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PROOF OF INSURANCE (2019) CLOSEDA, DATE (MM/DD/YYYY) f CERTIFICATE OF LIABILITY INSURANCE 05/10/2019 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 NCONTACT Producer AMEInsurance Brokers West PHONE (805) 299-2150 A (805) 529-4887 A/C Na Ext :. A! N..�a 484 E. Los Angeles Ave. F-MAILSS: Suite 110 INSURER(S) AFFORDING COVERAGE NAIC # Moorpark CA 93021 INSURERA: Nautilus Insurance Company 17370 INSURED INSURERB: California Automobile Insurance Cc 38342 Pacific Tennis Courts, Inc. INSURERC: Scottsdale Insurance Company 41297 530 Los Angeles Ave INSURER D : State Compensaton Insurance Fund 35076 Suite 115-320 INSURER E : Moorpark CA 93021 INSURER F : COVERAGES CERTIFICATE NUMBER: 18/19All Lines 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 CONTRACTOR 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. LTR TYPE OF INSURANCE IN5D WVD POLICYNUMBER MM/DD/YYYY MM/DDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 50,000 MED EXP (AnX one person) $ 10,000 PERSONAL &ADV INJURY $ 1,000,000 A NN887720 10/28/2018 10/28/2019 GEN'LAGGREGATE LIMITAPPLIES PER: GENERALA13GREGATE $ 2,000,000 POLICY PRO- LOC JECf PRODUCTS-COMP/OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINEDSNGI.FLIMIT Era accddecrq, $ 1,000,000 BODILY INJURY (Per person) $..,. ANYAUTO B OWNED SCHEDULED AUTOS ONLY AUTOS BA040000023313 08/14/2018 08/14/2019 BODILY INJURY (Per accident) j �$ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTYDAMAGE Per acoiden $ $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ 2,000,000 X AGGREGATE $ 2,000,000 C EXCESS LIAB CLAIMS -MADE XBS0094374 10/28/2018 10/28/2019 DED .ETFNTION S 10,000 $ D WORKERS COMPENSATION '.AND EMPLOYERS'LIABILITY YIN '.ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N/A 9140811-16 08/14/2018 08/14/2019 H X1 gTA UTE ER E_L_ EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE IS 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E,L, DISEASE -POLICY LIMIT $ 1,000,000 ''.. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City, its officers, officials, employees, agents, and volunteers will be covered as insureds as respects: liability arising out of activities performed by or on behalf of the Contractor; products and completed operations of the Contractor; premises owned, occupied or used by the Contractor; or automobiles owned, leased, hired or borrowed by the Contractor. The coverage will contain no special limitations on the scope or protection afforded to the City, its officers, officials, employees, agents, or volunteers are included as additional insured per form CG20100413 attached. Waiver of subrogation is included per form 10217 attached. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo CITY CLERK ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street AUTHORIZED REPRESENTATIVE ElSegundo CA 90245 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Policy Number: NN887720 CG 20 10 0413 Insured Name: Pacific Tennis Courts, Inc Number: 44 Effective Date: 10/28/2018 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 Additional Insured Person(s) Or Organization(s): Location(s) Of Covered Operations City of El Segundo, its officials, employees, All locations for which you have agreed in a written agents and volunteers and executed contract prior to an "occurrence." Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended 2. If coverage provided to the additional to include as an additional insured the insured is required by a contract or person(s) or organization(s) shown in the agreement, the insurance afforded to such Schedule, but only with respect to liability for additional insured will not be broader than "bodily injury", "property damage" or "personal that which you are required by the contract and advertising injury" caused, in whole or in or agreement to provide for such additional part, by: insured. 1. Your acts or omissions; or B. With respect to the insurance afforded to 2. The acts or omissions of those acting on these additional insureds, the following your behalf; additional exclusions apply: in the performance of your ongoing operations This insurance does not apply to "bodily injury" for the additional insured(s) at the location(s) or "property damage" occurring after: designated above. 1. All work, including materials, parts or equipment furnished in connection with However: such work, on the project (other than 1. The insurance afforded to such additional service, maintenance or repairs) to be insured only applies to the extent performed by or on behalf of the additional permitted by law; and insured(s) at the location of the covered operations has been completed; or CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 2 of 2 ENDORSEMENT AGREEMENT BROKER COPY WAIVER OF SUBROGATION REP B2 9140811-16 RENEWAL SC HOME OFFICE SAN FRANCISCO PAGE 1 OF 3 ALL EFFECTIVE DATES ARE AT 12;01 AM PACIFIC EFFECTIVE MAY 13, 2019 AT 12.01 A.M. STANDARD TIME OR THE TIME INDICATED AT AND EXPIRING AUGUST 14, 2019 AT 12.01 A.M. PACIFIC STANDARD TIME PACIFIC TENNIS COURTS, INC. 530 E LOS ANGELES AVE STE 115-320 MOORPARK, CA 93021 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF EL SEGUNDO WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, PACIFIC TENNIS COURTS, 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 CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT, COUNTERSIGNED AND ISSUED AT SAN FRANCISCO, AUTHDRI2ED REPRESENT` qVE SCIF FORM 10217 IREV.7-2014) MAY 13, 2019 PRESIDENT AND CEO 2570 OLD OF 217