respects to General Liability, Auto Liability, General waiver of subrogation, Auto waiver of subrogation, General Liability Primary Non -Contributory wording, and Workers Compensation waiver of subrogation, but limited to the operations of the Insured under said contract, and always subject to all the policy terms, conditions and exclusions per endorsements attached. Commercial Umbrella follows form according to the terms, conditions, and endorsements found in the policy. Re Project: Project NO.: 19-27, New pedestal meter at 101 W, Imperial AVE. EI Segundo, CA 0 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CI Of Se THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: A0122519 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 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) m ... ........._._............... Any person or organization from whom you are required to waive your right to recover under a written contract or agreement in effect prior to any loss or damage Location(s) Of Covered Operations All locations per written contract, agreement or permit Description: All jobs performed that have a written contract, agreement or permit 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. include 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. However: 1. The insurance afforded to such additional 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. 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. CG 20 10 0413 C Insurance Services Office, Inc., 2012 Page 1 of 2 C. 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 ©insurance Services Office, Inc., 2012 CG 2010 0413 POLICY NUMBER: A0122519 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 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) Location And Description Of Completed Or Organization(s) Operations .....-........_..... _.... _­ .............. Any person or organization you are required to add as Jobsites as described in contracts. Codes per the an additional insured under a written contract or General Liability Declaration Page. agreement in effect prior to any accident, injury, loss or damage. 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 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 designated and 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 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. 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. CG 20 37 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: A0122519 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO HS 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: Any person or organization from whom you are required to waive your right to recover under a written contract or agreement in effect prior to any loss or damage 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 ©Insurance Services Office, Inc., 2008 Page 1 of 1 POLICY NUMBER: A0122519 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: A0122519 COMMERCIAL AUTO CA 76 01 06 15 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED - PRIMARY AND NONCONTRIBUTORY - COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM AUTO DEALERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated. Named Insured: Polaris Electric, Inc. Endorsement Effective Date: 3/18/2019 SCHEDULE Name Of Person(s) Or Organization(s): Any person or organization you are required to add as an additional insured under a written contract or agreement in effect prior to any accident, injury, loss or damage. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in: (1) Paragraph A.1. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms; or (2) Paragraph D.2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form. B. Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other auto insurance issued to the person or organization in the schedule under your policy provided that: (1) The person or organization is a Named Insured under such other insurance; and (2) Prior to the "accident' you have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the person or organization. CA 76 01 06 15 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1 with its permission. POLICY NUMBER: A0122519 COMMERCIAL AUTO CA 20 48 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Polaris Electric, Inc. Endorsement Effective Date: 3/18/2019 SCHEDULE Name of Person(s) or Organization(s): Any person or organization from whom you are required to waive your right to recover under a written contract or agreement in effect prior to any loss or damage Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1 POLICY NUMBER: A0122519 COMMERCIAL AUTO CA 04 44 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVED OF SUBROGATION) This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Polaris Electric, Inc. Endorsement Effective Date: 3/18/2019 SCHEDULE Name(s) Of Person(s) Or Organization(s): Any person or organization from whom you are required to waive your right to recover under a written contract or agreement in effect prior to any loss or damage Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us Condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the 'loss" under a contract with that person or organization. CA 04 4410 13 © Insurance Services Office, Inc., 2011 Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) 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% 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 6/1/2018 Policy No. SWC1196823 Endorsement No. 0 Insured POLARIS ELECTRIC CO., INC. Premium $ 64803 Insurance Company Security National Insurance Company Countersigned by WC 04 03 06 (Ed. 04-84)