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PROOF OF INSURANCE (2019 - 2020) CLOSED20
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CERTIFICATE OF LIABILITY INSURANCE flATEi0611188/!22019019 Y)
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 endorsementfs)-
PRODUCER ONTACI
NHON.IE EXtI;� 8 Al
...•._
S�irffP "'lif9 SKALA INSl1RANCE AGENCY INC PHONE
AD9-583-8861 Arc, Nay
�& 4214 N SIERRA WAY E-MAILNE GENESKALA.CO
a
EDr1M ...�_.. ...__......._.�. _.....
ITm,mm•�mm-, GCOVEf�.QGE
(409
GENE SKALA, AGENT LIC. 0557032 StaterFa Farm Insurance SAM BERNARDINO, CA 92407 Rls)_aFFoaorN
INSURER ralTce Company 25151
I INSURED INSURER suRER : State Fane Mutual Automohile Insurance Company 25178
NANCY K BOHL INC INSURER C: ..,_w,w_,w,
DBA THE COUNSELING TEAM INTFIRNATIONAL INSURER D:
.........................
AND DBATHE ORGANIZATIONAL NETWORK INSURER E:
IN§yRER F:
...
COVERAGE$ CERTIFICATE NUMBER: R'EVIS'ION NUMBER:
THIS IS TO CERTIFY THAT THF POLICIES OF INSURAI14GF LISTFD BELOW HAVE BEEN ISSIJFD TO TNF IM%JRF_D NAMED ABOVE FOR THF POLICY PERIOD
INDICATED. NOTWTHSTANDING ANY REOUIREMEN I-, I -E -RM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMEN I WI I H RESPLCT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED IIEREIN IS SUBJECT TO ALL TI IE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
d.TR OINSURANCE ._..,_.,, ..
w MMER IALC NERPOLICY NUMBER
AL(ABILITY I 4L1 Y hi7 Yf AkAR015tw YM Jr1MRDORYYYYI LIMITS
(NSR COMMERCIAL
O """" AUUL.�If�'�R—...-_._ POLIGYE, s.. :114bS,r,,liihUrlY"YY"`I. g 1,000,000
eDAMAtIt
I �.i'`Si�Nr,1I5„n,wx,A�,�Inc;,nacm,L„_�, $ ,,00.000
A �TNOL DAUIO PIh b ;IUIiL uww,n�UR $5,00D
.... � d.-.Lllrnotra.L°F+Lub'Ps'u'I-u°- Y Y 92L614261&92YD04220 07/1212019 O7i1212020`!E�NERAL.�G"`..EGrnTEl,n__.5�.2...........................................".
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AUTOMOB
f.ro'HIl¢ Io ma rohf"&IflAlp �:, ._
ILE LIABILITY Y 4414167F2475 06/24/2019 1212412019 „ •I,i, -•,
PVjylj
h, 1 11 0"P Urdl V
rsr,a':nl. ,' ukl.yl-!Awry (G r�✓p,e« uriB s 1.000,000
t'ff,'IM9",Y(P"'rc.:ioMI s 1,000,000
PROK R1 exiW40F' _....__....$.....1..000.000
,lR�L+rcarY�lorra4,' .
UMBRELLA LIAR eOr,. ,l V4 Lq'- 6 'Lr O R'R11i Pf l
EXCESS L.IAB ,.,r APIVI.; IVA it AG'Cir'EGATE
'WORKERS COMPENSATIONC('I"�' CitF-i_
AND EMPLOYERS° LIABILITY YIN_•_ --
ANY PRJnRIETORrPARTNE€/EY.ECUTIVE r.11 II" t 41 K Y l Ulmml-IJV n
Y711 N L Lt IAWI r l_._.._
(M fide ory IY'.V
MNHJ EXCLUDED?N I a I, s
If yes describe andar
_ DESCRIPTION OF nPF,Rs.T! (V5 MEE�L DISEASE -POLICY LINAT S
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES iACORD 101, Additional Remarks Schedule, may be attacl;ed if more space rs regmredl
Business Office Policy Property Locations:
1881 Business Center Dr, San Bernardino, CA 92408 39755 Murrieta Hot Springs Rd, Ste D16D, Murrieta, CA 92563
1545 Anacapa Rd Ste 7C, Victorville, CA 92392 135 S State College Blvd Ste 200, Brea, CA 92821
444 Camino Del Rio Ste 2015,San Dieoo, CA 92108 7701 Palomar Airport Rd #300, Carlsbad, CA 92011
74075 FI Paseo Ste A9 Palm Desert, CA 92260
232 Harrison Ste D, Claremont, CA 91711
CERTIFICATE HOLDER
CANCELLATION
0 0.2015 A ROCO ORA N. All rights reserved.
ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE
THEREOF,
NOTICE WILL BE DELIVERED IN
City of EI Segundo, its officers; officials, employees, agents
ACCORDANCE WITH THE POLICY PROVISIONS.
and volunteers
35D Main St
A I ED R'EP TIVE
EJ Segundo, CA 90245
0 0.2015 A ROCO ORA N. All rights reserved.
ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD
92 -YD -0422-0 028378 CMP -4786 1
. s Page 1 of 2
THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY.
CMP -4786.1 ADDITIONAL INSURED — OWNERS, LESSEES, OR CONTRACTORS
(Scheduled)
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
SCHEDULE
Policy Number: 92 -YD -0422-0
Named Insured:
NANCY K KOHL INC
DBA THE COUNSELING TEAM
INTERNATIONAL AND DBA THE
ORGANIZATIONAL NETWORK
PO BOX 110427
SN BERNRDNO CA 92423-0427
Name And Address Of Additional Insured Person Or Organization:
CITY OF EL SEGiUNDO
ITS OFFICERS OFFICIALS
EMPLOYEES AGENTS & VOLUNTEERS
350 MAIN ST
EL SEGUNDO CA 90245-3895
1. SECTION II — WHO IS AN INSURED of
b. If coverage provided to the additional in -
SECTION II — LIABILITY is amended to in-
sured is required by a contract or agree-
clu'de', as an additional insured, any person or
ment, the insurance provided to the
organization shown In the Schedule, but only
additional insured will not be broader than
with respect to liability for "bodily injury",
that which you are required by the contract
or '"personal and advertls-
or agreement to provide for such addition -
ing Injury" caused, in whole or In part, by:
al insured; and
a. Ongoing Operations
c. If the contract or agreement between you
(1) Your acts or omissions, or
and the additional insured is governed by
(2) The acts or omissions of those acting
California) Civil Code Section 2782 or
2782.05, the insurance provided to the
on your behalf;
additional insured is the lesser of that
in the performance of your ongoing opera-
tions for that additional insured; or
which:
(1) Is allowed for the satisfaction of a de-
b. Products – Completed Operations
fense or indemnity obligationby� Cali -
`"Your work" performed for that additional
fornia Civil Code Section 2782 or
insured and included in the "products-
2782.05 for your sole liability; or
completed operations hazard".
(2) You are required by contract or
However, Paragraph 1, above is subject to the
agreement to provide for such addi-
following:
tional Insured,
a. The insurance afforded to the additional
We have no duty to defend or indemnify the
insured only applies to the extent permit-
additional insured under this endorsement un -
ted by law;
til a claim or "suit" is tendered to us,
@, Copyright, State Farm Murmal Automobile Insurance Company, 2013
Includes copyrighted material or Insurance Services Guice, Inc., vwdh its permission.
-VD -0422-0 D28378
M 28370 CMP -1786 1
Page 2 of 2
2. Any ;a.,d to Lh,,- ,:additional in-
(3) The nature and location of any injury
;cured shall only apply with respect to a claim
or damage arising out of the "occur -
made of a "$Llit°" bI`ougIU for danna es for
rence" or offense;
which you are provided coverage.
b. Tender the defense and indemnity of any
3. With respect to the insurance afforded to the
claim or "suit" to us and to all other insur-
aclditponal insured, the following is added to
ers who may have Insurance potentially
SECTION II -M-- LIMITS OF INSURANCE
available to the additional insured; and
If coverage providod to the additional insured
c. Agree to make available any other insur-
is required by contract or agreement, the most
ance the additional insured has for de -
we will pay on belialf of the additional insured
fence or damages for which we would
will 'be t ae lesser of tlIaraIorint of insurelice�
provide coverage under SECTION 11 —
a. Required by the contract or agreement; or
LIABILITY.
b. Available under the applicable Limits Of
5. With respect to the insurance afforded the ad -
Insurance shown in the Declarations.
ditaonal insured, the following replaces SEC-
TION 11 —LIABILITY of Paragraph 7. Other
This endorsement shall not increase the ap-
Insurance of SECTION I AND SECTION Il ---
plicable Limits Of Insurance shown in the
COMMON POLICY CONDITIONS:
Declarations.
a. This insurance is primary to and will not
4. With respect to the insurance afforded to the
seek contribution from any other insurance
additional insured, the following is added. to
available to the. additional. insured, provided
Paragraph 3. Duties In The Event Of Occur-
thai the additional insured is a h arne� d in-
rence, Offense, Claim Or Suit of SECTION
sured under such other insurance,
II — GENERAL CONDITIONS:
b. regardless of .any agreement between
The additional insured must:
you and the additional INUI-ori, this il'1sur-
ance is excess over any other insurance
a. See to it that we are notified as soon as
whether primary, excoss„ contingent or on
practicable of an "occurrence" or an of-
any other basis for which the additional in-
fense which may result in a claim. To the
cured has been added as an additional in -
extent possible, notice should include:
sured on other policies.
(1) How, when and where the "occur-
There will be no refund of premium in the event
rence" or offense took place;
this endorsement is cancelled.
(2) The names and addresses of any in-
jured personas and witnesses; and
All other policy provisions apply.
CMP -4786 1
©, Copyright, State Farm Mutual Automobile Insurance Company, 2013
Includes copyrighted material of Insurance Services Office, Inc., with its permission
92 -YD -0422.0 028380
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CMP -4787 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST
OTHERS TOUS....,,,, .. ... . , .. ., ... ..
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
SCHEDULE
Policy Number: 92 -YD -0422-0
Named Insured:
NANCY K BOH!L INC
DBA THE COUNSELING TEAM
INTERNATIONAL AND DEA THE
ORGANIZATIONAL NETWORK
PO BOK 10427
SN EERNRDNO CA 92423.0427
Name And Address Of Person Or Organization:
CITY OF EL SEGUNDO
ITS OFFICERS OFFICIALS
EMPLOYEES AGENTS & VOLUNTEERS
350 MAIN ST
EL 'SEGUNDO CA 90245-3895
The following is added to Paragraph 10.b. of SECTION I AND SECTION II — COMMON POLICY
CONDITIONS:
We waive any right of recovery we may have against the person or organization shown in the Schedule
because of.payments we make for injury or damage arising out of.-
a.
f:a. Your ongoing operations; or
b. "Your work" done under 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.
All other policy provisions apply.
CMP -4787
©, Copyright, State Farm Mutual Automobile Insurance Company, 2008
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
PHILADELPHIA
1CPH INSURANCE COMPANIES
4 01Sa'CS' RTES
Certificate of Liability Insurance
Date Issued: 07/2912019
Underwritten by: Philadelphia Indemnity Insurance Company • One Bala Plaza, Suite 100 • Bala Cynwyd, PA 19004 - NAIC #: 18058
Administered by: CPH & Associates - 711 S. Dearborn St. Ste 205 - Chicago, IL 60605 - P 800.875.1911 - F 312.987.0902 • info@cphins.com
DISCLAIMER: This certificate is issued as a matter of information only and confers no rights upon the certificate holder. The Certificate of Insurance does not
constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend,
extend, or alter the coverage afforded by the policies listed thereon.
Insured: Nancy K. Bohl Inc. dba The Counseling Policy Number: 025826
Team International
Nancy Bohl Policy Term: 08/31/2019 to 08/31/2020
1881 Business Center Drive #11
San Bernardino, CA 92408
Covered Locations
Professional Liability: Portable coverage, not location sDecific
Coverage Type
Per Incident
Aggregate
(Occurrence Form)
(Per Individual claim)
(Total amount per year)
Professional Liability
$ 1,000,000
$ 5,000,000
Supplemental Liability
$ 1,000,000
$ 5,000,000
Licensing Board Defense
$ 35,000
$ 35,000
Commercial General
N/A
N/A
Liability
N/A
N/A
Fire/Water Legal Liability
Business Personal Property
N/A
N/A
Vicarious Sexual
$ 1,000,000
$ 1,000,000
Misconduct
Cyber Liability
(Claims Made Form)
$ 25,000
$ 25,000
Retroactive Date:
08/31/2018
Comments/Special Descriptions:
Certificate Holder
EI Segundo Police Department
348 Main Street
EI Segundo, CA 90245
® Certificate Holder has been added as an additional insured
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder In
lieu of such endorsement(s). Notice of Cancellation will only be provided to the first named Insured In accordance with policy provisions, who shall act on behalf of all
additional insureds with respect to giving notice of cancellation.
(' P)&f Aw*,-
Authorized Representative
C- Philip Hodson
POLICYHOLDER COPY SP
P.O. BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 08-12-2019
EL SEGUNDO POLICE DEPARTMENT SP
348 MAIN ST
EL SEGUNDO CA 90245-3813
GROUP:
POLICY NUMBER: 0702761-2019
CERTIFICATE ID: 94
CERTIFICATE EXPIRES: 08-12-2020
08-12-2019/08-12-2020
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer.
We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by The policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy.
Authorized Representative President and CEO
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2018-11-28 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED:
EL SEGUNDO POLICE DEPARTMENT
ENDORSEMENT #2085 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08-12-2011 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2019-08-12 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME:
EL SEGUNDO POLICE DEPARTMENT
EMPLOYER
NANCY K BOHL INC SP
1881 BUS CTR DR STE 11
SAN BERNADINO CA 92408
M0410
PRINTED : 07-17-2019
(REV.7-2014)
ENDORSEMENT AGREEMENT
WAIVER OF SUBROGATION
702761-19
RENEWAL
SP
HOME OFFICE 2-47-86-99
SAN FRANCISCO PAGE 25 OF 27
ALL EFFECTIVE DATES ARE
AT 12:01 AM PACIFIC EFFECTIVE AUGUST 12, 2019 AT 12.01 A.M.
STANDARD TIME OR THE
TIME INDICATED AT AND EXPIRING AUGUST 12, 2020 AT 12.01 A.M.
PACIFIC STANDARD TIME
NANCY K BOHL INC
1881 BUS CTR DR STE 11
SAN BERNADINO, CA 92408
ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING,
IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND
WAIVES ANY RIGHT OF SUBROGATION AGAINST,
EL SEGUNDO POLICE DEPARTMENT
WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS
POLICY IN CONNECTION WITH WORK PERFORMED BY,
NANCY K BOHL INC
IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN
PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION
OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE
EMPLOYER.
IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH
EMPLOYEES SHALL BE INCREASED BY 03%.
NOTHING IN THIS ENDORSEMENT SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND
ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY
OTHER THAN AS ABOVE STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE
HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR
LIMITATIONS IN THIS ENDORSEMENT.
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO:
AUTHORIZED REPRESENT IVE'
SCIF FORM 10217 (REV.4-2018)
AUGUST 2, 2019 2570
PRESIDENT AND CEO
OLD DP 217