ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE IMMORTA
3/4/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTFICATE 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 INSURERS), AUTHORIZED
REPRESENTATIVE OR PRODUCER, ARID THE CERTIFICATE HOLDER MPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject! he terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights lo tr certificate holder in lieu of such endorsements).
TOMACT Dina Corsi
Alandale Insurance Agency PHONE (562) 493-3521 TA 11: 1562) 430-3300 JAI No. Eat:
11022 Winners Circle, Ste. 100 E-MAIL
Sales Dina Corsi
INSURERS) APPORDING COVERAGE
Los Alanitos CA 90720 00914
gURER A Hartford Insurance Co.
USURED
NURER Sentanel Insurance Company LTD 11000
MaURER Travelers Insurance Company 25658
INSURERO:
NOURGA E:
Cypress INSURER F
COVERAGES CERTIFICATE NUMBER:Master 16-17
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANOING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VIHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS
EXCLUSIONS AND CONITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
ADDUSUBR POLICY IF
LTR TYPE OF INSURANCE INSE. WYR POLICY NUMBER
GENERAL LIBAUTY
EACH OCCURHENCE 1,000,000
COMERCIAL GENERAL LIABILITY DAMAGE YO RENTED
PAEMISES (fa occurance) 300,000
CLAMS MADE X OCCUR 72UUN3H9452 1/10/2015 7/10/2016
MED EX* (Ary one personi 10,000
PERSONAL A JURY 1,000,000
GENERAL AGGREGATE 2,000,000
GENL AGGREGATE LIMIT APPLES PER: 2,000,000
X POLICY 1 PEO LOG
AUTOWOBNLE LIABILITY TED SINGER
1,000,000
ANY AUTO DEJURY (Per person
• OHNED SAMPLE ON
ALL
AUTOS BODILY INJURY (Per accenly
X HIRED AUTOS PROPERTY DAMAGE
(Per seeded!
Hred borrowad
OCCUR EACH OCCURRENCE
EXCE 408 CLAMS-MADE
AGGREGATE
DED X RETENTIONS 10,000 2003959 D/10/2015 7/10/2016
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY X ORY ANYT
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFCERMEMBER EXCLUDED? NIA EL EACH ACCIDENT 1,000,000
(Mandatory in WHI U88025872916 3/6/2016 3/6/2017
EL INSEASE - EA EMPLOYER S 1,000,000
yes, desire unde
ESCRIPTION OF OPERATONS bote EL DISEASE • POLICY LIMIT 1 1,000,000 Business Property 720UKJH9452 7/10/2015 7/10/2016 Land uf $5,000 deci 157,000 Business Income 7200MTH9452 7/10/2013 1/10/2016 Lima 500,000 a ne Sadonado SaGA r of era, lead and appointed oficials, employees and voluntare are named as addiltonal insured.
olicy ia Brinary with written contraot- son attachod HG 0001 O60 30 Daye Notice of Cancellation with 10 Days Notide for Non-Payment of Premis
CERTIFICATE HOLDER CANCELLATION
HOULO ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOR THE EXPIRATION DATE HEREOF, NOTICE WILL BE DELIVERED |
City of Redondo Beach ACCORDANCE WITH THE POLICY PROVISIONS. 415 Diamond Street
Redondo Beach, CA 90277 AUTHORIZED REPRESENTATIVE
Dina Corei/DINA
ACORD 26(2010/05) @ 1968-2010 ACORD CORPORATION. All rights reserved.
INS025 1201005) 01 The ACORD name and logo are registered marks of ACORD
CITY OF REDONDO BEACH
DEPARTMENT OF ENGINEERING & BUILDING SERVICES
INSURANCE REQUIREMENTS
COVERAGE
CERTIFICATE
L A CERTIFICATE OF INSURANCE EVIDENCING COMPLIANCE WITH ALL THE INSURANCE REQUIREMENTS MUST BE
SUBMITTED PRIOR TO PROJECT INCEPTION
ENDORSEMENT
L SUCH INSURANCE SHALL CONTAIN ENDORSEMENT(S) WHICH:
1. NAME THE CITY OF REDONDO BEACH, ITS OFFICERS, ELECTED AND APPOINTED OFFICIALS.
EMPLOYEES, AND VOLUNTEERS AS ADDITIONAL INSUREDS WITH RESPECT TO ANY LIABILIT
ARISING OUT OF WORK OR OPERATIONS PERFORMED BY OR ON BEHALF OF THE INSURED Il. STATE THAT COVERAGE IS PRIMARY AND SHALL NOT CONTRIBUTE WITH ANY INSURANCE OI
SELF-INSURANCE MAINTAINED BY THE CITY
i#t. CONTAIN THE COMMERCIAL GENERAL LIABILITY POLICY NUMBER.
FILING
ALL REQUIRED CERTIFICATES OF INSURANCE AND ENDORSEMENTS MUST BE SUBMITTED AS ONE PACKAGE AND FILED, BY MAIL OR IN PERSON, AT THE FOLLOWING ADDRESS:
CITY OF REDONDO BEACH
DEPARTMENT OF ENGINEERING AND BUILDING SERVICE!
415 DIAMOND STREET
REDONDO BEACH, CA. 90277
THE REVIEW PROCESS MAY TAKE UP TO TEN (10) WORKING DAYS. 415 DIAMAOND STREET, REDONDO BEACH CALIFORSRA BOZTI • TELEPHONE 310-318-0001 • FACRMLE 310-776-483 • WED: WWW. REDOMDO ORG • FORM NO BO, VERBIONNO 3 PAOE 1 OF / . ALQUST 2012 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY
CG 20 37 07 04
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
SCHEDULE
lame Of Additional Insured Person(s
)r Organization(s) Location And Description Of Completed Operations [Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
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
and included in the "products-completed
operations hazard".
CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 POLICY NUMBER: COMMERGIAL GENERA 2 97 10 TY
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
SCHEDULE
Name of Person or Organization:
Location And Description of Completed Operations:
Additional Premium:
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.)
CG 20 37 10 01 © ISO Properties, Inc., 2000 Page 1 of 1 POLICY NUMBER: 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:
The City of Redondo Beach, its officers, elected and appointed officials, employees, and volunteers
(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 is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" for that insured by or for you.
This insurance shall be primary as respects the insured shown in the schedule above, or if excess, shall stand in an unbroken chain of coverage excess of the Named Insured's scheduled underlying primary coverage. In either event, any other insurance maintained by the Insured scheduled above shall be in excess of this insurance and shall not be called upon to contribute with it.
CG 20 10 11 85 Copyright, Insurance Services Office, Inc., 1984 POLICY NUMBER:
COMMERCIAL GENERAL LIABILITY
CG 20 37 10 01
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DDITIONAL INSURED - OWNERS, LESSEES OF
'ONTRACTORS - COMPLETED OPERATION:
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
The City of Redondo Beach, its officers, elected and appointed officials, employees, and volunteers
Location And Description of Completed Operations:
Additional Premium:
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.)
Section II - Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" at the location designated and described in the schedule of this endorsement performed for that insured and included in the "products-completed operations hazard"
This insurance shall be primary as respects the insured shown in the schedule above, or if excess, shall stand in an ebroken other score incis the lasted sted bedie stal de ies ri onsurance and shall not be called upon to contribute with it.
CG 20 37 10 01 Page 1 of 1
Copyright, ISO Properties, Inc.,
2000
GENERAL LIABILITY ENDORSEMENT
CITY OF REDONDO BEACH
415 DIAMOND STREET
REDONDO BEACH, CA 90277
POLICY INFORMATION
Insurance Company _Policy Number
Policy Term (From) _ (To)_ Endorsement Effective Date
Named Insured
Address of Named Insured
Limit of Liability any One Occurrence/Aggregate $ 1.000.000 / $2,000,000 General Liability Aggregate Applies Separately to This Project/Location: Yes No Deductible or Self-Insured Retention (None unless otherwise specified):
Coverage is equivalent to Commercial General Liability occurrence form CG 0001: Yes _No.
POLICY AMENDMENTS
WHO IS AN INSURED (Section II) is amended to include as an insured the City of Redondo Beach, its quipment furnished in connection with such work or operation
2. 3.
INCIDENT AND CLAIM REPORTING PROCEDURE
Inoidents and claims are to be reported to the insurer at:
(Name/Department)
(Company)
(Address)
(City/State/Zip)
(Phone)
SIGNATURE OF INSURER OR AUTHORIZED RePS are Varan tat have alhority to bind the below listed insurance company and by my signature hereon do so bind this company Signature - Authorized Representative / Title
Organization
Address/Telephone
Date
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED ENDORSEMENT
This endorsement modifies insurance provided under the following
COMMERCIAL GENERAL LIABILITY COVERAGE PART
ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS (FORM B) CG 20 10 11 85
SCHEDULE
Name of Person or Organization:
Any person or organization that the named insured is obligated by virtue of a written contract or agreement to provide insurance such as is afforded by this policy and is approved by the Company in writing within 30 days of the inception of the contract or agreement, or the inception of this policy, whichever is later.
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" for that insured by or for you.
The following additional provisions apply to any entity that is an insured by the terms of this endorsement:
1. Primary Wording
If required by written contract or agreement: Such insurance as is afforded by this policy shall be primary insurance, and any insurance or self-insurance maintained by the above additional insured(s) shall be excess of the insurance afforded to the named insured and shall not contribute to it.
3. Neither the coverages provided by this insurance policy nor the provisions of this endorsement shall apply to any claim arising out of the sole negligence of any additional insured or any of their agents/employees.
Authorized Representative Date
ANF 160(08/99)
O BR
CITY OF REDONDO BEACH
PUBLIC WORKS DEPARTMENT - ENGINEERING SERVICES DIVISION
SIGNATURE AUTHORIZATION
THE UNDERSIGNED ("GRANTOR"), DOES HEREBY EXPRESSLY AUTHORIZE AND GIVE CONSENT TO _ ("REPRESENTATIVE"), CALIFORNIA ID
NO. _ — TO EXECUTE, ON BEHALF OF THE GRANTOR,
AND AT GRANTOR'S DIRECTION, ALL DOCUMENTS REQUIRED TO OBTAIN PERMITS
FROM THE REDONDO' BEACH PUBLIC WORKS DEPARTMENT - ENGINEERING SERVICES DIVISION ("CITY").
GRANTOR HEREBY WARRANTS THAT HE/SHE/IT HAS THE FULL AUTHORITY TO GRANT SUCH SIGNATURE AUTHORIZATION TO REPRESENTATIVE. CITY SHALL RECOGNIZE
THE AUTHORITY OF REPRESENTATIVE TO EXECUTE ON GRANTOR'S BEHALF ALL DOCUMENTS NECESSARY TO OBTAIN SAID PERMITS. THE AUTHORITY VESTED IN
REPRESENTATIVE SHALL REMAIN VALID UNTIL CITY RECEIVES A WRITTEN NOTICE REVOKING THE AUTHORITY OF REPRESENTATIVE. ALL SIGNATURES HEREIN SHALL BE DULY NOTARIZED.
GRANTOR'S NAME:
GRANTOR'S TITLE:
FIRM NAME / DBA:
FIRM ADDRESS:
GRANTOR'S SIGNATURE: