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PROOF OF INSURANCE (2020 - 2020) CLOSEDI 7 a DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 11/08/2019 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 CONTACT NAME: Hiscox Inc. d/b/a/ Hiscox Insurance Agency in CA QA"" EII (888) 202-3007 FAX A X, NSI,, 520 Madison Avenue EMAIL hiscox coma,o), 32nd Floor ADDRESS::oon,p@ New York, NY 10022 INSURER(S) AFFORDING COVERAGE NAIC# INSURERA: Hiscox Insurance Company Inc 10200 INSURED IMGB Solutions 9506 Karmont Ave South Gate CA 90280 INSURER B INSURER C INSURER D INSURER E: 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 ILTR TYPE OF INSURANCE ADD SUBR POLICY EFF POLICY EXP _ LIMITS _ WVD POLICY NUMBER _ IMMIDDIYYYY?IMMIDDIYYYYI _ _ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S, 2,000.000 X CLAIMS -MADE X OCCUR PREMISE'SBEay.�G.IEU .,S ., Oa MAGE IC REN 100,000 ra:��rrw.�ncab,p A Y UDC -1506408 -CGL -19 GEN'L AGGREGATE LIMIT APPLIES PER: r7R(y., X POLICY JECT LOC OTIHrR, GENERAL AGGREGATE AUTOMOBILE LIABILITY PRODUCTS - COMPIOPAGO ANY AUTO OWNED.. SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS -MADE DED RETENTION S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANYPROPRI ETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F_ NIA (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below MED EXP 4,ny one person S 5,000 10/24/2019 10/24/2020, PERSONAL & ADV INJURY s 2,000,000 GENERAL AGGREGATE S 2,000,000 PRODUCTS - COMPIOPAGO S SIT Gen.Agg. Cf:1"u"a`�VfvF.DSXIlf",LE L41vIIR S ---- — -- ,E'a accudun)1 BODILY INJURY (Per person) S BODILY INJURY (Per accident) $ PROPERTY DAMAGE ,S (Per accidentl S EACH OCCURRENCE S AGGREGATE S s PER OTH- „ STATUTE ER E L EACH ACCIDENT S E L DISEASE - EA EMPLOYEE S E L DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of EI Segundo is an addtional insured CERTIFICATE HOLDER City Of EI Segundo 350 Main St EI Segundo, CA 90245 ACORD 25 (2016/03) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE i i T ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 4AM H I SCOX Policy Number: Named Insured: Endorsement Number: Endorsement Effective: UDC -1506408 -CGL -19 IMGB Solutions 17 October 24, 2019 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED 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) City of EL Segudo, its officers, employees, agents and volunteers 350 Main St EI Segundo,CA 90245 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 in- clude as an additional insured the person(s) or organi- zation(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omis- sions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 C ISO Properties, Inc., 2004 Page 1 of 1 0 DATE (MMIDD/YYYY) AC"RV CERTIFICATE OF LIABILITY INSURANCE 11/08/2019 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 'CONTA'CT NAME: Hiscox Inc, d/b/a/ Hiscox Insurance Agency in CA PHONE () 888 202-3007 FAX (Air,, N9, Ertl: , ¢AIC. Not: 520 Madison Avenue E-MAIL 32nd Floor ADDRESS: contact@h'iscox com New York, NY 10022 INSURER(S)AFFORDING COVERAGE NAICN INSURER A: Hiscox Insurance Company Inc 10200 INSURED IMGB Solutions 9506 Karmont Ave South Gate CA 90280 INSURER B: INSURER C: INSURER D: INSURER E t 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 ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER IMMIDDIYYW') MMIOD(YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE N;;e'AMAGr '1"0 RE6N'l It i' CLAIMS -MADE OCCUR PPEMO'SE$(Ea iorc:14earrpe) S GEN'L AGGREGATE LIMIT APPLIES PER PRO S PERSONAL & ADV INJURY S OTHER s AUTOMOBILE LIABILITY S ANY AUTO S OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LAB OCCUR EXCESS LAB CLAIMS -MADE DEG,) RETENTION S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? NIA (Mandatory in NH) If yes, describo under DESCRIPTION OF OPERATIONS below A Professional Liability Y MEG EXP (Any one person) S PERSONAL & ADV INJURY S GENERAL AGGREGATE s PRODUCTS - COMP/OPAGG S S t:C')MNNED SINGLE LOWT $ ,IEa anc'ide'm) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PR 0PE'.R'G'Y DAMAGE $ (Per acodenrp S EACH OCCURRENCE s AGGREGATE s s PER OTH- STATI.ITE ER EL EACH ACCIDENT s E L DISEASE - EA EMPLOYEE $ E L DISEASE - POLICY LIMIT $ UDC -1506408 -EO -19 10/24/2019 10/24/2020 Each Claim: $ 1,000,000 Aggregate: $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) City Of EI Segundo is an addtional insured CERTIFICATE H'OLDE'R City Of EI Segundo 350 Main St EI Segundo, CA 90245 ACORD 25 (2016/03) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved, The ACORD name and logo are registered marks of ACORD A01 Get your digital proof of insurance &membership card on the AAA App X>Download the app. Click AAA.com/app75 I rm, I'm V', Ia III W IUI„i I o I[ l`I—,11, ,u• Igi',fil Ul III 1ok 11 la., l', n I n dlr,l h,: I �, it luvrd �r,,q,p �,x•,w� i I � m' I IIP III' �"I;quI r� ir.�,,�Iofn,.rnhr�r�;rh,I„i �Vllu� °,�� +,i I �.�ri,i� I,,'r�iJini�l Iri�llnl. iP�dl ilitr,,,hrll'Ii,Ii rrI11,Ii,ll l� n ____~--------- -m----- ------ --------------- .. -T__ .. __ .. _________,-------_-..__..___--- PR INSURANCEVEHICLES ON POLICY n ,I Interinsurance Exchange of the Automobile Club YEAR MAKE VEH I D # !JP NAIC #: 15598 a �r.;a,+ 2012 VLKS NEW JETTA SE 3VWDP7AJ1CM377075 w u .maq:, u 2012 TYTA PRIUS PHEV JTDKN3DP2C3008610 w a Named Insured Policy Number: CAA107391418 2019 HOND CIVIC EX -L 19XFC1F7XKE202947 GABRIEL BARRIENTOS 2019 VLVO XC90TIS INSCRIPTION YV4A22PL6K1449543 � w Lu + w DRIVERS ON POLICY O BARRIENTOS, GABRIEL u- 1 Effective Date: 06/16/2019 Expiration Date: 06/16/2020 ; KRASIKOVA, VIKTORIIA This policy provides at least the minimum amounts of liability insurance required by the CA VEH CODE SECTION 16056 for the specified vehicles and named insureds Coverage subject to policy terms and limits iI!” ll; ,,U I "n u;dN'IV1111!I!' II L.. V. VCI:wP, lu.nW II".,II VI �; p'; V 1111:',u""i i III �;ii, "i I"it C w':d. ';' I'. .li I i After an accident, exchange information with the other party and follow these 5 easy steps: l Step 1: Pull vehicle over to a safe place Get the names, addresses, , and phone numbers of all persons involved in the accident, a g., u, pedestrians, witnesses, other passengers, etc w I Step 2: Take photos of or write down the other person's driver's o I license information and other vehicle's license plate number, ILL including state of registration. , Step 3: Take photos of or write down the other person's insurance Step 4: Take photos of the vehicles involved, damages and surrounding area of the accident, if it is safe to do so.. Step 5: Call our AAA Accident Assist Hotline at 800-672-5246 to report the loss, If necessary, we will arrange to have your vehicle towed. Our provider's tow trucks always display the AAA emblem Do not admit responsibility for or discuss the circumstances of the accident with anyone other than the police or an authorized Auto Club claims representative Do not disclose your policy limits to anyone For questions or changes to your policy, call 1-877-422-2100, Monday through Friday from 7 a . to 9 p m or Saturday from 8 a.m. to 5 p.m Place a Proof of Insurance card in each vehicle insured under your policy In addition, we suggest that each listed driver carry a card Under California law, Call our AAA Accident Assist drivers and owners of a motor vehicle must be able to show proof of financial Hotline at 1-800-672-5246 responsibility at all times. These cards become invalid and should be destroyed on the expiration or termination date of the policy. .,_.._...,_______.._________...._......_.._...._..___.._____.._____..__......___________________..__________......______________..___..___..__- PROOF OF INSURANCE VEHICLES ON POLICY tl za";%, Interinsurance Exchange of the Automobile Club YEAR MAKE VEH I D # µP NAIC #: 15598 2012 VLKS NEW JETTA SE 3VWDP7AJ1CM377075 ca" 2012 TYTA PRIUS PHEV JTDKN3DP2C3008610 Named Insured Policy Number: CAA107391418 2019 HOND CIVIC EX -L 19XFClF7XKE202947 GABRIEL BARRIENTOS I 2019 VLVO XC90 T6 INSCRIPTION YV4A22PL6K1449543 � w i W i w � DRIVERS ON POLICY ® BARRIENTOS, GABRIEL Effective Date: 06/16/2019 Expiration Date: 06/16/2020 ; KRASIKOVA, VIKTORIIA i This policy provides at least the minimum amounts of liability insurance required by the CA VEH CODE SECTION 16056 for the specified vehicles and named insureds Coverage subject to policy terms and limits --------------------------------------------------------- V: lll” " 0 kI II AVlll.r. N „. t,�,1`. �� � ; IP D i : IP'4 ""IG"" (,,Aill... 0 il. R "'.117 A jD„” A A C C I III.) lll: u After an accident, exchange information with the other party and w follow these 5 easy steps: n Step 1: Pull vehicle over to a safe place. Get the names, addresses, , and phone numbers of all persons involved in the accident, e.g., u, pedestrians, witnesses, other passengers, etc w d Step 2: Take photos of or write down the other person's driver's license information and other vehicle's license plate number, ILL o 0 including state of registration. Step 3: Take photos of or write down the other person's insurance card information. ------_______..______________..______.._ d"�r�,S S „ 1 .,.„t... , r 'Illm .,; f..'~I�..."�w..r"'Y....°"ri + `� yr IIllW � � % W x. V m.... III ,..Y II IU �.., � ta....l � � IU.... �i .s �.. �.. ,. k� m.. ,. m.. � �. i B Step 4: Take photos of the vehicles involved, damages and surrounding area of the accident, if it is safe to do so Step 5: Call our AAA Accident Assist Hotline at 800-672-5246 to report the loss If necessary, we will arrange to have your vehicle towed. Our provider's tow trucks always display the AAA emblem Do not admit responsibility for or discuss the circumstances of the accident with anyone other than the police or an authorized Auto Club claims representative, Do not disclose your policy limits to anyone For questions or changes to your policy, call 1-877-422-2100, Monday throug E2050622 -----------------._ __,--- ��__,__..,__.._..,.. _..___________—__..__....__ _ m__ _ 111419 , h Friday from 7 a m to 9 p m, or Saturday from S a m to 5 p.m ----------------------------------------------- 4 E 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. (_) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 forthe 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 # (_4X .) 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 th?se provisions or the agreement will automatically become void. Signature of Applicant "o^" µ Date 02/01/19 ��i���' tiil�►n ° ��rv�e� -- gyp,--r� Agreement for- Dated:-3/ or:Dated:-3 Reviewed b :. Y .K�,