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PROOF OF INSURANCE (2019 - 2020) CLOSED0 � DATE (MM/DD/YYYY) A► "RV CERTIFICATE OF LIABILITY INSURANCE 8/23/2019 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 endorsement(s). PRODUCER CONTACT InterWest Insurance Services PHONE AiW Joanne Cadar FAX N g16 979 -6 1109-8362e m . _,M; 7562 License #0601094 E-MAILss. Icadarette@i ,.ns.,00 t t — �i�x t+�> � P.O. Box 255188 EMAIL Sacramento CA 95865-5188 INSURER(S)AFFORDING COVERAGE NAIC#m' Lir rases..4t. 91W_4 INSURERA: Financial Pacific Ins Company. 31453 ........... INSURED AMERI26 INSURER 8: Arch Insurance Company 11150 meri Santa haltAna South p Inc INSURER C : Travelers P C s Co of Amer 25674 Fontana CA 92337 INSURER.D : Westchester Surplus Lines Ins ...... .... �_ 10172......__, _INSURER E INSURER F: ...... COVERAGES CERTIFICATE NUMBER: 1545689402 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. INSIR .F INSURANCE AIN D__ NS9killsD__ I POLICY NUMBER 1MM/DCY EFF POLICY EXE LIMITS TYPE O D/YYYY1 /MM1DDrYY'YY A X... COMMERCIAL GENERAL Y Y 60423382 12131/2018 12/31/2019 –EACH OCCURRENCE n-WMp;i W' 70p5gNftb.....—...g2000,000 ... DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: Protect #PW1.9-19, FY 18-19 Slurry Seal Project, Additional Insured Status applies if required by Written contract per endorsement attached City of EI Segundo, its officers, officials, employees, agents, and volunteer, Per ProjectA gregates applies to General Liability per the attached endorsement. Primary Wording per attached endorsement. Waiver of Subrogation applies to General Liability, Automobile Liability and Workers Compensation per the attached endorsements. 30 day notice of cancellation, except 10 day notice for non-payment of premium applies per policy provisions, CERTIFICATE HOLDER City of EI Segundo Public Works Department Engineering Division 350 Main Street EI Segundo CA 90245 • 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 om ;4' ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD CLAIMS -MADE � X I OCCUR PREMISE$„( 2„ocmcurr, ncel $100,000 . Contractual Liab MED EXP (Any one person) $ 5,000 _ X J Ded $5,000 .... .......... 4Y41 ........A .. $ 2,000,000 PERSONAL 8 ADV INJURY GEN'LAGGREGATE LIMIT APPLIES PER: ENERALAGGREGATE $4,000,000 O. LOCPRODUCTS L— CT ISINGLE PRODUCTS -CO s4,000,000 MP/OP .. . AGG... $ OTHER, A AUTOMOBILE LIABILITY Y Y 60423382 12/31/2018 COMBINED L LIMIT 12131/2019 �„pp eitED L • ) $ ,000,000 X ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED � BODILY INJURY accident) $ �•--- AUTOS ONLY AUTOS ... _ ..� HIRED NON -OWNED X X PROPERTY DAtlVfAG... $ AUTOS ONLY AUTOS ONLY t. p_Lz tden0 $ C LL X UMBRELLA A LIAB XOCCUR ZUP71M8933018 12/31/2018 12/31/2019 EACH OCCURRENCE $6,000_.,000 LII CLAIMS -MADE GG REGATE $6,000,000 DED I X I RETENTION $ n ( $ g WORKERS COMPENSATION Y ZAWCI9413902 4/1/2019 PER TH 4/1/2020 X u AND EM LOYER ' LI _ CUDEDo L. EACHACCIDENTOR...,,, $1 E $1,000,000 .. 0_.0 ,_0 FFICE /MEMB REXC EXCLUDED? NIA OFFICER/MEMBER (Mandatory in NH) 0.... E DISEASE -EAEMPLOYEEI' $1,00 0 If yes, describe under EL DISEASE POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS below - D POLLUTION LIABILITY G70915613002 8/27/2019 8/27/2020 LIMIT/EA OCC $2,000,000 ' LIMIT/AGG $2,000,000 DEDUCTIBLE $10,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: Protect #PW1.9-19, FY 18-19 Slurry Seal Project, Additional Insured Status applies if required by Written contract per endorsement attached City of EI Segundo, its officers, officials, employees, agents, and volunteer, Per ProjectA gregates applies to General Liability per the attached endorsement. Primary Wording per attached endorsement. Waiver of Subrogation applies to General Liability, Automobile Liability and Workers Compensation per the attached endorsements. 30 day notice of cancellation, except 10 day notice for non-payment of premium applies per policy provisions, CERTIFICATE HOLDER City of EI Segundo Public Works Department Engineering Division 350 Main Street EI Segundo CA 90245 • 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 om ;4' ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Re: Project #PW19-19, FY 18-19 Slurry Seal Project. Additional Insured Status applies if required by written contract per endorsement attached City of EI Segundo, its officers, officials, employees, agents, and volunteer. Per Project Aggregates applies to General Liability per the attached endorsement. Primary wording per attached endorsement. Waiver of Subrogation applies to General Liability, Automobile Liability and Workers Compensation per the (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization is held liable for "your work" for that person or organization by or for you. This endorsement applies to the following work: Description of Job: See Above Location of Job: See Above Al only Effective from: Effective Date: 12/31/2018 Expiration Date: 12/31/2019 When this endorsement applies, such insurance as is afforded by the general liability policy is primary and any other insurance shall be excess and shall not contribute to the insurance afforded by this endorsement. CG 20 10 1185 Modified (07-01) Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. COMMERCIAL GENERAL LIABILITY CG 20 21 01 96 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART WHO IS AN INSURED (Section 11) is amended to include as an insured any person(s) who are volun- teer worker(s) for you, but only while acting at the direction of, and within the scope of their duties for you. However, none of these volunteer worker(s) are insureds for: 1. 'Bodily injury" or "personal injury": a. To you, to your partners or members (if you are a partnership or joint venture), to your members (if you are a limited liability com- pany), to your other volunteer worker(s) or to your "employees" arising out of and in the course of their duties for you; b. To the spouse, child, parent, brother or sister of your volunteer worker(s) or your "employees" as a consequence of para- graph 1.a. above; c. For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in paragraphs 1.a. or b. above; or d. Arising out of his or her providing or failing to provide professional health care serv- ices. 2. "Property damage" to property: a. Owned, occupied, or used by, b. Rented to, in the care, custody or control of, or over which physical control is being exercised for any purpose by you, any of your other volunteer workers, your "employees", any partner or member (if you are a partnership or joint venture), or any member (if you are a limited liability company). CG 20 21 01 96 Copyright, Insurance Services Office, Inc., 1994 Page 1 of 1 0 Policy #60423382 COMMERCIAL GENERAL LIABILITY CG 20 32 07 98 Modified THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - ENGINEERS, ARCHITECTS OR SURVEYORS NOT ENGAGED BY THE, NAMED INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENIERAL LIABILITY r_.OVUPAGE PART SCHEDULE Name Of Engineers, Architects Or Surveyors Not Engaged By The Named Insured: AS PER ACORD25 CERTIFICATE OF INSURANCE (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section II — Who Is An Insured is amended to include as an insured the architects, engineers or surveyors shown in the Schedule, but only to the extent such rarohiteot, engineer, car surveyor is Held liable for your ongoing operations performed by you or on your behalf. Such architects, engineers or surveyors, while not engaged by you, are con- tractually required to be added as an additional in- sured to your policy. B. With respect to such architects, engineers or sur- veyUrS dllUwri In file 6UIIWule dUUve, llie IUIIUwIny exclusion is added to Paragraph 2., Exclusions of Section I — Coverage A — Bodily Injury And Property Damage Liability incl Section I — Cov- erage B — Personal And Advertising Injury Li- ability: This insurance does not apply to "bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of or the failure to render rany profcssionral services, including. 1. The preparing, approving, or failing to prepare or approve maps, drawings, opinions, reports, v_jrvays, n_hangp nrdars, ela-6gna or cpacifica- tions; and 2. Supervisory, inspection or engineering serv- ices. CG 20 32 07 98 Modified Page 1 of 1 ❑ Includes copyrighted material of Insurance Services Office, Inc., with its permission. POLICY NUMBER: 60423382 COMMERCIAL GENERAL LIABILITY CG 24 0410 93 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. of ZWOITAii This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Re: Project #P'V"+119-19, FY 18-19 Slurry Seal Project. Additional Insured Status applies if required by written contract per endorsement attached City of EI Segundo, its officers, officials, employees, agents, and volunteer. Per Project Aggregates applies to General Liability per the (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMMER- CIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products -completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 0410 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 POLICY NUMBER; 60423382 COMMERCIAL GENERAL LIABILITY CG 25 03 03 97 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Projects: ALL PROJECTS WITH THE POLICY PERIOD. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under COVERAGE A (SECTION 1), and for all medical expenses caused by acci- dents under COVERAGE C (SECTION 1), which can be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. A separate Designated Construction Project General Aggregate Limit applies to each designated construction project, and that limit is equal to the amount of the General Aggre- gate Limit shown in the Declarations 2. The Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under COVERAGE A, except damages because of "bodily injury" or "property damage" included in the "products -completed operations hazard", and for medical expenses under COVERAGE C regardless of the number of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits". 3. Any payments made under COVERAGE A for damages or under COVERAGE C for medical expenses shall reduce the Desig- nated Construction Project General Aggre- gate Limit for that designated construction project. Such payments shall not reduce the General Aggregate Limit shown in the Decla- rations nor shall they reduce any other Des- ignated Construction Project General Aggre- gate Limit for any other designated construc- tion project shown in the Schedule above. 4. The limits shown in the Declarations for Each Occurrence, Fire Damage and Medical Ex- pense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Designated Con- struction Project General Aggregate Limit. B. For all sums which the insured becomes legally obligated to pay as damages caused by "occurrences" under COVERAGE A (SECTION 1), and for all medical expenses caused by acci- dents under COVERAGE C (SECTION 1), which cannot be attributed only to ongoing operations at a single designated construction project shown in the Schedule above; 1. Any payments made under COVERAGE A for damages or under COVERAGE C for medical expenses shall reduce the amount available under the General Aggregate Limit or the Products -Completed Operations Ag- gregate Limit, whichever is applicable; and 2. Such payments shall not reduce any Deslg- nated Construction Project General Aggre- gate Limit. C. When coverage for liability arising out of the "products -completed operations hazard" is pro- vided, any payments for damages because of "bodily injury" or "property damage" included in the "products -completed operations hazard" will reduce the Products -Completed Operations Ag- gregate Limit, and not reduce the General Ag- gregate Limit nor the Designated Construction Project General Aggregate Limit. CG 25 03 03 97 Coovrioht_ InSiiranr.p SPrvirP.0 Offirp Int, 10QR eft -e 4 -91) D. If the applicable designated construction project has been abandoned, delayed, or abandoned and then restated, or if the authorized contract- ing parties deviate from plans, blueprints, de- signs, specifications or timetables, the project will still be deemed to be the same construction project. E. The provisions of Limits Of Insurance (SECTION III) not otherwise modified by this endorsement shall continue to apply as stipulated. --- _Z „ f -.A_64 nffi . 1^^ 1 ooa M.'25 na n_'A 07 POLICY NUMBER: 60423382 ASDA AU 07 01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ! rr► y 11 �. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM SCHEDULE NAMED INSURED: American Asphalt South, Inc 14436 Santa Arra Avenue Fontana CA 92337 ADDITIONAL INSURED: Re: Project #PW19-19, FY 18-19 Slurry Seal Project, Additional Insured Status applies if required by written contract per endorsement attached City of EI Segundo, its officers, officials, employees, agents, and volunteer. Per Project Aggregates applies to General Liability per the attached endorsement. Primary wording per attached endorsement. Waiver of Subrogation applies to General Liability, Automobile Liability and Workers Compensation per the attached endorsements. 30 day WHO IS AN INSURED (SECTION II) is amended to include as an insured the organization shown in the Schedule above, but only with respect to the operation of vehicles owned by the named insured and operated on behalf of the named insured. This endorsement does not apply to any operations for other than the named insured. Each person or organization named above is an insured for liability coverage, but only to the extent that person or organization qualifies as an insured under the Who Is An Insured provision of Section II Liability Coverage. The additional insured is not required to pay for any premiums stated in the policy or earned from the policy. Any return premium, if applicable, declared by us shall be paid to you. You are authorized to act for the additional insured in all mailers pertaining to this insurance. We will mail the additional insured notice of any cancellation of this policy. If the cancellation is by us, we will give thirty days notice to the additional insured. The additional insured will retain any right of recovery as a claimant under this policy. ASDA AU 07 01 Page 1 of 1 POLICY NUMBER: 60423382 ASDA AU 07 02 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM SCHEDULE Name of Person or Organization: Re: Project #PW19-19, FY 18-19 Slurry Seal Project. Additional Insured Status applies if required by written contract per endorsement attached City of EI Segundo, its officers, officials, employees, The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV BUSINESS AUTO CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above be- cause of payments we make for bodily injury or property damage arising out of losses or accidents which occur during the policy period. This waiver applies only to liability you assume pursuant to a contract with the person or organization shown in the schedule. ASDA AU 07 02 Page 1 of 1 WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need be completed only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective on 8/23/2019 at 12:01 A.M. standard time, forms a part of (DATE) Policy No. ZAWC19413902 Endorsement No. of the Arch Insurance Company issued to American Asphalt South, Inc Premium (if any) $ (NAME OF INSURANCE COMPANY) Authorized Representative 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 *% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description ALL PERSONS AND/OR ORGANIZATIONS THAT REQUIRE A WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE ACCIDENT OR LOSS, THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY FOR WORK PERFORMED BY YOU FOR THAT PERSON AND/OR ORGANIZATION WC 252 (4-84) WC 04 03 06 (Ed. 4-84) Page 1 of 1