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PROOF OF INSURANCE (2020 - 2020) CLOSED
' `R 0 CERTIFICATE OF LIABILITY INSURANCE �TE(I�D 06272019 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 terns and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer Hants to the certificate holder in lieu of such endorsement(s). PRODUCERQNTA ,ENTER FEDERATED MUTUAL INSURANCE COMPANY PHONE C CONTACT NAME CLIENT ,., 949........... � IFAXOAIC, Nut: 507 46-4&54 .... ................................ HOME OFFICE: P.O. BOX 328 [+..I..Mq,*.E?!1'_SS&.gym ......... OWATONNA, MN 55060 1 IAAIL ADDRESS: CUENTCONTACTCE,NTEft FEDINS.COM INSURER(S) AFFORDING COVERAGE NAIL # _......................................._._........._..-.-................................. ....................... INSURER A: FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 308-577-6 INSURER B: WATERLINE TECHNOLOGIES INC INSURER C: ' 620 N SANTIAGO ST SANTA ANA, CA 92701-3942 INSURER D: INSURER E:..................... . :............................................................................................................ ............................... _______....,.,....... . .. 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. INSR 19DL SUB,R POLICY EFF POLICY EXP LTR TYPE OF INSUR'AN'CE IrUSR VP,![y POLICY NUMBER IMMIDDIYYYYI IMMIDDIYYYYI LIMITS X I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 7 DAMAGE TO RENTED $100,000 —]CLAIMSMADE ❑X OCCUR MED EXP (Any one person) EXCLUDED A I Y N 0623485 08/15/2019 06/15/2020 PER SONAL$ ADV INJURV $1000 000 (POCKY ................_'...,.,........'................... L.J. SPER: GENERAL AGGREGATE $2,000,000 X ! ❑ � ❑ WWW............................000,000 O �N'L AGGREGATE LIMIT APPLIES X LOG PRODUCTS - COMPIOP A00 $2,000,000 OTHER: AUTOMOBILE LIABILIVY COM .,sBINED SIhdOSINGLELY�GddT $1,000,000 's lMndY X ANY AUTO BODILY INJURY IPer person) SCHEOUIED„,,,,,......................... A OWNED AUTOS ONLY AUTOS Y N 0623465 08/15/2019 08/15/2020 BODILY INJURY (Par accident! NON -OWNED ........................................... PROPERTY AMAGE HIRED AUTOS ONLY AUTOS ONLY g,'np,r� a;�Eylle�plPj _ UMURELLA LIAR X OCCUR EACH OCCURRENCE $8,000,000 A EXCESS LIAB CLAIMS -MADE N N 0623486 08/15/2019 08/15/2020 (AGGREGATE $8,00(),000 . RETENTION .,�...,�...,�...,�...,�...,�.Y ., 1 ... .. WORKERS COMPENSATION w --r 1 OTH- AND EMPLOYERS' LIABILITY (PER STATUTE ER . ANY PROPRIETORIPARTNERIEXECUTIVE EL EACH ACCIDENT OFFICERIMEMBER EXCLUDED? r N I A (Mandatory in NH) E L DISEASE - EA EMPLOYEE It yes, describe under E L DISEASE . POLICY LIMIT DESCRIPTION OF OPERATIONS beloW DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addlbonal Remarks Schedule, may be attached i1 more space is required) SEE ATTACHED PAGE CERTIFICATE HOLDER CANCELLATION f 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 © 1966-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 308-577-6 .......................... ............... _.......................... .� LOCAt _............................................................................................................................................................................................................... AC"RVV� i*�" ADDITIONAL REMARKS SCHEDULE Page 1 of AGENCY NAMED INSURED FEDERATED MUTUAL INSURANCE COMPANY WATERLINE TECHNOLOGIES INC ................. _..................................................................................... 620 N SANTIAGO ST pol1CY NUMBER SEE CERTIFICATE # 217.0 SANTA ANA, CA 92701-3942 CARRIER NAIC CODE SEE CERTIFICATE 217.0 eE�ec....._...,. _•SEE'CERTIF.............I'll ................._............. _.__.._._._-...-..-............................. _............ ................ ...., # EFFECTIVE DATE: CERTIFICATE # 217.0 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITYIN5.0ANQE..._.................... .. 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. ACORD 101 (2008/01) O 2OD8 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. �I • • . W • . • S 1 i K . Z, • • 11 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 and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek 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 (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. © Insurance Services Office, Inc., 2012 Page 1 of 1 CG 20 01 04 13 Policy Number: 0623485 Transaction Effective Date: 08-15-2019 POLICY NUMBER: 0623485 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Name Of Additional Insured Person(s) Or Organizations: _............... CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO CA 90245 SCHEDULE Location(s) Of Covered Operations ...�............................ ........... ANY COVERAGE PROVIDED BY THIS ENDORSEMENT APPLIES ONLY WITH RESPECT TO NAMED INSURED'S DELIVERY OF PRODUCTS TO CERTIFICATE HOLDER. ADDITIONAL INSUREDS ALSO INCLUDE: CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES AND VOLUNTEERS. .. ............... 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", "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. 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. WATERLINE TECHNOLOGIES INC 620 N SANTIAGO ST SANTA ANA CA 92701 B. 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. © Insurance Services Office, Inc., 2012 Page 1 of 2 CG 20 10 04 13 Policy Number: 0623485 Transaction Effective Date: 08-15-2019 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. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13 Policy Number: 0623485 Transaction Effective Date: 08-15-2019 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: WATERLINE TECHNOLOGIES INC 620 N SANTIAGO ST SANTA ANA CA 92701 1. WHO IS AN INSURED for "bodily injury" and "property damage" liability is amended to include the Additional Insured specified below but only with respect to liability arising out of your operations or premises owned by or rented to you. 2. The insurance does not apply to "bodily injury" or "property damage" liability arising out of the sole negligence of the Additional Insured named below. 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 Insured: See IL -F-40-0027 Additional Insured Name and Address: CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO CA 90245 Includes copyrighted material of Insurance Services Office, Inc. with its permission. CA -F-75 (10-13) Policy Number: 0623485 Transaction Effective Date: 08-15-2019 EXTENSION ENDORSEMENT Extension - CA -F-75 - CITY OF EL SEGUNDO ANY COVERAGE PROVIDED BY THIS ENDORSEMENT APPLIES ONLY WITH RESPECT TO NAMED INSURED'S DELIVERY OF PRODUCTS TO CERTIFICATE HOLDER. ADDITIONAL INSUREDS ALSO INCLUDE: CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES AND VOLUNTEERS. IL -F-40-0027 (05-10) Policy Number: 0623485 Transaction Effective Date: 08-15-2019 .,w WATETEC-01 SHOS'9tl CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 7/25/2019 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 olic les) must have ADDITIONAL INSURED provisions or b p y(' p e endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain poli'ci'es may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endocaement(s). PRODUCER (' N� Eatir (616 �_.�.....�....�....._ PH�NE F 167 Encino,Ventura9Bl Exclusive Insurance Services, Inc. p 986-7283 '' 986-4949 15760 Vnta Blvd. Suite 500 ) EW AiL 995.:...1...... INSURER A . 8 INS'UR RIS) AFFORDING COVERAGE NAIC' F" � Insurance Co. 41394 INSURED 1 .,m._ _ �I�RER B ; Benchmark ,....IT.......__..........._ ....... ....._ Waterline Technologies, Inc. Ns UR'Ea�:: _..... 620 N. Santiago St. INsiRfw.. p . Santa Ana, CA 92701 uS-9–RER.k..?.....................,.. ....w... ... ...... .. x._.. _ww..._ iNSUR'ER F : V 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 AN CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY BEEN REDUCED BY D CLAIMS. IITRR TYPE OF INSURANCE INSO ^.Sw o 'MI�1�GY Y1 P Ltl',CY EdIP h LIMITS Y.tLI AL LIABILITYEACH COMCLAIMIS OCCr..�RRE.N.9�..—_ $ ..,,,,,, ......, ... p YI MADE)OCCUR OCCUR -.,..,.._......, DAMAGE $t REQN7E0 B,E)�ilSl~..'iEli.ssQCrsll!isa34 _. _1__ . .................... ... MED EXP (Anv one oersoU),__$ PERSONAL&APV INJURY S N'L AG ATE LIMIT APPLIES PER: e. GE.. AGGREGATE .S ^_ PKIN RATS YR POLICJEQr LOC - COMP/OP AGG ODUC�.... .w _..... m OTHER I S AUT I N L LIMIT I �p,,R.��!bN �OANOAUTOABILITY IN .......�..... Paracn S iE OWNED AUTOS ONLY RE� AUTOS ONLY SCHEDULED AUTOS W� g7 A60JT0' OfGr�+dan9I�AGE BODILY IN„ „ Y Par_accident S .----•.•.....) .— pYJUR �. ................ ? _ ............ tl I $ UMBRELLA OCCUR %� EACH OCCURRENCE �m$ BAB . I EXCESS LI mm, CLAIMS -MADE m LLULL _.....�....... AGGREGATE 8 � 99 DED RETENTIONS _,_,_,_ A WORKERSPENSATION EMP9LOYERS' H- X I �.. 1 LI AND LIABILITY ANY PRIET 'R EXCLUDED? 7yNIAN / a X CST5016365 bb q _ y ~I} ....,.... 7/1/2019 7/112020 E.L EACH _ �0�0,000 CCE anda a has N) (M i Jr E �'M.ST47 DISE EA EMP VE,,, „ S ' ........._. if DESCd scribe RIPTION O0,000 nder F OPERATIONS below,1100,000 E,L DISEASE�PENI�TVLI_MI7 g.. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACCRO 101, Additional Remarks Schedule, may be attached if more apace is required) Waiver of Subrogation in favor of City of Segundo. CERTIFICATE HOLDER CAN'CELLATI'ON' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE City Of Segundo ACCORDANCE WITH THE POLICY P OVISIONS. WILL BE DELIVERED IN 401 Sheldon St EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE I ACORD 25 (2016103) ©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 Insured: Waterline Technologies Inc Carrier Name /Code: Benchmark Insurance Company WC 04 03 06 (Ed. 4-84) Countersigned by Premium $ Page 1 of 1