Loading...
PROOF OF INSURANCE (2020 - 2020) CLOSEDRESCH-1 QE IDLQ DATE (MMIDDIY0412312019YYY) .. CERTIFICATE OF LIABILITY INSURANCE 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('iss) 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 endorsemerltls). CD'oper In Book 79-f134.3152 ( ......�IAIc.Nel, . . PRODUCER ��cT St'ev'e B.,Carraw Insurance Service, Inc PHONE 765-534.31'52 FAIL 786'-634.2067' Pia_y roun AIC No Est): P,O^ ox 638 el, IN 46051 Steve B.Carraway INsuRERD6NGCOYERArE. NAICMlskFO .......... ... Ma1SURERA:Scottsdale Insurance Co. .41297' �._. In ra g'e'11T I Co tructi'on, Inc yaIREI:a:11 _ 46 National Union Fire Ins Co 194 AN, �+ a evil, street INSURER c IN'SUR'ER D ': IN'SURE'R 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, POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, EXCLUSIONSX COMMERCIALL OENERALOLIABIOLITYSH�O Ulrk — PQUCY EFF POLICY EIiP - P TYPE OF INSURANCE �r —' b POL9C'YNUMB'ER ( OpyyyyI � C � I LIMITS ��y�� H E'Q_ _ gM" - S 1,00,000 E�� _ LV�REN _E CLAIMS MADE a '- x OCCUR X X TO RENTED � 00'(j00 RBSOC I BS84 04/22/2019 04/22/2020 p' E � (ka dzu �"I S X!CCU 000 .. ....... �W.._. hI.CE,' An one ersarr,L 'S + ._........... UMPNLALS,AQ1( &URY S 1,000,000 GFN"L AGGREGATE LIMIT APPLIES PER:2,000',000 Rp G#:NERAL AGGREGATE' S POLICY FK !ECT F LOC P'RODUC'TS.C'OMP/OPAG_O . � 2'lltitl,I�IiB; --ProfOTHfR .t, 1-1-0-6610 00,00'0 b�' AUTOMOBILE LIABILITY .. �INiEd: �II+IGLE LMTJ)) I . _.... ANYAUTO UTSULEDUTAO ONLY AO „QaarsclwMl _SPO��INLYIN�6 RA3 $S �UTOS U0)ONLY A MGA S .. ._. � S UMBRELLA LIAR X OCCUR S EACH OCCURRENCE 3000 Q0 rRRENCE X EXCESS LIAB CLAIMS -MADE X X BE015104528 04/2212019 04/2272020 3,000,006 DED Z RETENTIONS � � WORKERS COMPENSATION YY PER IN AND EMPLOYERS" LIABILITY YIN �L�i E'.,, h ST'ATs IT R ANY PRROPPpRIETORIPARTNER1EXECUTNE �FIasM�, EXC'LUDEDa N IA,.& AHACCiDEF T S Ifs's, doumbe under E L DISEASE _ Eq EMPLOYEE S EACRIPTION OF OPERATIONS b ow E L,., DISEASE _ POLICY LIMIT S „ DESCRIPTION OF OPERATIONS /LOCATIONS I VEHICLES (ACORD 101, Addklorrei Remarks Schedule, may be attached V more space In required) Drotect No. PW Ill- 3 HolIy Valle' Playground Protect Holly Ave & Valley 6t,, l 'Se undo, CA--thle CClty of �I Segundo lilt o'flicials & mployees areIdd'i'tiona insured regarding the general liability coverage on a frrimery & CERTIFICATE HO'LD'ER City of E1 Segundo 350 Main Street EI Segundo, CA 90245 6' ACORD 25 (2016103) ELSEGUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD HOLDERGODE ELSEGUN RESCH-1 NOTEPAD: INSUREDS NAME R.E. Schultz Construction, Inc OP ID: CS ttached . .Excess coverage follows form. 30 day notice of cancellation ther than cancellation for non-payment of in favor of certificate holder applies to the general libbility Policy. PAGE 2 2019 Dole 041/231� COMMERCIAL GENERAL LIABILITY CG 20 33 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section U — 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. However, the insurance afforded to such additional insured: 1. Only applies to the extent permitted by law; and 2. Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: ♦ 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. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that Insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury', involved the rendering of or the failure to render any professional architectural, engineering or surveying services. 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 applicable Limits of Declarations. shall not increase the Insurance shown in the Page 2 of 2 0 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. A 1! 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 Installation, inspection or repair of playground person or organization have agreed in writing in a equipment, ancillary fencing or playground surfacing contract or agreement, executed prior to the as agreed in writing in a contract or agreement. "occurrence" to which this Insurance applies, that such person or organization be added as an Additional insured 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 park, 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 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 2 B. With respect to the insurance afforded to these additional insureds, the follovAng 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 0 Insurance Services Office, Inc., 2012 CG 20 37 0413 13 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 JIT1.41 k7A :012 9 1-14W-11 0 14.1 a :3 *&Aol a U lei i 1 0 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. P 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 06 09 C Insurance Services Office, Inc., 2008 Page 1 of 1 [3 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. L Y1 : , a L .1 1 0 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 (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the This insurance is primary to and will not seek additional insured. 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 CG 20 01 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1 AC40RV CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYY1) �wa...•-""" I 06/13/2019 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. YIMPORTANT: 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 .-..........---..._._......_.-_... NAME: Carol KreaX, Debbie S. Taylor or Debbie Waler KGIB, INC. PHONE FAX �...(gl(t+Jc._.._.(71'4) 744-6537 ...................." KNOX GENERAL INSURANCE BROKERS E, MAIL t�p4)kgpb8nc3aom, debbie kgibinc,com ordWapler dtgibinc.com 226 SOUTH GLASSELL STREET INSURERj§) AFFORDING COVERAGE NAIL # ORANGE CA 92866 INSURERA: CALIFORNIA AUTOMOBILE INSURANCE CO. 38342 INSUREDiN ............................._ _ ..................._........ SURER B: ............................................ R.E. SCHULTZ CONSTRUCTION, INC INSURER C: 1767 N BATAVIA STREET INSURER D : INSURER E ORANGE CA 92865-4103 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 'ERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH 'OLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LT .......................................................... IN. WV.-...................................... .. ..... y"OFF1 NSR A-D$ORL Sett ......................._... PMIDDI 'EFF.... WMld$...Y EXP ........ R TYPE OF INSURANCE D POLICY NUMBER IMMI D DCV—Exp LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEurmn$ CLAIMS -MADE l: l OCCUR(..._................W............................................................ E'dl u�nceti $ ..,_........_,.-..................................-......_ ...MED E� P (Any one person) $ --N/A-" PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ ® PRO ..,-.....-....-�........... ..� ................ POLICY ❑ JECT LOC PRODUCTS - COMPIOP AGG$.....-.....m._.-............................................... . OT'H'ER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT E1agCA0000...... .-.......................................... $ 1,000,000 ANYAUTO BODILY INJURY Perperson) $ A„,,, AUTOS ONLY _"'+ SCHEDULED X BA040000046316 06/19/2019 06/19/2020 BODILY INJURY (Per accident) $ X HIRED NON -OWNED PROPERTY DAMAGE $ OWN ............... AUTOS AUTOS ONLY X,,,, AUTOS ONLY JEer ggp.A n)1 UMBRELLA LIAB ]__� OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE —N/A -- AGGREGATE $ DED I RETENTION $ �- WORKERS COMPENSATION PER OTH AND EMPLOYERS' LIABILITY Y / N STATUTE I I ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ NIA --N/A--.�..-..._..._.................._....................... ....................................� (Mandatory In NH) E„L. DISEASE - EA EMPLOYEE $ Fyes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) PROJECT NO. PW 18-33, HOLLY VALLEY PLAYGROUND PROJECT, HOLLY AVENUE & VALLEY STREET, EL SEGUNDO, CA THE CITY OF EL SEGUNDO ITS OFFICIALS AND EMPLOYEES ARE NAMED AS ADDITIONAL INSURED PER FORM MCA85100817-CA WITH RESPECT TO AUTO LIABILITY AS REQUIRED BY WRITTEN CONTRACT/PERMIT. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF EL SEGUNDO ACCORDANCE WITH THE POLICY PROVISIONS. 350 MAIN STREET AUTHORIZED REPRESENTATIVE EL SEGUNDO CA 90245 .. •�, . .,....�” • „_ '� - -�^”` ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD THIS &=RSEIEW CHANOBS THE POL CI PLEUR R TrOAR@FIR,LY. BLAWET ADDITIONAL INSURED . 'i'hleaaidor>ur�ntmodlbee� ceproatiaedunderihe &IMRCARRPBRCOMMAOEFOW FOM Rf�iilrraa taoaaw�q�a " 6p�endQaew�tengthapwwfe6esciCwed� +aPawmepp�rwh>rts Any � tay � erfCaraaaE» -ThelhlmWlhBiead�ladbihe�p—Lhbilll�Cos�ereQe�;�phl�l.iNi►abA�lcmind8tovk�orl: oro Qlatyrau womqdad to tlrodUftw *W dY =ed an Ma c4vova Ftp►to e vmvoh =r*act l ta'&od�vNur� pr" o dy Via'" wrhar�wi�iaerroa,ar�sard'�tPadP„s ituwiar awe " m�at� uedat'e Who1eAn kmtnvd wa ood*ewitnaatton IL UICA,20480711 0� f a 3 � tl E k f � a c w r� . Y d 1 f � " a 7 a. z x 0 a w g . Y d f w � " a 7 a. z x .r++rlr Policy Number: Date Entered: 04/09/2019 AC OR" DATE (MMI DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE I 4/24/2019 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 pollcy(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). ONlgl.l PRODUCER The Hulett Agency NAAE: 13959 Saddlelrood Drive pncN ah,: (858) 618-5442 FAX Nos: (858) 618-5444 Poway, CA 92064 ADpREss, hulettagenc'y8 abcglobal . net INSURER(S) AFFORDING COVERAGE NAICk INSURER A: Mururaince C=Pww of the West 27847 INSURED R E Schultz Construction, Inc. INSURER B: INSURER C: 1767 N. Batavia St Orange, CA 92865 INSURER D: INSURER E: INSURER F: COVERAGE'S CE'R'TIFICATE 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. INBR "" AOOL'BUUR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD NMo . POLICY NUMBER • iMNW DOAYYYYI INAW OONYYYI LIMITS COMMERCIAL GENERAL LIABILITY y EACH OCCURRENCE $ CLAIMS-0AADE OCCUR YE L#VA5 tlEt axe$ $ MED EXP (Any one person) $ _ PERSONAL &ADV INJURY S GENLAGGREGATEpLIMITAPPLIESPER: GENERAL AGGREGATE S JR Poucy F7 M LOC PRODUCTS -COMPIOPAGG $ OTHER: AUTOMD BILE LIABILITY' ANY AUTO ®""- OWNED SCHEDULED AUTOS ONLYAUTOS " ® HIRED NON -OWNED AUTOS ONLY H AUTOS ONLY UMB RELLA LIAROCCUR �. EXCESS LIAR F7 CLAIMS -MADE DED RETENTION $ WORKERS COMPENSATION AND EMPLOVERWLIABILMY YIN ANY PROPRIETORIPARTNERIEXECUTIVE NIA WSD 504757600 A OFFICERIMEMBER EXCLUDED? y (Manda4my In NH) under " IR ON OFOF CPERATIONS below DEB CRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached d more space is mquimd) Project: PW 18-33 Holly Valley Playground Project Holly Ave & Valley Street E1 Segundo, CA Blanket Waiver of Subrogation Attached. CERTIFICATE FOLDER CANCELLATION City of El 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 1,.X.A,.. Ken! \ en, \ g . 1 01988.2015 ACORD CORPORATION, All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Produced Using Fore Boas Plus soRwme www.FormsBose.cDrn; Impressive Publishing, LLC 800.208-IWR $ MiGY iNL�:.L:LgrAuh $ BODLYINJURY(PerperSon) $ BODILY INJURY (Per wdded) $ (.r1'La"L�:HI Ca MAW. $ - $ EACH OCCURRENCE $ AGGREGATE $ I STATUTE I I ERN 04/14/2019 04/14/2020 EL EACHACCIDENT S 1,000,000 EL DISEASE -EA EMPLOYEE $ 1,000,000 VELDISEASE- POLICY LIMIT $ 1,000,000 DEB CRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached d more space is mquimd) Project: PW 18-33 Holly Valley Playground Project Holly Ave & Valley Street E1 Segundo, CA Blanket Waiver of Subrogation Attached. CERTIFICATE FOLDER CANCELLATION City of El 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 1,.X.A,.. Ken! \ en, \ g . 1 01988.2015 ACORD CORPORATION, All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Produced Using Fore Boas Plus soRwme www.FormsBose.cDrn; Impressive Publishing, LLC 800.208-IWR 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/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. 8.00) INSURED