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PROOF OF INSURANCE (2020 - 2020) CLOSEDD"A"TE YYYY) ..1..1 /0 ...- �at c�;►�ci CERTIFICATE OF LIABILITY INSURANCE (MMIDDI 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... n....__ ....................... ............m............................. older is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATIONIS 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). ....AUTO CLUB (NSU.. . CONTACT (866 )467 ) 72253682 RANCE AGENCY LLC/PHS PHONE 873.... ..... _ .w-------------- AIc,..N.... 888 443-6112 m NAM A/C, No, Ext):( o): The Hartford Business Service Center 3600 VUseman Blvd E-MAIL San Antonio, TX 78265 ADDRESS' INSURED David Ebeling 3456 LOTUS ST IRVINE CA 92606-2117 INSURER(S) AFFORDING COVERAGE?NAIC# r . .............. SerYtinL-'U........_.............................. ...................................,........ INSURER A ._L. ....... n..s....... ranCe u Company 11000 ............. INSURER B : .............................. _,................ . -_... INSURERC: 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 INSR� ........ AODL SUBR POLICY NUMBER POLICY EFF POLICY EXP ...................�.................................................IM"I'."S............_......................_.......,_____._...�. - LTRW.wr_.... ....CIOAL.GENE.RANC....LIABILITY NSR WD IMMID,)�,YYY,).,,,,,•,,,-EACH OCCURRENCE•"••LI•MITS $2.000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Fa pCCurrenGe) $1^^000 ___ ,000 ..... ..__... X General Liability MED EXP (Any one person) $10,000 n�._.•.,_.. A 72 SBM BC9401 11/07/2019 11/07/2020 PERSONAL & ADV INJURY .................. .•.. $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $4,000,000 LOC TS CO MP/OPAGG ....- PR........_..._.... $4,000,000 — L..-.._d...JECT .......... ................ OTHER .—..�. _ .........__. .....................m_����..._.m... AUTOMOBILE LIABILITY ._ww.................................................._.ODUC ........ COMBINED SINGLE LIMIT ....., ( a ar .j•ent ANY AUTO BODILY ALL OWNED�.mm, SCHEDULED (Per acdent) (mBODILY accident) AUTOS AUTOS •,w,m,,,,,,, HIRED' NON-OWNEDPROPERTY DAMAGE AUTOS AUTOS (Per accident) —......-......u.. ......... 8.................._.� UMBRELIAB _-�...�...........,,.u..........................._____..�..........._............................................................______....__......_______............_......... OCCUR EACH OCCURRENCE EXCESS CLAIMS - [MADE AGGREGATE mAND k"L'V ..........hRETENTION $ .............. .................... KERS COMPENSATION WCR ,�"""`"""'""""'..____..........___........................__________. PER OTH- (STATUTE .....................p EMPLOYERS' LIABILITY IER ANY Y/N� 4 E L EACH ACCIDENT PROPRIETOR/PARTNER/EXECUTIVE NIA OFFICER/MEMBER EXCLUDED C E L DISEASE -EA EMPLOYEE (Mandatory in NH) _..w,w..w.................._,.W..............�.........___................_ If yes, describe under E L DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if, more space is required) Those usual to the Insured's Operations.THE CITY OF EL SEGUNDO its officers, officials, employees and volunteers is additional insured per the Business Liability Coverage S,Iaatttacched tothisHOLDER pol cyCANCELLATION CERTIFICATE SEO008rm SS0008 attached to this policy Coverage is primary and per the Business Liablli6 overage Form "THE CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 350 MAIN ST BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED EL SEGUNDO CA 90245-3813 IN ACCORDANCE WITH THE POLICY PROVISIONS. ................................ AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 72 SBM BC9401 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - VENDOR CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO CA 90245 Form IH 12 00 11 85 T SEQ. NO. 001 Printed in U.S.A. Page 00.1. Process Date: 11/0s/19 Expiration Date: 11/07/20 M THE HARTFORD BUSINESS SERVICE CENTER THE 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 THE CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO CA 90245-3813 Account Information: Policy Holder Details : David Ebeling November 5, 2019 %Q Contact Us Business Service Center Business Hours: Monday - Friday (7AM - 7PM Central Standard Time) Phone: (866) 467-8730 Fax: (888) 443-6112 Email: 29�gficv.services@thehartford.com Website: httr)s./Ibusiness.thehartford,com Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team WLTR005 a a' " Interinsurance Exchange of the Automobile Club ti Automobile Insurance Policy Coverages and Limits Modified Renewal Declarations We are pleased to offer you a renewal for your automobile insurance policy To renew your policy, send at least the minimum payment on or before the due date Insurance is in effect only for the vehicles, coverages, and limits of liability shown on this declarations page and as set forth in the insurance policy and endorsements These declarations, together with the contract and the endorsements in effect, complete your policy If any change to your policy or to the information we have on file results In a premium decrease during the policy period, the Interinsurance Exchange reserves the right to apply any refund due to your outstanding balance NAMED INSURED I'llem 1.) - AUTO POLICY NUMBER: CAA 071832643 EBELING, KATHLEEN & DAVID POLICY PERIOD (PACIFIC STANDARD POLICY EFFECTIVE VE RD TIME) 3456 LOTUS ST T DATE: 07-28-19 12:01 AM. IRVINE CA 92606-2117 POLICY EXPIRATION DATE: 07-28-20 12:01 A.M. VEHICLES VEH YEAR MAKE MODEL IDENTIFICATION NO. VEHICLE GARAGE ANNUAL" VERIFIED SALVAGE NUMBER USE ZIP CODE MILES MILEAGE 3 2013 SUBA OUTBACK SW 2.51 COMMUTE 92606 7,501 - 10,000 VERIFIED NO 4 2013 HOND PILOT EX PLEASURE 92606 20,001 -25,000 VERIFIED NO 5 2013 VLKS NEW JETTA BASE/S COMMUTE 92606 10,001 -12,500 VERIFIED NO COVERAGES AND LIMITS Coverage is not in effect unless a premium or the word "included" is shown. ANNUAL PREMIUMS COVERAGES LIMITS OF LIABILITY Vehicle 3 Vehicle 4 Vehicle 5 Vehicle Vehicle Liability - -- .................................. ........ ......w Bodily Injury $500,000 each person/ $500,000 each occurrence $ 248 $ 336 $ 651 Property Damage $100,000 each occurrence $ 204 $ 294 $ 630 Medical - Excess Medical Payments $2,000 each person ....WW.w $ 14 $ 14 $ 18 Physical Damage (Actual cash Value unless otherwise stated less deductible) Vehicle 3 Vehicle 4 Vehicle 5 Vehicle Vehicle Comprehensive ACV ACV ACV $ 37 $ 47 $ 70 (Less Deductible) $250 $250 $250 Collision ACV ACV ACV $ 320 $ 412 $ 1158 (Less Deductible) $500 $500 $1000 Car Rental Expense (Per 'Dray) $35 $35 No Crwerage $ 43 $ 52 No Coveraqe Uninsured Motorist Bodily Injury - $1 D0,000 each person/ $300,000 each accident $ 90 $ 101 $ 154 Uninsured & Underinsured Vehicles Uninsured Deductible Waiver Included Included Included Uninsured Collision No Coverage I' No Coverage,' No Coverage; Total Premium $ 956 $ 1256 $ 2681 PREMIUM DISCOUNTS "No Coverage" indicates coverage not purchased Pleaserefer to tt he encloseddocument entitled "Premium Discounts Applied to Your Automobile Policy" oou Total Annual Premium* $ 4893 Ifeat an me cho * choose to pay less than the full balance outstanding, y Y (Includes all applicable discounts.) finance charges of up to 1.5% per month of the balance outstanding will apply Less Policyholder Savings Dividend $ 664 as explained in your billing statements, which are part of these declarations. [N et""prem"ium* $4229"' ** To see the annual mileage for your expiring policy, please refer to the "Notice of Annual Mileage" page contained in your renewal package. E20 9007 PROCESS DATE 07-15-19 PLEASE ATTACH TO YOUR POLICY (SEE REVERSE) 071519 DATEM/DDIYYYY) A<7f? CERTIFICATE OF LIABILITY INSURANCE V rr.r•"'" ll(/114/2019 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(les) 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 Bonnie Ayersman NAME: SPIB Insurance Agency, Inc PHONE (949) 582-5220FA (949) 582-3512 WC. No. Ex'll° AV'C, Nay License Number 0719264 E'-M'AIL bonnie@spib,com ADDRESS' 26441 Crown Valley Parkway#200 INSURERI'S) AFFORDING COVERAGE NAIC # Mission Viejo CA 92691 INSURERA: RLI Insurance Company AM Best Rating A+ 13056 .....................................................................-_.............� INSURED INSURER B: Ebeling Communications, DBA: E -Link com INSURER C 3456 Lotus St INSURER D INSURER E Irvine CA 92606 INSURER F: W COVERAGES CERTIFICATE NUMBER: MASTER 2019-2020 REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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 MAYBE 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 0bLI6Y FF�-T��1"Ei`E"V'E=7i....-........................�......................... LIMITS LTR INSD WVD (MMIDOIYYYY) (MMIDDlYYYY)„ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR GEN'LAGGREGATELIMITAPPLIES PER: POLICY PRO LOC JECT OTHER. AUTOMOBILE LIABILITY ANY AUTO .._ OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY __,__ ......... ..... UMBRELLA LIABV I OCCUR EXCESS LABCLAIMS-MADE DED II I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE NIA OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below PROFESSIONAL LIABILITY A RTP0017308 11/07/2019 11/07/2020 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER. CITY OF EL SEGUNDO 350 MAIN STREET ELSEGUNDO I ACORD 25 (2016103) CANCELLATION EACH OCCURRENCE S UAMAUF 10 REN I EU PRF..MISFS �,Ea occurrence) $ MED EXP (Any one person) s PERSONAL &ADV INJURY S GENERALAGGREGATE S PRODUCTS - COMP/OPAGG S S COM204ED S'BNGLE OJWIT' S tlEa acvdnon BODILY INJURY (Per person) s BODILY INJURY (Per accident) $ PROPERTY DAMAGE S (Per accident) $ EACH OCCURRENCE $ AGGREGATE $ hPER RS V STATUTE FH E L EACH ACCIDENT $ E L DISEASE - EA EMPLOYEE $ E L DISEASE - POLICY LIMIT S PL 1,000,000 OCC 1,000,000 AGG DED 1,000 r�- 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 CA 90245 �'� ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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. affirm under penalty of perjury under the laws of California one of the following declarations: L_) 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. U 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 Policy Number Expiration Date Name of Agent Phone # p 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 or the agreement will automatically become void. "F. ... ..... ... _Signature A licant Date ........... Print Name Agreement for: ` I rv� Dated: Reviewed by: 17 r►,