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PROOF OF INSURANCE (2020) CLOSED'f ACC'M ' DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 10/15/2019 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 on ADDITIONAL INSURED, the policy(ies)mus[ have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to lite terms and conditions ofthe policy, certain policies may Y require an endorsement. A statement on this certificate docs not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER I CONTACT NAME: Foundcr5hield, LLC PHONE (A/C No. Ext): 646-854-1058 FAX (A/C No): 119 W 24th Street, 3rd Floor E-MAIL ADDRESS: coi@ronndersltield.com New York, New York, 10011 .. INSURER(S) AFFORDING COVERAGE NAIC 0 INSURER A: TWIN CITY FIRE INSURANCE CO 29459 INSURER B: AXIS INSURANCE COMPANY 37273 INSURED ., .,., ........I INSURER C:..... EIucJ 81 Prospect St. INSURER D: Brooklyn, New York, 11201 U INSURER E: ISI 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 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD I WVD (MM/DD/YYYV) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY CLAIMS MADE :+y// OCCUR A GEN'L AGGREGATE LIMITAPPLIES PER: POLICY � PROJECT .V, LOC OTHER t AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS ONLY HIREDAUTOS ONLY UMBRELLA LIAB OCCUR SCHEDULED NON -OWNED AUTOS ONLY EXCESS LIAB CLAIMS -MADE WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYP ROPRIETOR/PARTNER/EXECUTIV YM OFFICER/MEMBER EXCLUDED? N (Mandatory in NH) H yes, describe under DESCRIPTION OF OPERATIONS below B Cyber Liability,Errors & Omissions,Privacy A Errors & Omissions N/A EACH OCCURRENCE $1,000,000.00 DAMAGE TO RENTED $1,000,000.00 PREMISES (En occurrence) ��Ipppi MED EXP (Any one person) $10,000.00 IOSBMBA1724 09/21/2019 09/21/2020 q PERSONAL & ADV INJURY $1,000,000.00 I` GENERAL AGGREGATE $2,000,000.00 PRODUCTS-COMP/OP AGG $2,000,000.00 $ COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) Each occurence ITTN-200074.02 09/21/2019 09/21/2020 JOSBMBA1724 09/21/2019 09/21/2020 Aggregate PERSTATUTE OTHER E.L. EACH ACCIDEN E.L. DISEASE- EA EMPLOYEE E.L. DISEASE - POLICY LIMIT S 1,000,000 per occ 51,000,000 in agg S 1,000,000 per oce 52,000,000 in agg t DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may he attached if mare space is required) The Certificnle Holder is included as on Additional Insured on lite above referenced policy where required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE City of El Segundo THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ., ., 350 Main Street, EL Segundo CA 90245 AUTHORIZED REPRESENTATIVE A 4 0 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGE This endorsement changes the policy effective on the Inception Date of the policy unless another date is indicated below: Policy Number: 10 SBM BA1724 SB Named Insured and Mailing Address; ELUCD INC. 7U 81 PROSPECT ST BROOKLYN NY 11201 Policy Change Effective Date: 09/21/19 Effective hour is the same as stated in the Declarations Page of the Policy. Policy Change Number: 001 Agent Name: FOUNDERSHIELD LLC Code: 257698 POLICY CHANGES: TWIN CITY FIRE INSURANCE COMPANY ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING STATEMENT.IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BANK ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A BILL. NO PREMIUM DUE AS OF POLICY CHANGE EFFECTIVE DATE BUSINESS LIABILITY OPTIONAL COVERAGES ARE REVISED ADDITIONAL INSURED(S) ARE ADDED THE FOLLOWING ARE ADDITIONAL INSURED FOR BUSINESS LIABILITY COVERAGE IN THIS POLICY. LOCATION 001 BUILDING 001 PERSON/ORGANIZATION: SEE FORM IH 12 00 FORM NUMBERS OF ENDORSEMENTS ADDED AT ENDORSEMENT ISSUE: PRO RATA FACTOR: 1.000 THIS ENDORSEMENT DOES NOT CHANGE THE POLICY EXCEPT AS SHOWN. Form SS 1211 0405 T Page 001 (CONTINUED ON NEXT PAGE) Process Date: 0 9 / 0 9 / 19 Policy Effective Date: 09/21/19 Policy Expiration Date: 09/21/20 POLICY CHANGE (Continued) Policy Number: 10 SBM BA1724 Policy Change Number: 001 IH12001185 ADDITIONAL INSURED - PERSON -ORGANIZATION Form SS 12 11 04 05 T Page 002 Process Date: 09/09/19 Policy Effective Date: 09/21/19 Policy Expiration Date: 09/21/20 POLICY NUMBER: 10 SBM BA1724 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PERSON -ORGANIZATION LOC:001 BLDG:001 CITY OF EL SEGUNDO 350 MAIN STREET, EL SEGUNDO CA 90245 Form IH 12 00 11 85 T SEQ. NO. 001 Process Date: 0 9 / 0 9 / 19 Printed in U.S.A. Page 003, Expiration Date: 09/21/20 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations:. (_) I have and will maintain a certificate of consent of self -insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement with the City of EI Segundo. Policy No. L_) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance of the work for which the agreement with the City of EI Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Name of Agent Policy Number Expiration Date Phone # I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with thop vi ' ns or the agreement will automatically become void. Signature of Applicant 2; Date 08/26/2019 Agreement for: Elucd Inc Dated:C (0/u//'� Reviewed by: Ick —3-0 —Iq Doc ID:ac367d81314539524ea96ba1e5ab89905d012d8a