Loading...
PROOF OF INSURANCE (2020) CLOSEDAC 07/166//22019019 CERTIFICATE OF LIABILITY INSURANCE DATE (M L___._Y) 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). rNAO NTACT PRODUCER ME;Kathy Macias -Ramirez Millennium Corporate Solutions a,2 ._ „ext): (818) 844 4100 I FAX (818) 638-7920 An ISU Network Member #01_12555E -MAIL kathY m@ mcsins.com ADrJRESs: 550 N Brand Blvd #1100 I INSURERS) AFFORDING COVERAGE Glendale CA 91203 INSURED Trueline 1651 Market St Ste B Corona CA 92880-1710 INSURERA: Mt Hawley Insurance CO INSURER B: WestAmerican Insurance Company INSURER C: RSUI Indemnity Company INSURER D: Everest National Ins Cc INSURER E: $ 1,000,000 II INSURER F : 2,000,000 COVERAGES CERTIFICATE NUMBER: 2019-2020 REVISION NUMBER: THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWTHSTANDING 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. p INI TYPE OF INSURANCE INSD SWVRI 4 Y O POLICY NUMBER (MMIDD/YYYY) (MMIDDlYYYY) I LIMITS X COMMERCIAL GENERAL LIABILITY $ 1,000,000 CLAIMS -MADE Fx� OCCUR 50000 X $2,500 Ded - Per Occ $ , A Y MGLO189571 GEN"LAGGRIEGATE LIMITAPPLIES PER $ 1,000,000 PRO- POLICY 0 PRO F LOC 2,000,000 O'THE'R': $ AUTOMOBILE LIABILITY I $ 2,000,000 XII ANYAUTO V $ 1,000,000 B OWNED SCHEDULED BAS (20) 56945605 AUTOS ONLY AUTOS HIRED NON - OWNED i $ AUTOS ONLY AUTOS ONLY NX $ X COMP -$1K COLL-$1K $ X UMBRELLA LIA.B7XJ OCCUR C EXCESS LIAB CLAIMS -MADE NHA247633 DED XI R'E'TEN'T'ION $ 1,000 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/ N ANY PROPRIETOR/PARTNER/EXECUTIVE D OFFICER/MEMBER EXCLUDED? NIA 7600016618191 (Mandatory in NH) If yes, describe under ® DESCRIPTION OF OPERATIONS below 07/25/2019 07/25/2020 07/25/2019 07/25/2020 NAIC # 37974 44393 22314 10120 EACH OCCURRENCE $ 1,000,000 DA9iMAU:; I RENTED 50000 PREMISES PEa m4urrenca) $ , MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 2,000,000 GENERALAGGREGATE $ PRODUCTS - COMP/OP AGG I $ 2,000,000 Employee Benefits V $ 1,000,000 COMBINED SINGLE LIMVT $ 1,000,000 (Ea accidenO BODILY INJURY (Per person) i $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Weraccidonll I EACH OCCURRENCE $ 4,000,000 07/25/2019 1 07/25/2020 II AGGREGATE $ 4,000,000 I I $ XPER OT I STATUTE I I ERH 07/25/2019 07/25/2020 E1 EACH ACCIDENT I $ 1,000,000 E.L,DISEASE-EAEMPLOYEE $ 1,000,000 EL DISEASE -POLICY LIMIT I $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: City of EI Segundo Hockey Rink, The City of EI Segundo, its officers, officials, employees, agents, and volunteers are included as additional insureds with primary & non-contributory wording for General Liability as respects to the insureds operations and only if required by written contract per the attached endorsements. Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. CERTIFICATE HOLDER City of EI Segundo 350 Main St, EI Segundo I ACORD 25 (2016/03) 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 CA 90245 4QV_ ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Policy Number: MGLO189571 Mt. Hawley Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. 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 PART Name Of Additional Insured Person(s) Or Organization(s): All persons or organizations where required by written contract executed prior to the commencement of your work. SCHEDULE Location(s) Of Covered Operations: All Locations 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 in- not be broader than that which you are required clude as an additional insured the person(s) or organi- by the contract or agreement to provide for such zation(s) shown in the Schedule, but only with respect additional insured. to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or B. With respect to the insurance afforded to these in part, by: additional insureds, the following additional exclusions apply: 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: 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 re- pairs) to be performed by or on behalf of the addi- tional insured(s) at the location of the covered operations has been completed; or 1. The insurance afforded to such additional insured 2. That portion of "your work" out of which the injury only applies to the extent permitted by law; and or damage arises has been put to its intended use by any person or organization other than another 2. If coverage provided to the additional insured is contractor or subcontractor engaged in performing required by a contract or agreement, the in- operations for a principal as a part of the same surance afforded to such additional insured will project. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 Insured C. 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. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 2 of 2 Insured Policy Number: MGL0189571 Mt. Hawley Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS 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) Location and Description of or Organization(s) Completed Operations All persons or organizations where required by written All Locations and All Projects contract executed prior to the commencement of your work. 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 dam- age" 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 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 re- quired 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. 2. If coverage provided to the additional insured is required by a contract or agreement, the insur- This endorsement shall not increase the applicable ance afforded to such additional insured will not Limits of Insurance shown in the Declarations. 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 C Insurance Services Office, Inc., 2012 Page 1 of 1 Insured Policy Number: MGL0189571 Mt. Hawley Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION 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 (2) You have agreed in writing in a contract or agree - and supersedes any provision to the contrary: ment that this insurance would be primary and would not seek contribution from any other in - Primary And Noncontributory Insurance surance available to the additional insured. This insurance is primary to and will not seek con- tribution 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 © Insurance Services Office, Inc., 2012 Page 1 of 1 Insured 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 2% of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOM THE BLANKET WAIVER OF SUBROGATION NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER 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: 07/25/2019 Policy No. 7600016618191 Endorsement No. 001 Insured: Trueline Construction & Surfacing, 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.