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PROOF OF INSURANCE (2019 - 2020) CLOSEDRESCH-1 OP ID: C� A�Ro CERTIFICATE OF LIABILITY INSURANCE I DATE(MMIDDIYYYY) II 04/2312019 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 . Ro CT ..Way Cooper Service, Inc796-534-5'2 4( No, 'a„ i lam„ 34`2Car r Co round Book 52 FAX 765-534-2067 CoS P.P,lO. BoX 638 — I 1 c Lapel, IN 46051 E Steve B. Carraway �NsuRle s a�, .. prnl� COVERAGE I....� ._—. 41297 INSURE, A. ............ Scottsda Insurance ,, Co. Costruction Inc .... I ce Co 19446' U' D INSURER B : 5 �I�II nal Union Ire ns I Ba av "a treet gR p : -- Orange, ,lay INSURE a o INSURER,D,.:...._........,,,, _ ................__........... INSURER F: 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 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, E BEEN REDUCED BY PAID CLAIMS. PEXCLUSIONS Y E OF INSURANCE E LIABILITY POLICIES. LIMITS SHOWN Y Nu BERV t POLICY EFF POLICY EXP Im EACH OGGURRENCE„ 1,000,000 INA X COMMERCIAL G INAN O� � I � LIMITS$ CLAIMS -MADE X OCCUR RBS0018684 04/2212019 04122/2020 $ 000 __._ Rr t Eq aDAMAGE TO Erc�G'.g1.......... 100..... _...,, X XCU X X MED ,EXP,(Anyone, eRni........ 5000'1 ,.., 1 000000 OEN'L AGGREGATE LIMIT APPLIES PER: POLICY X JEST i LOC OTHER: AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS .......... AUTOS ONLY AUbO�Y EXCESS LIAB CLAIMS -MADE X X BE015104528 UMBRELLA UAB OCCUR X D V RETENTION $ DE WORKERS COMPENSATION AND EMPLOYERS" L%ABILITY Y d N ANYCCPROPRIETORIPARTNER/EXECUTIVE .. NIA 9.111 story i'n NH) EXCLUDED? If yes, describe under DESCRIPTION OF OPERATIONS below PER LI a OTH- —���,...xS.TwA.T.11.TE...�..�Eoli_.... ................... .... „E,L„„E,ACH,AGCIDENT $,,,,,,.... E,L,m,OISEASE - EA EMPLOYEE, $„ EL DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Prosect No. PW 1'8-33 HoIIyr Valle Playground Prosect Holly Ave S Va"By St., EI Se undo, CA --°Tire Cull of I Segunaio ist o cia�s S en wpioyees are additionainsured reg,ard'ing the general liability coverage' on a prwyrnary & non-'contributoof ry batsis Inc uding completed operations With a wfauw a C subrogation per written contract 8w forms CG2'033, CG2001, CG2404 , CG2037 CERTIFICATE HOLDER CANCELLATION ELSEGUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ATE THEREOF, City of EI Segundo ACCORDANCEIWITH THE POLICY PROVISIONS. WILL BE DELIVERED IN 350 Main Street EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD PERSONAI & ADV INJIJ,RY . _ 0001 G,ERAi,AGGREGATE ....................$ 2,000) 00) RO GTS - COMP/OP„AGG,,, S ..-, Prof Liab 1,0001,000 COMBNN'EDSIFdGLE LIMIT . BQDILY INJURY�,I?er,,,Perspn)___$ __� BQgILY INJURY .(Egr.eccidentZ $ ...........................__� P'ROPE'RT'Y DAMAGE _( er a-�defl,......................... __,............... __— 3"000,00,0 EACH-OGGURRENCE $„ 04/2212019 04/2212020 _AGGREGATE.... §...... 3,000',000 PER LI a OTH- —���,...xS.TwA.T.11.TE...�..�Eoli_.... ................... .... „E,L„„E,ACH,AGCIDENT $,,,,,,.... E,L,m,OISEASE - EA EMPLOYEE, $„ EL DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Prosect No. PW 1'8-33 HoIIyr Valle Playground Prosect Holly Ave S Va"By St., EI Se undo, CA --°Tire Cull of I Segunaio ist o cia�s S en wpioyees are additionainsured reg,ard'ing the general liability coverage' on a prwyrnary & non-'contributoof ry batsis Inc uding completed operations With a wfauw a C subrogation per written contract 8w forms CG2'033, CG2001, CG2404 , CG2037 CERTIFICATE HOLDER CANCELLATION ELSEGUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ATE THEREOF, City of EI Segundo ACCORDANCEIWITH THE POLICY PROVISIONS. WILL BE DELIVERED IN 350 Main Street EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD L... DE ELSEGUN� � ..... RESCH 1 PAGE 2 NOTEPAD: OP ID: CS Date HOLDERC NAME R.E. Schultz Construction, Inc 04/23/2019 I INSURED'S attached. Excess coverage follows form. 30 day notice of cancellation other than cancellation for non --payment of premium in favor of certificate holder applies to the general liability policy. COMMERCIAL GENERAL LIABILITY CG 20 33 0413 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 II — Who Is An Insured is amended to include as an additional insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured 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. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: 1. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. However, the insurance afforded to such This exclusion applies even if the claims against additional insured: any insured allege negligence or other wrongdoing 1. Only applies to the extent permitted by law; in the supervision, hiring, employment, training or and monitoring of others by that insured, if the 2. Will not be broader than that which you are "occurrence" which caused the "bodily injury" or required by the contract or agreement to "property damage", or the offense which caused provide for such additional insured. the "personal and advertising injury", involved the rendering of or the failure to render any A person's or organization's status as an professional architectural, engineering or additional insured under this endorsement ends surveying services. when your operations for that additional insured are completed. CG 20 33 0413 © Insurance Services Office, Inc., 2012 Page 1 of 2 2. 'Bodily injury" or "property damage" occurring after: 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 location 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 same project. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement you have entered into with the additional insured; 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 20 33 0413 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 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 Any person or organization when you and such person or organization have agreed in writing in a contract or agreement, executed prior to the "occurrence" to which this insurance applies, that such person or organization be added as an Additional Insured Installation, inspection or repair of playground equipment, ancillary fencing or playground surfacing as agreed in writing in a 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 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. 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 C Insurance Services Office, Inc., 2012 CG 20 37 04 13 0 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF FIGHTS 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: Any person or organization with whom the insured has agreed to waive rights of recovery, provided such agreement is made in writing and prior to the loss. 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 ❑ COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. &VOT"W": III . • • 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 ACC>RV CERTIFICATE OF LIABILITY INSURANCE DATE(MIYYDDIYYYY) 1 0310612019 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 pollcy(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 endorsement(s). PRODUCER rtlliAbe Rader Insurance rights to the,certifkate,holder In lieu o such= - (14) 21 C , (� CONTACT ,Mendez 730 E. Lincoln EMAIL 14)821-4148 Orange, CA 92865 atexpalberadorins.com License #: OC28298 q4M SI AFFORDING COVERAGE MAID s INSIJRERA: rc.urjJnsuonce Corn9my 138342 INSURED INSURER e RE. SCHULTZ CONSTRUCTION, INC INSURERC,- 1767 N Batavia St INSURER ID: Orange, CA 92865-4103INSURI R V u INSURERF: COVERAGES CERTIFICATE INUMSER, 0000100004 REVISION NUMBER: 1 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. . INSR TYPE AD BR ,LTR I.., POLICY NUMB I POLICY Isi•'F _ al POLICYEXP Y1 �� LIMITS .,. a' COMMERCIALGENERAL LIABILITY li EACH E OCCURRENCE �I CLAIMS•MADE ED OCCUR qq OA@1ASiE I'O�Y F� V S EXP (AnYone person) ,.is {MED 1j PERSONAL&ADVINJURY S CEN"LAGGREGATE ,LIMIT APPLIES PER: P GENERALAGGREGATE 5 PORCT0 LOC POLICY PRODUCTS -COMP/OPAGG S 0 EWS ..., A AUTOMOBILeuaeluTY BA04000004631fi Osl19l2018 06118120191'! r LI NGLELIAIiT s 1.000 000 1I ANYAUTO BODILY INJURY (Per person) 5 ONMEDSCHEDULED J„ AUTOS ONLY AUTOS BODILY INJURY (Peracoidenl) 5 HIRED ALTOS ONLY + NON-OVIMED AUTOS ONLY PROPERIY'DAMACE S IPer SII UMBRELLA LUI6�� OCCUR EXCESSUABCLAIMS-MADE DED V RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' UABRITY Y I N ANY PROPRIETORIPARTNERIEXECUTIVE OFMCERIMEMBEREXCLUDED? E-1 NIA (Mandalolyv In NH). IC&RIPr�ION 0„= Cdesaft iPERATIONS b.6, EACH OCCURRENCE 3 AGGREGATE $ I SSTTA UTE G 8 6TRH p E L EACHACCIDENT 5 IIW E L DISEASE- EA EMPLOYEE 5 R E.L. DISEASE- POLICY LIMIT 5 063CRIPTIomoFOPERATIDNB/LOCATIONSlVEHIOLES(ACORD 101,AddlllonalRemarks Schedule,maybe attached If men space is required) Project: Project No. PW 18-33 Holly Valley Playground Project Holly Ave & Valley St., EI Segundo, CA CERTIFICATE HOLDER City of EI Segundo 350 Main Street El Segundo, CA 90245 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATI Ni DATE TI�RI;OF, NOTICE WILL BE DELIVERED IN ACCORDANCI4!'ITH THEI OLIC'Y PROVISIONS. AUTHORIZED (JAH) CORPORATION, All rights reserved. ACORD 26 (2016103) The ACORD name and logo are registere5,4arks tv ACOR N6)ted by JAH on March 06, 2019 at 03:28PM vilS ei mRsEma T6HAtti ew THE PoLicY.pimaE IT-cApmLLY. BLANKET ADD17IONA,L INSURE? i'hIs atiBoreaara>+ntmadlbes irasas`omeepra�vk+ed underlhe fa3o�hhtp: BUSW sAM COVM409 FORM AAOT40R OAfRRIER CQVERAW FCSR@f TRLUMS COVER, GE FCFW il)Mo loomlonepr "fa an�t rnentthepmulaionsciOnC i�w emapp� unleas f mcd bylhsandoramrtara -The%7awlhgis iaid9dluths 9aoflon IF—LlebiliiSr Cosera� �'$q�IpItA4. iNhc ISAi1h>lsnraadPiOYis1011: Any pa an crownkaffon ftycu wa rorlUkad to WUde sada lftW d wed an Me Covmqp Fom to a wed+ �mragrea aaaClits#d�si9 d exaexakatclby9ctalaairasi$ao'boe�(rafaxrj r`P edydona9d' c� end �?h In �t0*9 ft pod pedael an°pasted"" i'or Lw bas anly i r damzgs n to wehkh dais Imumm = appltea arW aMy to the edeffl Ihatpeam or cMw9zbffom qwetmw Ss an tmsaaot~" wndar roe Who Is An iaasurod ptvbbn coOoMedinSartt'on IL iMCA204S0717 q 1 A j ,. Policy Number: Date Entered: 04/09/2019 AC "R CERTIFICATE OF LIABILITY INSURANCE DATE (DDIYYYY) 4/24MN/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 ' CONTACT The Hulett Agency O NAME" 13959 Saddlemood Drive prdO.NdJo.E rya (858) 618-5442 11AfC Nv), (858) 618-5444 ADDREMAIL huletta enc Poway, CA 92064 ADRSS: g y@ebcglobal.net INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Insurance Company Of the West 27847 InsuranCompany INSURED R E Schultz Construction, Inc. INSURER 8� N INSURER C: 1767 N. Batavia St I INSURER D: Orange, CA 92865 (INSURER E: INSURER F: 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 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, (NSR LTR TYPE OF INSURANCE IVSD Syp yyPOLICY NUMBER POLICY EMF POLdCY EXP LIMITS %MYN DDIYYYYY dMIhV DD�"fYYYd COMM'I RCtlAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR uRvIS 'f `, rure rMa) $ MED EXP (Any one person) $ �. PERSONAL &ADV INJURY $ GENL AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE S POLICY F JE T LOC PRODUCTS - COMP/OP AGG $ OTHER: AUTOMO BILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAa OCCUR EXCESppSLIAR I CLAIMS -MADE DED p I RETENTION $ WORKERS COMPENSATION AND 4MPLOYERS'LNAWLITY YIN ANY PROP RIE TO RMAR THE RIEXECUTIVF IA OF°FECEMMEMSER'IEXCtl.UDED? ""NIA,}r" (Mandatory In NHI 1 11 ppas desonbe under DESCRIIPTION' OF OPE RATIDNS below WSD 504757600 04/14/2019 L.RLwwlW'tU'161NULt 41 I $ (Ea addend) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ "PR J ,ttc a Yk�AMAUt $ Per' accoend EACH OCCURRENCE $ (AGGREGATE $ FtK UIH- STATU7E ER 04/14/2020 EL EACHACCIDENT $ 1,000,000 EL,DISEASE -EAEMPLOYEE ', $ 1,000,000 EL DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required) Project: PW 18-33 Holly Valley Playground Project Holly Ave & Valley Street E1 Segundo, CA Blanket Waiver of Subrogation Attached. CERTIFICATE HOLDER CANCELLATION City of E1 Segundo 350 Main Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE - THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS AUTHORIZED REPRESENTATIVE MUTkONY@OOCxaG$&MTKT'PE I ©1980-2015 ACORD CORPORATION. AIR rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Produced using Forms Boss Plus software www FonnsBoss com; Impressive Publishing, LLC 800-20B-1 9T7 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 34 . :-Wi 111 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/ORGANIZATION 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 04/14/2019 Policy No. WSD 5047576 00 Endorsement No. Insured R E SCHULTZ CONSTRUCTION INC Premium $ INCL. Insurance Company INSURANCE COMPANY OF THE WEST Countersigned By WC 99 06 34 (Ed. &00) INSURED