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PROOF OF INSURANCE (2020 - 2020) CLOSED,^^. 0' DATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 3/6/2019 THIS CERTIFICATE IS ISSUED ASA 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 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). IUNIA l PRODUCER Maile Jeppesen Brennan and Associates Risk Mgmt & Insurance Svc License # 0649629 1551 N. Tustin Ave., Ste 500 Santa Ana CA 92705 NAME: .............. PHONE 714-509-1073 FAX 714-975-8966 P10 E'rt47: I'APC.N'o'i;..__....._...... ._._....... ...-.� E•MA4U. S� INSURER($) AFFORDING COVERAGE NAIC # �INSURER A: C010 Insurance Company INSURED INSURER B: Berkshire Hath awa Homestate Ins Cc Krause ACT, Inc. �N.,SURERc:Ohio Security Insurance Company ._...m....m.__.....__..._,m,_......._.......DBA: Air Cleaning Technology URER D: -...W W W W W.-........_......_ ............................... 411 Rowland Ave INSURER E : Santa Ana CA 92707 INSURER F: COVERAGES CERTIFICATE NUMBER:2019 PxG & XS Renewal n al 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. _.W ......................_. .............. ..... ... . _...-..W..-..W W W ...................................................... W W .......... ......_........................... m INSR ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE ukSD WVn POLICY NUMBER (MM/OD/YYYY) PMM'VDDfY'YYYM LIMITS X COMMERCIAL GENERAL LIABILITY ,_.,�_.�........., ._........... A CLAIMS -MADE X OCCUR X $2,500 Deductible X .......... ................................... .._.......................... each occurence GEN'LAGGREGATEp LIMITAPPLIES PER: POLICY [_ A PECT F-1 LOC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED _ AUTOS AUTOS NON -OWNED HIREDAUTOS q AUTOS UMBRELLA LIAB X OCCUR A X ! EXCESS LIAppB f W CLAIMS -MADE DED II I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY PACE4245133 3/7/2019 3/7/2020 EXC4245134 3/7/2019 3/7/2020 Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A B (Mandatory in NH) y KRWC016856 If yes, describe under DESCRIPTION OF OPERATIONS below C Contractors Equip/Tools BKS57761799 A Errors & Omissions PACE4245133 EACH OCCURRENCE $ 1,000,000 . DANA�, R(NTED ,..._._.._................ __ PREMISES"cld,C,C�;liPr:�nd;e�1 300,000 ,$,. MED EXP (Any one person) S50,000 ............................... PERSONAL & ADV INJURY $ 1,000,000 ..GENERAL AGGREGATE .................................... $ 2,000,000 PRODUCTS - COMP__ /OPAGG $ 2,000,000 COkISINEIl'$IWil.S q, IMI'7 $ .....................................w.�.�... BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DA14^F+GE $ $ EACH OCCURRENCE $ AGGREGATE $ OTH- X I PERSTATUTE Ii I FIR E L EACH ACCIDENT $ 1/1/2019 1/1/2020 E L DISEASE - EA EMPLOYEE $ E L DISEASE - POLICY LIMIT $ 2/1/2019 2/1/2020 3/7/2019 3/7/2020 4,000,000 4,000,000 1,000,000 1,000,000 1,000,000 $10,000/$1000 $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: E1 Segundo Fire Department, 314 Main Street, E1 Segundo, CA 90245. The City of E1 Segundo is included as Additional Insured with regard to General Liability per attached forms EPACEIOO-0814 & EPACE101-0814. Waiver of Subrogation applies to Workers' Compensation per attached form WC990410B. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of E1 Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn : City Clerk ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE Greg Havill/MJ I © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) POLICY NUMBER: PACE4245133 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NMI ' �' • 09 1 1 WK4 [ O%k Real 0 10190111101161 ]K01:1:4 This endorsement modifies insurance provided under the following; EnviroPACE Insurance Policy SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Where Required By Written Contract Location And Description Of Completed Operations Where Required By Written Contract A. Section XX. WHO IS AN INSURED, Coverage Part 1 and Part 2 is amended to include as an additional insured the person(s) or organization(s) shown in the SCHEDULE above, but only with respect to liability for bodily injury, property damage, environmental damage, or cleanup costs caused, in whole or in part, by your work at the location designated and described in the SCHEDULE of this endorsement performed for that additional insured and included in the products -completed operations hazard. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to section XXI. LIMITS OF LIABILITY AND DEDUCTIBLE: 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 Liability shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Liability shown in the Declarations. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED... EPACE100-0814 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1 with its permission. POLICY NUMBER: PACE4245133 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: EnviroPACE Insurance Policy SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Where Required By Written Contract Location(s) Of Covered Operations Where Required By Written Contract A. Section XX. WHO IS AN INSURED, Coverage Part 1 and Part 2 is amended to include as an additional insured the person(s) or organization(s) shown in the SCHEDULE above, but only with respect to liability for bodily injury, property damage, personal and advertising injury, environmental damage, or cleanup costs caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to bodily injury or property damage occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 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. EPACE101-0814 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 2 with its permission. C. With respect to the insurance afforded to these additional insureds, the following is added to section XXI. LIMITS OF LIABILITY AND DEDUCTIBLE: 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 Liability shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Liability shown in the Declarations. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED, EPACE101-0814 Includes copyrighted material of Insurance Services Office, Inc., Page 2 of 2 with its permission. AC CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) L 11/27/2019 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 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 I CONTACT Kath D­ Dan Dan Rickabus IF: y State Farm Insurance -36 u.AAcc�....... 99.363 1836 'a F 30131 Town Center Drive, Suite 275 ENAMA°LF'rs. kat benne. r Tiff statefarm.com pe IYO......ww.....w.... ••-•••••-••�-- Laguna Niguel, CA .92677 INSURER(S) AFFORDING COVERAGE NAIC# ................................................................................. INSURER A -.State Farm Mutual Automobile Insurance Company 25178 INSURED Krause A C T - ............................���.........,.........�..�..,..... INSURER B : DBA Air Cleaning Technology INSURER C: 411 Rowland Ave .._._.. ..... �............ ....... ............... � INSURER D : Santa Ana, CA 927073445 INSURER E f .........m. 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 INM SUBR LTR, TYPE OF INSURANCE iN„i ,gyp POLICY NUMBER ' POIEFF POLICY EXP IMMIDD/DI YYYYI IMMfODrYYYY1 •_......................... OMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S qq CLAIMS OCCUR bi "PSD REMISE p.............W..r, -MADE i� PREMISES Ilia avrcurronre'N $ MED EXP (Any one person) S PERSONALS ADV INJURY $ G MPOAGCREGATEPIMOIT APPLIES PER: RALAGGREGATE $ ,E ❑ JECT PROD.....�.�.�.�... 11CTS-COMP/OPAGG _$ ...............m........ O"iHER', A AUTOMOBILE LwBwTYY 54,5111174 -COI -75 09/01/2019 03/01/2020 -C qr dtroo 9NCLE LIMIT $ i,000,00D X ANY AUTO 519 1539-C01-75 09/01/2019 03/01/2020 BODILY INJURY (Per person) $ X ALL OWNED AUTOS SCHEDULED AUTOSBODILY 5451763-C01-75 " INJURY (Per accident) $ 09/01/2019 03/01/2020 .--..- _ -..� X HIRED AUTOS AUTOS D 497 1093-C01-75 ........._w_ww.__.........�. ROPE ? Y DAMA(: E $ 09/01/2019 03/0112020 t — -- ....••••••••••• ••••••••-• - $ UMBLA _EA,,22C.URRENCE $ _E.LLIAB EXCESS AB ..,,, .�. .,OCCUR CLAIMS -MADE � „ ............ AGGREGATE$ ..._ DED..ONS RETENTIONS $ WORKERS COMPENSATION ” y �g PER ERH AND EMPLOYERS' LIABILITY YIN R ANY EACH IDENT $ OFFICERIMEMBER EXCLUDED? N / A (Mandatory in NH) E L. DISEASE - EA EM $ Ifyes_...- I DESCRIPT ON OF OPERAT PNSEbeUowVE E,L DISEASECPOLICPLOYEE Y LIMIT S A ENCL Y $1,000,000 CSL 507 2152-C01-75 09/01/2019 03/01/2020 $250 Physical Damage deductible DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 701, Additional Remarks Schedule, may be attached If more space is required) City of EI Segundo, its officials and employees are named additional insured Location: EI Segundo Fire Department CERTIFICATE MOLDER CANCELLATION EI Segundo Fire Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 360 Main St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EI Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. r r r AUTHORIZED REPREAENTATIVE F1✓(�K� z ©1988-2014 ACORD CORPORATION. All rights�yerved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 1001486 132849.9 02-04-2014 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 04 10B (Ed. 9-14) WAIVER OF UUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -CALIFORNIA BLANKET BASIS We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) The additional premium for this endorsement shall be 2% of the total manual premium otherwise due on such remuneration. The minimum premium for this endorsement is $350. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. SCHEDULE BLANKET WAIVER Person/Organization Blanket Waiver — Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. Job Description All California Operations This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 01/01/2019 Insured Krause ACT, Inc. Policy No. KRWC016856 Endorsement No. 001 Insurance Company Berkshire Hathaway Homestate Ins. Co. WC 99 04 10B (Ed. 9-14) Countersigned by Premium $