PROOF OF INSURANCE (2019 - 2020) CLOSEDDATE (MM/DD/YYYY)
AC"RCERT WICATE OF LIABILITY INSURANCE 6/6/2019
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 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 GUN a At: a
NAME:
Western Republic Insurance Services o Ne. ExM 714.536.0500 I ( C, Na):
19900 Beach Blvd ADDRESS: dustin@wrinsurance.com
Suite F1 INSURER(S) AFFORDING COVERAGE NAIC #
Huntington Beach CA 92648 INSURER A: EVEREST PREMIER INS CO
INSURED INSURER B: KINSALE INS CO 38920
Golden Meters Service, Inc. ( INSURER C: CALIFORNIA AUTOMOBILE INS CO
14812 Hunter Lane I INSURER D: NATIONAL UNION FIRE INS CO OF PITT, PA
INSURER E:
Midway City CA 92655 I 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.
INSK TYPE OF INSURANCE AW.L.r'M'UD. r°t LUM Y W-1-FULn.Y ft-Al'
INSD WVD POLICY NUMBER (MMIDWYYYY) (MMIDD/YYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE F OCCUR
Y Y 01000320093
GEN'L AGGREGATE LIMIT APPLIES PER:
PRO.
POLICY F-1
_]
PRO. LOC
OTHER:
AUTOMOBILE LIABILITY
ANY AUTO
C ALL AUTOS OWNED X SCHEDULED Y
AUTOS
Y BA040000002873
X HIRED AUTONON-OWNED
AUTOS
V
X UMBRELLA LIAB X OCCUR
$ 100,000
D EXCESS LIAB CLAIMS -MADE
EBU13207526
DED I I RETENTION $
09/09/2018 09/09/2019
WORKERS COMPENSATION
$ 1,000,000
AND EMPLOYERS' LIABILITY Y I N
GENERAL AGGREGATE
ANY PROPRIETOR/PARTNER/EXECUTIVE
AOFFICER/MEMBER EXCLUDED? N/A
Y 7600020192191
(Mandatory in NH)
CGL
If yes, describe under
DESCRIPTION OF OPERATIONS below
$ 1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
Those usual to the insureds operations. A blanket additional insured and blanket waiver of subrogation are included with the general liability and
commercial auto policies. Additional insured status is automatically granted where required by written contract. A Waiver of Subrogation applies in favor of
Owners Parties for Workers Compensation, General Liability, Auto and Umbrella policies where required by written contract. The certificate holder is
named as additional insured where required by written contract.
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 St. AUTHORIZED REPRESENTATIVE
El Segundo, CA 90245 � �,�'' n1r
I
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
EACH OCCURRENCE
$ 1,000,000
unMAur r a.r me w i ru
PREMISESI'Ea occurrence)
$ 100,000
MED EXP (Any one person)
$ 5,000
09/09/2018 09/09/2019
PERSONAL & ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS - COMP/OP AGG
$ 2,000,000
CGL
$
a..4.)MUPNt6)'w"i tNkokI t LIMI I
(Era accident)
$ 1,000,000
BODILY INJURY (Per person)
$
11/02/2018 11/02/2019
BODILY INJURY (Per accident)
$
"Vet:K I Y VAMA4„wt,
$
(Por accldonl)
$
EACH OCCURRENCE
$ 4,000,000
09/09/2018 09/09/2019
AGGREGATE
$ 4,000,000
H-
I ( I
STATUTE ER
XX
03/07/2019 03/07/2020
EACH ACCIDENT
$ 1,000,000
E.L. DISEASE - EA EMPLOYEE $
1,000,000
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
Those usual to the insureds operations. A blanket additional insured and blanket waiver of subrogation are included with the general liability and
commercial auto policies. Additional insured status is automatically granted where required by written contract. A Waiver of Subrogation applies in favor of
Owners Parties for Workers Compensation, General Liability, Auto and Umbrella policies where required by written contract. The certificate holder is
named as additional insured where required by written contract.
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 St. AUTHORIZED REPRESENTATIVE
El Segundo, CA 90245 � �,�'' n1r
I
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) 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
0100032009-3 09/09/201812:01AM at the Named Insured Manuel Alba Moreno
address shown on the Declarations
Additional Premium: Return Premium:
$0 $0
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
J�-
SCHEDULE
Name of Additional Insured Person(s) or Organization(s): Location(s) of Covered Operations
Blanket, as required by written contract.
_ Y
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 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 2010 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WC 04 03 06
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 5 % of the California workers' compensation premium
otherwise due on such remuneration.
PERSON OR ORGANIZATION
CITY OF EL SEGUNDO
350 MAIN ST.
EL SEGUNDO, CA 90245
SCHEDULE
JOB DESCRIPTION
WATER METER TESTING
JOB NAME 2019 METER TESTING
JOB LOCATION: CITY OF EL SEGUNDO,
350 MAIN ST.
EL SEGUNDO, CA 90245
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 07/16/2019 Policy No. 7600020192191 Endorsement No. 003
Insured GOLDEN METERS SERVICE INC Premium $ INCL.
Insurance Company EVEREST PREMIER INSURANCE COMPANY
Countersigned By
-1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved.
From the WCIRB's California Workers' Compensation Insurance Forms Manual - 1999.
INSURED COPY