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PROOF OF INSURANCE (2020) CLOSEDOCEABLU-06 RDEAN'DA CERTIFICATE OF LIABILITY INSURANCE DAT7 3/2 D/YYYY) 7/3/2019 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 endorsements) �..................._.... �..._......... _ ...m_....._ ........................_. PRODUCER License # 0757776 C 41ACT Elias Yousuf HUB International Insurance Services Inc. (AM,we Eat) �g77) 825-2681 PArc, Ne);�951) 231-2572 SanSScranton Diego, CA 9212 Suite 100 U%Rkss; Cal.Cpu hu'binternation'ai.CoYin INSURER(S) AFFORDING COVERAGE NAIC # INSURER A; Nautilus Insurance Company 17370 INSURED INSURERS Great Divide 'Insurance Company 25224 Ocean Blue Environmental Services, Inc. INSURERC: 925 West Esther Street INSURER D c Long Beach, CA 90813 INSURER E 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 CONTRACTOR 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 TYPE OF INSURANCE �ADDL,SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD_ WVD IMM/DD/YYYYI 1MMIDD.IYYYYI A COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remark's Schedule may be attached if more apace is required) City of EI Segundo its officials, and employees are Additional Insured with regard to General Liability when required by written contract per the attached endorsement form ECP1004 08/16. Waiver of Subrogation with regard to General Liability applies when required by written contract per the attached endorsement form ENV2004 06/18. Excess Liability follows form of underlying General, Auto & Employers Liability. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Ci of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City 9 ACCORDANCE WITH THE POLICY PROVISIONS. its officials, and employees City Clerk 350 Main Street, Room 5 AUTHORIZED REPRESENTATIVE EI Segundo, CA 90245 ow, A -61 ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CLAIMS -MADE X OCCUR X ECP2018650-13 XPREMISES 7/1/2019 7/1/2020 DAMAGE r0 ( RENTED Ea occuaaranca) 100,000 $ MED EXP (Any one person,) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'LAGGREGA"I'ELIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X JPRO- POLICY EILOC PRODUCTS - COMPIOP AGG $ 2,000,000 X OTHER. SIR: $20,000 $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) 1,000,000 $ X ANY AUTO BAP2018652-13 7/1/2019 7/1/2020 BODILY INJURY (Par,person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) , $ r� p X , A % ONLY X M16i O 9 Xbuio+& (Per accidentDAMAGE Hazardous Waste $ $ 5,000,000 A _._._ ._. _ UMBRELLA LIAB X OCCUR _......�.._._._._.._.._.._........._.._.._.._.._.._.�. _..._m...-......._._...............-..._. ................................... ._._ EACH OCCURRENCE $ 9,000,000 X EXCESS LIAB CLAIMS -MADE FFX2018651-13 7/1/2019 7/1/2020 AGGREGATE $ 91000,000 DED RETENTION $ $ B WORKERS COMPENSATION ANDEMPLOYERS'LIABWTY YINWCA2018653-13 ANY �rPROPRIETOR/PARTNER/EXECUTIVEg�MEREXCLUDEDN / A andandry➢n NH) 7/1/2019 7/1/2020 XPER,,, ,STATUTE X OTHH- EL EACH ACCIDENT EL DISEASE -ID EMPLOYEE 1,000,000 $ 1,000,000 $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L DISEASE - POLICY LIMIT 1,000,000 $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remark's Schedule may be attached if more apace is required) City of EI Segundo its officials, and employees are Additional Insured with regard to General Liability when required by written contract per the attached endorsement form ECP1004 08/16. Waiver of Subrogation with regard to General Liability applies when required by written contract per the attached endorsement form ENV2004 06/18. Excess Liability follows form of underlying General, Auto & Employers Liability. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Ci of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City 9 ACCORDANCE WITH THE POLICY PROVISIONS. its officials, and employees City Clerk 350 Main Street, Room 5 AUTHORIZED REPRESENTATIVE EI Segundo, CA 90245 ow, A -61 ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD =111 �P1*1 JJA_I_=10 Ill This endorsement forms a part of the policy to which it is attached. Please read it carefully, ADDITIONAL INSURED BLANKET....... ......... .... ..... ..... .. .... This endorsement modifies insurance provided under the following: ENVIRONMENTAL COMBINED POLICY In consideration of the premium charged and notwithstanding anything contained in this policy to the contrary, it is hereby agreed and understood that this endorsement shall apply only to the Coverage Part(s) corresponding with the box or boxes marked below. COVERAGES PARTS A AND B — GENERAL LIABILITY COVERAGE D — CONTRACTORS POLLUTION LIABILITY SECTION III — WHO IS AN INSURED is amended to include as an insured, with respect to Coverage A, B and D, any person(s) or organization(s) when you and such person(s) or organization(s) have agreed in a written contract or written agreement that such person(s) or organization(s) be added as an additional insured on your policy. Such written contract or written agreement must be in effect prior to the performance of your work which is the subject of such written contract or written agreement. Such additional insured status applies only: »� 1. Under COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY and COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY for claims or suits resulting from: a. Your work performed for such person(s) or organization(s) in the performance of your ongoing operations for the additional insured; or b. Your work performed for such person(s) or organizations(s) and included in the products -completed operations hazard. 2. Under COVERAGE D CONTRACTORS POLLUTION LIABILITY for claims or suits arising out of pollution conditions that are the result of: a. Your work performed for such person(s) or organization(s) in the performance of your ongoing operations for the additional insured; or b. Your work performed for such person(s) or organizations(s) and included in the products -completed operations hazard. With respect to damages caused by your work, as described above, the coverage provided hereunder shall be primary and not contributing with any other insurance available to those person(s) or organization(s) with which you have so agreed in a written contract or written agreement. ALL OTHER TERMS AND CONDITIONS OF THE POLICY SHALL APPLY AND REMAIN UNCHANGED. ECP 1004 08 16 Page 1 of 1 ENDORSEMENT This endorsement forms a part of the policy to which it is attached. Please read it carefully, WAIVER OF SUBROGATION I It is agreed that the Company, in the event of any payment under this policy, waives its right of recovery against any Principal, but only at the specific written request of the Named Insured either before or after loss, wherein such waiver has been included before loss as part of a contractual undertaking by the Named Insured. This waiver shall apply only with respect to losses occurring due to operations undertaken as per the specific contract existing between the Named Insured and such Principal and shall not be construed to be a waiver with respect to other operations of such Principal in which the Named Insured has no contractual interest. No waiver of subrogation shall directly or indirectly apply to any employee, employees or agents of either the Named Insured or of the Principal, and the Company reserves its right or lien to be reimbursed from any recovery funds obtained by any injured employee. This waiver does not apply in any jurisdiction or situation where such waiver is held to be illegal or against public policy or in any situation wherein the Principal against whom subrogation is to be waived is found to be solely negligent. ALL OTHER TERMS AND CONDITIONS OF THE POLICY SHALL APPLY AND REMAIN UNCHANGED. ENV 2004 06 18 Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 04 84 • ► c 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 0.00% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Any Principal wherein such waiver has been included before loss as part of a contractual undertaking by the Named Insured. 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 07/01/2019 Insured Ocean Blue Environmental Services, Inc. Insurance Company: Great Divide Insurance Company Policy No. WCA2018653 13 Countersigned by Endorsement No. Premium WC 04 03 06 04 84 1998 by the Workers' Compensation Insurance Rating Bureau of California. Page 1 of 1 All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual 2001.