DATE (MM/DD/YYYY)
ACORD® CERTIFICATE OF LIABILITY INSURANCE 0/13/2024
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 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).
NAME: vivian windross
PRODUCER
PHONE
QAE INSURANCE BROKERAGE INC PAC.NO. EXE: 714 793 8262
13382 GOLDENWEST ST, SUITE 118 ADDRESS:
WESTMINSTER CA 92683 INSURERS) AFFORDING COVERAGE NAIC # INSURER A : BENCHMARK INSURANCE COMPANY 41394
INSURER B: INPINITY SELECT INSURANCE COMPANY 20260
INSURED
INSURER C: GUIDEONE NATIONAL INSURANCE COMPANY 14167
OM ROOFING INC
INSURER D: BERSHIRE HATHAWAY DIRECT INSURANCE COMPANY 10391 18000 Studebaker Road, Suite 700
Cerritos CA 90703 INSURER E: ADMIRAL INSURANCE COMPANY 24856 CERTIFICATE NUMBER: REVISION NUMBER:
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD 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.
MADDY MADONN
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 2,000,000
BIC5025631 01/14/2024 01/14/2025 DAMAGE TO RENTED 100,000 CLAIMS MADE V OCCUR PREMISES (ia occurrence)
MED EXP (Any one person) 5,000
ERRORS & OMMISION
PERSONAL & ADV INJURY 1,000,000
A EMPLOYMENT LIABILITY Y Y
GENERAL AGGREGATE 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER
PRODUCTS - COMP/OP AGG 2,000,000
POLICY LOC
BACH CLAIM/AGG $2,000,000
OTHER COMBINED SINGLE LIMIT
1,000,000
AUTOMOBILE LIABILITY 504610131059001 11/08/2023 11/0B/2024 (En accident) BODILY INJURY (Per person)
ANY AUTO
ALL OWNED SCHEDULED Y BODILY INJURY (Per accident)
B AUTOS AUTOS PROPERTY DAMAGE
NON-OWNED
/ HIRED AUTOS (Per. accident)
AUTOS
01/14/2024 01/14/2025 EACH OCCURRENCE 5,000,000
UMBRELLA LIAB OCCUR 4478457
AGGREGATE 5,000,000
EXCESS LIAB CLAIMS-MADE
DED RETENTIONS 10000 PER
WORKERS COMPENSATION 06/15/2023 06/15/2024 STATUTE
WSA506820600
AND EMPLOYERS' LIABILITY YIN 1,000,000
EL EACH ACCIDENT
ANY PROPRIETOR PARTNER/EXECUTIVE N N/A Y
D OFFICER MEMBER EXCLUDED? EL DISEASE - EA EMPLOYEE S 1,000,000 (Mandatory in NH)
ins describe und EL DISEASE - POLICY LIMIT | 3 1,000,000 SCRIPTION OF OPERATIONS beld
E POLLUTION LIABILITY Y У 4479214 01/14/2024|01/14/2025 EACH OCC/AGG $2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
ROOFER- ALL ROOFS
RE: VARIOUS LOCATIONS- SOUTHERN CA
ITY of REDONDO BEACH, Its officers, elected and appointed officials, employees and volunteers are named additiona! nsured as regards to their interest in work performed by the named insured SHOELAN NOTICE VILL BE DELIVERED ENACCORDANCE WET THE POLICY PRESTONS THE EXPIRATION DATE THEREOE, A 30 DAX OF
CERTIFICATE HOLDER CANCELLATION
CITY OF REDONDO BEACH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 415 DIAMOND STREET ACCORDANCE WITH THE POLICY PROVISIONS.
REDONDO BEACH, CA 90277
AUTHORIZED REPRESENTATIVE
© 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 4478457 COMMERCIAL GENERAL LIABILITY
CG 20 10 10 01
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
SCHEDULE
Name of Person or Organization:
City of Redondo Beach its officers, elected and appointed officials, employees and volunteers 415 DIAMOND STREET
REDONDO BEACH, CA 90277
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.)
A Section Il - Who Is An Insured is amended to (1) All work, including materials, parts or include as an insured the person or organization equipment furnished in connection with shown in the Schedule, but only with respect to I- such work, on the project (other than ability arising out of your ongoing operations per- service, maintenance or repairs) to be formed for that insured. performed by or on behalf of the addi- tional insured(s) at the site of the cor
B. With respect to the insurance afforded to these
ered operations has been completed; or
additional insureds, the following exclusion is
(2) That portion of "your work" out of which
the injury or damage arises has been
2. Exclusions put to its intended use by any person or
This insurance does not apply to "bodily injury" organization other than another or "property damage" occurring after: contractor or subcontractor engaged in performing operations for a principal as
a part of the same project
CG 20 10 10 01 © ISO Properties, Inc., 2000 Page 1 of 1 POLICY NUMBER: 504610131059001 COMMERCIAL AUTO
CA 20 48 02 99
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED INSURED
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
TRUCKERS COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement.
This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provi- sion of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form.
This endorsement changes the policy effective on the inception date of the policy unless another date is indi- Endorsement Effective: 11/08/2023 Countersigned By:
Named Insured: OM ROOFING INC
(Authorized Representative)
SCHEDULE
Name of Person(s) or Organization(s):
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 the endorsement.)
Each person or organization shown in the Schedule 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 contained in Section Il of the Coverage Form.
CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1