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PROOF OF INSURANCE (2019 - 2019) CLOSEDDATE(MMIDD/YYYY) C. CERTIFICATE OF LIABILITY INSURANCE 6/5/2019 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). License #0601094 tp °-ACT -° PRODUCERAMT J HO I 916 6'09 83612 ............... ........... ). _._... N e InterWest Insurance Services Pr"atir;tE FAX N� 916«979-7562 E„ canna a ar plWdns..co ......- d P.O. Box 255188 ADDRESS: )cadarette. m Sacramento CA 95865-5188 INSURER(S) AFFORDING COVERAGE mm NAIC# INSURER A: Financial Pacific Ins Company 31453 INSURED AMERI26 INSURERS: Arch Insurance Company 1.1.1.50 American Asphalt South, Inc__.....•. 14436 Santa Ana Avenue INSURER c , Travelers Prop Cas Co of Amer 25674 Fontana CA 92337 INSURER D: Westchester Surplus Lines Ins 10172........... ,INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 1492779648 REVISION NUMBER', THIS 15 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. .._._, .. INSURANCE INSD WV POLICY NUMBER IMOLIC--..-...W...•.•.....................•.•.•.. .•.•.•.•.•.•.•.•.•. ....•.•.•.. LTR TYPE OF INS... _:D°'.. POLICY EFF POLICY EXP INSR /YYYYI lMMdDDJYYVYi LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y 60423382 12/31/2018 12/31/2019 EACHOCCURRENCE $2,000,000 CLAIMS -MADE X OCCUR X Contractual Liab _X Ded. $5,000 GEN'L AGGREGATE LIMIT APPLIES PER. POLICY JECT ❑ LOC OTHER AUTOMOBILE LIABILITY X ANY AUTO •° OWNED SCHEDULED X AUTOS ONLY N AUTOS HIRED NON -OWNED AUTOS ONLYAUTOS ONLY X UMBRELLA LIAB X] OCCUR Y Y 60423382 EXCESS LIAR I CLAIMS -MADE DED["X" RETENTION $ 9 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE N/A OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below D POLLUTION LIABILITY ZUP71M8933018 Y ZAWC19413902 -6A'NiA�i '1'URENnrl „WI?REM,ISES,,(Ea occurrence) $,1,00,000 MED EXP (Any one person) s 5,000 PERSONAL&Apy,TJURY $2,000,000 ....................•.•.••.•.,.•...•.•.•.•.•.•.•.•.•.•.•.•.•.... GENERAL AGGREGATE $4,000,000 ...... ......•.•.•......_.....•.•.•., .•.•.•.•....•.•.•.•.•..... ...,. PRODUCTS - COMPIOP AGG $ 4,000,000 12/31/2018 12/31/2019 COMBINED SINGLE LIMIiT $ 1,000,000 .�,E�mn„ ea,�Cdertk' BODILY INJURY (Per person) $ BODILY INJURY (Per accident) PROPERTY' DAMAGE C'pw accldoml 12/31/2018 12/31/2019 EACHOCCURRENCE$_6,000.000 N AGGREGATE s 6,000,000 4/1/2019 4/1/2020 X PERP ^OTH- STATUTE C ER,_,,,,,m. E EACH ACCIDENT $ 1,000,000 .. ... .....•..w.,.. .......... ..�— ELDISEASE - EA EMPLOYEE $1,000,000 EL DISEASE -POLICY LIMIT $ 1,000,000 G70915613001 _ 8/27/2018 8/27/2019 LIMIT/EA OCC $2,000,000 LIMT/AGG $2,000,000 DEDUCTIBLE $10,000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Re; Project #PW19-19, FY 18-19 Slurry Sea$ Project, Additional Insured 'Status applies If required by Written contract per endorsement attached City of EI Segundo, its officers, officials, employees, agents, and volunteer. Per Project Aggregates applies to General Liability per the attached endorsement. Primary wording per attached endorsement. Waiver of Subrogallon applies to General Liability, Automobile Liability and Workers Compensation per the attached endorsements. 30 day notice of cancellation, except 10 day notice for non-payment of premium applies per policy provisions. I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE N THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN V City of EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS. Public Works Department Engineering Division 350 Main Street AUTHORIZED REPRESENTATIVE EI Segundo CA 90245 L M� fi ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Re: Project #PW19-19, FY 18-19 Slurry Seal Project. Additional Insured Status applies if required by written contract per endorsement attached City of EI Segundo, its officers, officials, employees, agents, and volunteer. Per Project Aggregates applies to General Liability per the attached endorsement. Primary wording per attached endorsement. Waiver of Subrogation applies to General Liability, Automobile Liability and Workers Compensation per the (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization is held liable for "your work" for that person or organization by or for you. This endorsement applies to the following work: Description of Job: See Above Location of Job: see Above Al only Effective from: Effective Date: 12/31/2018 Expiration Date: 12/31/2019 When this endorsement applies, such insurance as is afforded by the general liability policy is primary and any other insurance shall be excess and shall not contribute to the insurance afforded by this endorsement. CG 20 10 11 85 Modified (07-01) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. COMMERCIAL GENERAL LIABILITY CG 20 21 01 96 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - VOLUNTEER WORKERS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART WHO IS AN INSURED (Section II) is amended, to include as an insured any person(s) who are volun- teer worker(s) for you, but only while acting at the direction of, and within the scope of their duties for you. However, none of these volunteer worker(s) are insureds for: 1. 'Bodily injury" or "personal injury": a. To you, to your partners or members (if you are a partnership or joint venture), to your members (if you are a limited liability com- pany), to your other volunteer worker(s) or to your "employees" arising out of and in the course of their duties for you; b. To the spouse, child, parent, brother or sister of your volunteer worker(s) or your "employees" as a consequence of para- graph 1.a. above; c. For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in paragraphs 1.a. or b. above; or d. Arising out of his or her providing or failing to provide professional health care serv- ices. 2. "Property damage" to property: a. Owned, occupied, or used by, b. Rented to, in the care, custody or control of, or over which physical control is being exercised for any purpose by you, any of your other volunteer workers, your "employees", any partner or member (if you are a partnership or joint venture), or any member (if you are a limited liability company). CG 20 21 01 96 Copyright, Insurance Services Office, Inc., 1994 Page 1 of 1 0 Policy #60423382 COMMERCIAL GENERAL LIABILITY CG 20 32 07 98 Modified THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - ENGINEERS, ARCHITECTS OR SURVEYORS NOT ENGAGED BY THE NAMED INSURED This endorsement modifies insurance provided under the following, COMMERCIAL GEnIERA.L LIABILITY CCtVERA.GE PART SCHEDULE Name Of Engineers, Architects Or Surveyors Not Engaged By The Named Insured: o A.S PER ACORD25 CFRTfICATF OF INSURANCE (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. B Section II — Who Is An Insured is amended to include as an insured the architects, engineers or surveyors shown in the Schedule, but only to the extent suvh arohiteot, engineer, or surveyor iv hiekl liable for your ongoing operations performed by you or on your behalf. Such architects, engineers or surveyors, while not engaged by you, are con- tractually required to be added as an additional in- sured to your policy. With respect to such architects, engineers or sur- veyuls tMumi Irl We %13clluoule aUuve, Me lullvwlrlcg exclusion is added to Paragraph 2., Exclusions of Section I — Coverage A — Bodily Injury And Property DamaOa Liability and fiction I — Cov- erage B — Personal And Advertising Injury Li- ability: This insurance does not apply to "bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of or the failure to reridt-r eany inoludir ig: 1. The preparing, approving, or failing to prepare or approve maps, drawings, opinions, reports, c_urvQys, ohnngp nrders, docigns nr srgr_ifina- tions; and 2. Supervisory, inspection or engineering serv- ices. CG 20 32 07 98 Modified Page 1 of 1 I Includes copyrighted material of insurance Services'Office, inc., with its permission. POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY CG 24 0410 93 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF'' TRANSFER OF FIGHTS OF RECOVERY AGAINST OTHERS TO SNS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Re: Project #PW19-19, FY 18-19 Slurry Seal Project. Additional Insured Status applies if required by written contract per endorsement attached City of El Segundo, its officers, officials, employees, agents, and volunteer. Per Project Aggregates applies to General Liability per the (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMMER- CIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: 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 10 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 POLICY NUMBER: 60423382 ASDA AU 07 01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. FAU This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM SCHEDULE NAMED INSURED: American Asphalt South, Inc 14436 Santa Ana Avenue Fontana CA 92337 ADDITIONAL INSURED: Re: Project #PW19-19, FY 18-19 Slurry Seal Project. Additional Insured Status applies if required by written contract per endorsement attached City of EI Segundo, its officers, officials, employees, agents, and volunteer. Per Project Aggregates applies to General Liability per the attached endorsement. Primary wording per attached endorsement. Waiver of Subrogation applies to General Liability, Automobile Liability and Workers Compensation per the attached endorsements. 30 day WHO IS AN INSURED (SECTION II) is amended to include as an insured the organization shown in the Schedule above, but only with respect to the operation of vehicles owned by the named insured and operated on behalf of the named insured. This endorsement does not apply to any operations for other than the named insured. Each person or organization named above is an insured for liability coverage, but only to the extent that person or organization qualifies as an insured under the Who Is An Insured provision of Section II Liability Coverage. The additional insured is not required to pay for any premiums stated in the policy or earned from the policy. Any return premium, if applicable, declared by us shall be paid to you. You are authorized to act for the additional insured in all mailers pertaining to this insurance. We will mail the additional insured notice of any cancellation of this policy. If the cancellation is by us, we will give thirty days notice to the additional insured. The additional insured will retain any right of recovery as a claimant under this policy. ASDA AU 07 01 Page 1 of 1 POLICY NUMBER: 60423382 ASDA AU 07 02 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM SCHEDULE Name of Person or Organization: Re: Project #PW19-19, FY 18-19 Slurry Seal Project. Additional Insured Status applies if required by written contract per endorsement attached City of EI Segundo, its officers, officials, employees, The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV BUSINESS AUTO CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above be- cause of payments we make for bodily injury or property damage arising out of losses or accidents which occur during the policy period. This waiver applies only to liability you assume pursuant to a contract with the person or organization shown in the schedule. ASDA AU 07 02 Page 1 of 1 WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective on 6/5/2019 at 12:01 A.M. standard time, forms a part of (DATE) 'L Policy No. ZAWC19413902 Endorsement No. -14 of the Arch Insurance Company issued to American Asphalt South, Inc Premium (if any) $ (NAME OF INSURANCE COMPANY) Authorized Representative 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 *% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description ALL PERSONS AND/OR ORGANIZATIONS THAT REQUIRE A WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY FOR WORK PERFORMED BY YOU FOR THAT PERSON AND/OR ORGANIZATION WC 252 (4-84) WC 04 03 06 (Ed. 4-84) Page 1 of 1