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PROOF OF INSURANCE (2019 - 2020) CLOSED'"` 02/04/2019 CERTIFICATE OF LIABILITYINSURANCE II I DATE(MM/DD/YYYY) 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 riqhts to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT FEDERATED MUTUAL INSURANCE COMPANY PHONE CLI AIC No ....__ ENT CO ItAM.E:_........... ext X88 Fax HOME OFFICE: P.O. BOX 328 E-MAH OWATONNA, MN 55060 ADURL A........."." ......................9 . "JaPf{Ess: CLIENTCONTACTC, E,N"T,ER, FEDINS.COM INSURER(S) AFFORDING COVERAGE NAIC# —........_...,_.......... .........................-.,... INSURER A: FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURER B: INSURED .... 309-577-6 l I..... .......... .... .... ..., WATERLINE TECHNOLOGIES INC I INSURER C 620 N SANTIAGO ST SANTA ANA, CA 92701-3942 1:URER:D URER E: I INSURER F: COVERAGES CERTIFICATE NUMBER: 217 REVISION NUMBER: 0 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. iINSR ADDL SUER POLICY EFF POLICY LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER WMIDDIYYYYI (MMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED $100 DOD CLAIMS -MADE X OCCUR A S'E J'L AGGREGATE LIMIT APPLIES PER: X POLICY El PRO- LOC JECT OTHER: _AUTOMOBILE LIABILITY X- I ANY AUTO Y N 0623485 0623485 0623486 _)?REMISES (Ea occurrence) ..,......... _„„_.„„.„„ MED EXP (Any one person) A OWNED AUTOS ONLY AUTOSULED Y I N ......_---- ..._ .. GENERAL AGGREGATE NON -OWNED PRODUCTS - COMP/OP AGG HIRED AUTOS ONLY AUTOS ONLY $1,000,000.. X UMBRELLA LIAR X OCCUR BODILY INJURY (Per person) A EXCESS LIAB CLAIMS -MADE N N I W_ .. DED RETENTION .................................. ”. ...-." ........................ WORKERS COMPENSATION EACH AND EMPLOYERS' LIABILITY y� ry._.... ...... APER STATUTE 1OTH- ...-.".VV ER � ANY PROPRIETORIPARTNERIEXECUTIVE C DENT OFFICERIMEMBER EXCLUDED? ........ NIA (Mandatory in NH) II yes, describe under DESCRIPTION OF OPERATIONS below 0623485 0623486 _)?REMISES (Ea occurrence) ..,......... _„„_.„„.„„ MED EXP (Any one person) EXCLUDED 08/15/2018 08/15/2019 PERSONAL & ADV INJURY$1,000,000 - ......_---- ..._ .. GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $2,000,000 COMBINE �llSIi Gl..E..1LIMI.T....,.. $1,000,000.. BODILY INJURY (Per person) 08/15/2018 08/15/2019 BODILY INJURY (Per accident) m PROPERTY DAMAGE ”. ...-." ........................ EACH 08/15/2018 08/15/2019 AGGR GATE "RENCE - __................. ............. $8,000,000 ry._.... ...... APER STATUTE 1OTH- ...-.".VV ER � ................._.....,,�.................. C DENT �... EE^L.,.E.A EASE . - ...... L, DIS EA EMPLOYEE ........ E.L DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) SEE ATTACHED PAGE CERTIFICATE HOLDER CANCELLATION 308-577-6 2170 CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 MAIN ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EL SEGUNDO, CA 90245-3813 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 308-577-6 ................ LOC #: .............................................................................. ADDITIONAL REMARKS SCHEDULE Page 1 of AGENCY NAMED INSURED FEDERATED MUTUAL INSURANCE COMPANY WATERLINE TECHNOLOGIES INC ................................................_.........._............................_...._........................ 620 N SANTIAGO ST POLICY NUMBER SANTA ANA, CA 92701-3942 SEE CERTIFICATE # 217.0 CARRIER SEE CERTIFICATE # 217...0.............................._............................... NAIC CODE EFFECTIVE DATE: SEE CERTIFICATE ## 217.0 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: R,J,FICATf OF LIABILITY III,,RANC,E ,,,,,,,,,,,, ............................................................. .... ..... ALL OPERATIONS TO VARIOUS LOCATIONS IN CA. CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSURED UNDER THE GENERAL LIABILITY ON A PRIMARY AND NON-CONTRIBUTORY BASIS. THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED ON GENERAL LIABILITY SUBJECT TO THE CONDITIONS OF THE ADDITIONAL INSURED - OWNERS, LESSEES, OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION ENDORSEMENT. THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED ON BUSINESS AUTO LIABILITY. ..................... C g . ................. ACORD 101 (2008101) O 2008 ACORD CORPORATION. All ri hts reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 0623485 COMMERCIAL GENERAL LIABILITY CC 2010 04 13 THIS ENDORSEMENT CHANGES THE € OLICY. 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 PARE SCHEDULE 45�� e .. Name Of Additional Insured Person(s).......... .......................................... ..------ ._ ..... ...... Or CSrganization st. Location(s) Of Covered Operations :i'I Y QI EL SEGt3NOO"'._......................................................_.,..., ANY COVERAGE "PRCV€DED BY THIS... .,.,....,,........,..... 5tt MAIN ST ''NOOR SEMENT APPLIES ONLY WITH RESPECT TO EL SE6UNDG CA 902x5 'NAMED INSURED'$ DELIVERY OF PRODUCTS TO CERTIFICATE HOLDER. ADDITIONAL INSUREDS iA€.,Std INCLUDE: CITY OF EL SEGUNDO, ITS OFFICERS. OFFICIALS, EMPLOYEES AND -VOLUNTEERS, s 8nfnr­11m,i ion required to complote this Schedule, if not shown above, wiil be shown in the Dec€ara ions. A, Section II - Who Is An In oumd Is amended to include as an additional insured the person(s) or organizalion(s) shown in tine Schedule, but only with respect to liability for 'bodily injury", "propea'fy damage" or 'personal and advertising injury" causad, 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 sur,h 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. WATE=RLINE: TECHNOLOGIES INC 620 N SANTIAGO ST SANTA ANA CA q'1701 0. With respect to the Insurance afforded to these additional insureds, the following add€tiona€ 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 praiect (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 sante project. 10 Insurance Services Office, Inc., 2012 Page 1 of 2 CG 20 10 04 13 Policy Numlor: 0623485 Transaction Effective Date; 02.04-2019 C, With respect to the insurance afforded to these additional insureds, the following is added to Section III - Unthe 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 CC 20 10 0413 policy Number. O623485 Transaction Effective Date: 02-0.4-2019 FEDERATED INSURANCE COMPANIES THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE. PART INSURED: WA -1 ERL€NE TECHNOLOGiES INC 620 N SANTIAGO ST SANTA ANA CA 92701 1. VIII -10 IS AN INSURED for "bodily injury" and `property damage' liability is amended to include the Additional Insured specified below but only wittl respect to liability arising out of your operations or premises owned by or rented to ynu- 2. The insurance does not apply to 'bodily injury' or "property damage" liability arising out of the sole negligence of the Additional Insured named Wow. 3. We agree to notify the Additional Insured named below at the address stated below of any cancellation of, or material change to, this policy. Relationship of the Additional insured to the tnSUre& See IL -F-40-0028 Additional Insured Mame and Address: C4TY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO CA 90245 Includes copyrighted materia€ of Insurance Services Office, Inc. with its permission. CA -r-75 (10-13) policy Number: 0623485 Transaction Effect€ve Date: 02-D4-2019 EXTENSION ENDORSEMENT Ektenalott - CA -F-75 - CITY OF EL SEGilldDO ANY COVERAGE PROVIDED BY THIS ENDORSEMENT APPLES ONLY WITH RESPECT TO NAMED IN8URED'S DELIVERY OF PRODUCTS TO CERTIFICATE HOLDER. ADDITIONAL INSUREDS ALSO INCLUDE: CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEE$ AND VOLUNTEERS. IL -F-40-0028 (05-10) Policv Number: 0623485 Transaction Effective Date: 02 -CA -20319 WATETEC-01 SILOS.) mlNll �� CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 7/25/2019 _._.. Wvv....................................................mW....._ 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 M.MRACT , Paramount Exclusive Insurance Services, Inc. (ac No, Ext): (818) 986-7283 I INC, Ne):( 15760 Ventura Blvd. Suite 500 818) 986-4949 Enr_inn_ CO 97436 E-MAnt�a3S INSURED Waterline Technologies, Inc. 620 N. Santiago St. Santa Ana, CA 92701 .!NSURERfS1 AFFORDING COVERAGE INSURER A:Benchmar..Insurance Co. INSU„R,,,,E,R..®..R.................................. IRSURER..q..;............ INSURER D: INSURER E INSURER F e ...... ...... NAIL,#� ...... .413,94......—� ..................................... .I...................... COVERAGES CERTIFICATE NUMBER: R Vi '0ON ;MUMBER: 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. ILTR ...INSURANCE .. ....................... ADDL SUB POLICY NUMBER. ..,.......--- POLICY EFF POLICY EXP ................................................ TYPE OF ....... ... Y 1MMIDD/YYYYI-� IMMIDDIYYYYIIMITS .................. COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR DAMAGE TO RENTED DE'SCRI'PTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Waiver of Subrogation in favor of City of Segundo. CERTIFICATE. HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Ci Of Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City 9 ACCORDANCE WITH THE POLICY PROVISIONS. 401 Sheldon St 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 MED EXP (Any ongperson) $ ...PE,RS,PNAL & ADV INJURY $ ........................................ GEN'L AGGREGATE LIMIT APPLIES PER: G„ENERAL AGGREGATE _, _$ ........................................................_ p . ........N JET T S OM P/OP AGG $ .. OTOHpEi� VGL D SII E LIMY ($, AUTOMOBILE LIABILITY .. Q;I9.CB,dA grill .................. ANY AUTO BODILY INJURY ................. OSDONLY GL.....,I INJURY(Per accident) ,$ ..................................... E� NUTOSULED p ST 9 PROPERTYI gr.dc rl��nrt $ .......... AUTOS ONLY _.m.-...,.,.,_........... .—. � ALG'605 OI IL1' I,._.._._.................... 'A, ................................. _i._$... . .............................. j _..........--- UMBREL OCCUR EOCCURRENCE ........... EXCESS LIAR CLAIMS -MADE AGGREGATE .. ...........5 ... ....................... DEDRETENTION$ $ A WORKERS COMPENSATION .m _ PER X I 57,4T AND YI 'CST5016365 �,ORH 7/1/2019 7/1/2020 1'���'��Q ANY PROPRIETOR/PARTNER/EXECUTIVE X NYPROMEMBEREXRTNER/CLILIDE[� E L EACH,A, CPI,DEN $ f^i Yr NIA 1,000,000 I ands aryl in NH) F,.LDISEASE ,,.-...EA EMPLOYEE If yes, describe under .,S 1,000,000 DESCRIPTION OF OPERATIONS below E1_piSF.ASE -•POLICY LIMIT $ DE'SCRI'PTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Waiver of Subrogation in favor of City of Segundo. CERTIFICATE. HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Ci Of Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City 9 ACCORDANCE WITH THE POLICY PROVISIONS. 401 Sheldon St 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 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (ed. 4-84) 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 2.0 % 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 Date: 7/1/2019 Policy No. CST5016365 Endorsement No. Policy Effective Dates: 07/01/2019 - 07/01/2020 Premium $ Insured: Waterline Technologies Inc Carrier Name/ Code: Benchmark Insurance Company WC 04 03 06 (Ed. 4-84) Countersigned by Page 1 of 1