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PROOF OF INSURANCE (2021) CLOSED (2)AC CERTIFICATE OF LIABILITY INSURANCE o„212020,,Y) DATE I 212020 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: it the certificate holder Is an ADDITIONAL INSURED, the dURED s or be If SUBROGATION S b WAIVED, subject to the terms and conditions of the policy, certain ertain po icies t have mayOrequire eNan endorsement d A statement on this (s). PRODUCER Cocertificate g he certificate holds. in lieu of such cuN ro r ("ra Aguinaga orsemon does not confer rights to T.(JN t.au Hay P ADDRESS: VWTw,, eellt 909) 243-8200 t N'e1:, PHONE 4200 Concours, Suite #350 ES,S: CERTIFICATE HOLDER City of EI Segundo 350 Main Street EI Segundo I 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 CA 90245 4 01968-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD INSURER($) AFFORDING COVERAGE NAIC N Ontario CA 91764 INSURERA: Sentinel Insurance Company Ltd 11000 INSURED INSURER B: HR Dynamics & Performance Management, Inc INSURERc: 461 Green Orchard PI I INSURER D INSURER E Riverside CA 92506 I I'NSUR'ER F ; 5 REVISION ES COVE, 2Y CY PERIOD TO THEINSUREDPOLIO AVE BEN NSUR E S TO CERTIFY THAT THE PCLC,' Of IN HAVE RESPECT INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION A CONTRACT DOCUMENT WITH RES 0 WHICH T HIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. (NSrt' AUUL'but$t LTR TYPE OF INSURANCE 1'NSO 'ANVO POLICY NUMBER POUCY'EPP POLIDYeXP LIMITS ('MMMOIYYYY) IMMIDDIYYYY) x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE y 2,000,000 CLAIMS -MADE ❑X OCCUR Lb�AMAtA iVHt;NItU PREMISE$ Eaoo�mncol 1.000.0'00 S MED EXP (Any cna parsan'y S 10,000 A Y 41SBANNO763 01/09/2020 01/0912021 I PERSONALS ADV INJURY S 2«000,000 GEN'LAGGREGATE LIMIT APPLIES PER: �i GENERAL AGGREGAT'E'S S 4,000,000 POLICY a JEC F-1LOC j PRODUCTS - C'OMPIOP AGG S 4«000,000 $ OTHER a NGLE(.tlMIT I g 1,000,000 AUTOMOBILE LIABILITY eaaadeeall, ANY AUTO BODILY INJURY (Per person) $ A OWNED SCHEDULED 41SBANNO763 AUTOS 01/09/2020 01/0912021 BODILY INJURY (Per accident) S + AUTOS ONLY HIRED NON -OWNED PROPER n4S IY DAMAGE I tear de' y AUTOS ONLY AUTOS ONLY UMBRELLA LIAR OCCUR _ HCLAIMS.MADEAGGREGATEAREGATF EACH OCCURRENCE I $ EXCESS LIAR RRR S OED RETENTION S S WORKERS COMPENSATIONPER --i OTH• S'TATU'TE I ER' .ANO EMPLOYERS' LIABILITY YIN ANY PROP'RIE'T'ORAAR�TNERI'EXECUVVE E L EACH ACCIDENT „ S NIA OF'FIOERIMEMSE,R EXCLUDED? El EL DISEASE - EAE'MPLOYEE, S (Mandatory in HH) I('yas« deacrlbe under O'ESCRIP7*N OF OPERATIONS tiol�aw E L DISEASE - POLICY LIMIT 5 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may De attached If more space Is required) City of EI Segundo is additional insured per attached policy form. CERTIFICATE HOLDER City of EI Segundo 350 Main Street EI Segundo I 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 CA 90245 4 01968-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD BUSINESS LIABILITY COVERAGE FORM F. OPTIONAL ADDITIONAL INSURED 3. Additional Insured - Grantor Of Franchise COVERAGES WHO IS AN INSURED under Section C. is If listed or shown as applicable in the Declarations, amended to include as an additional insured one or more of the following Optional Additional the person(s) or organization(s) shown in the Insured Coverages also apply. When any of these Declarations as an Additional Insured - Optional Additional Insured Coverages apply, Grantor Of Franchise, but only with respect to Paragraph 6. (Additional Insureds When Required their liability as grantor of franchise to you. by Written Contract, Written Agreement or Permit) 4. Additional Insured - Lessor Of Leased of Section C., Who Is An Insured, does not apply Equipment to the person or organization shown in the a. WHO IS AN INSURED under Section C. is Declarations. These coverages are subject to the amended to include as an additional terms and conditions applicable to Business insured the person(s) or organization(s) Liability Coverage in this policy, except as shown in the Declarations as an Additional provided below: Insured — Lessor of Leased Equipment, 1. Additional Insured - Designated Person Or but only with respect to liability for "bodily Organization injury", "property clamagV or "personal WHO IS AN INSURED under Section C. is and advertising injury'" caused, in whole or amended to include as an additional insured in part, by your maintenance, operation or the person(s) or organization(s) shown in the use of equipment leased to you by such Declarations, but only with respect to liability person(s) or organization(s). for "bodily injury", "property damage" or b. With respect to the insurance afforded to "personal and advertising injury" caused, in these additional insureds, this insurance whole or in part, by your acts or omissions or does not apply to any "occurrence" which the acts or omissions of those acting on your takes place after you cease to lease that behalf- equipment. a. In the performance of your ongoing 5. Additional Insured - Owners Or Other operations; or Interests From Whom Land Has Been b. In connection with your premises owned Leased by or rented to you. a. WHO IS AN INSURED under Section C. is 2. Additional Insured - Managers Or Lessors amended to include as an additional Of Premises insured the person(s) or organization(s) a. WHO IS AN INSURED under Section C. is shown In the Declarations as an Additional amended to include as an additional insured Insured — Owners Or Other Interests From the person(s) or organization(s) shown in the Whom Land Has Been Leased, but only Declarations as an Additional Insured - with respect to liability arising out of the Designated Person Or Organization; but only ownership, maintenance or use of that part with respect to liability arising out of the of the land leased to you and shown in the ownership, maintenance or use of that part of Declarations. the premises leased to you and shown in the b . With respect to the insurance afforded to Declarations. these additional insureds, the following b. With respect to the insurance afforded to additional exclusions apply: these additional insureds, the following This insurance does not apply to: additional exclusions apply: (1) Any "occurrence" that takes place This insurance does not apply to: after you cease to lease that land; or (1) Any "occurrence" which takes place (2) Structural alterations, new after you cease to be a tenant in that construction or demolition operations premises; or performed by or on behalf of such (2) Structural alterations, new person or organization. construction or demolition operations 6. Additional Insured - State Or Political performed by or on behalf of such Subdivision — Permits person or organization. a. WHO IS AN INSURED under Section C. is amended to include as an additional insured the state or political subdivision shown in the Declarations as an Additional Page 18 of 24 Form 33 00 08 04 05 BUSINESS LIABILITY COVERAGE FORM Insured — State Or Political Subdivision - (a) Any failure to make such Permits, but only with respect to Inspections, adjustments, tests or operations performed by you or on your servicing as the vendor has agreed behalf for which the state or political to make or normally undertakes to subdivision has issued a permit. make in the usual course of b. With respect to the insurance afforded to business, in connection with the these additional insureds, the following distribution or sale of the products; additional exclusions apply: (Q Demonstration, installation, This insurance does not apply to; servicing or repair operations, (1) "Bodily injury", "property damage" or except such operations performed "Personal and advertising injury" at the vendor's premises in arising out of operations performed for connection with the sale of the the state or municipality; or product; (2) "Bodily injury" or "property damage" (9) Products which, after distribution included in the "product -completed or sale by you, have been labeled operations" hazard, or relabeled or used as a container, pail or ingredient of any 7. Additional Insured —Vendors other thing or substance by or for a. WHO IS AN INSURED under Section C. is the vendor; or amended to include as an additional (h) "Bodily injury" or "property insured the person(s) or organization(s) damage" arising out of the sole (referred to below as vendor) shown in the negligence of the vendor for its Declarations as an Additional Insured - own acts or omissions or those of Vendor, but only with respect to "bodily its employees or anyone else injury" or "property damage" arising out of acting on its behalf. However, this "your products" which are distributed or exclusion does not apply to: sold in the regular course of the vendor's (I) The exceptions contained in business and only if this Coverage Part "bodily Subparagraphs (d) or (0; or provides coverage for injury" or "property damage" included within the (ii) Such inspections, "products -completed operations hazard". adjustments, tests or servicing b. The insurance afforded to the vendor is as the vendor has agreed to subject to the following additional exclusions: make or normally undertakes to make in the usual course of (1) This insurance does not apply to: business, in connection with (a) "Bodily injury" or "property the distribution or sale of the damage' for which the vendor is products. obligated to pay damages by (2) This insurance does not apply to any reason of the assumption of insured person or organization from liability in a contract or agreement, whom you have acquired such This exclusion does not apply to products, or any ingredient, part or liability for damages that the container, entering into, vendor would have in the absence accompanying or containing such of the contract or agreement; products. (b) Any express warranty 8. Additional Insured — Controlling Interest unauthorized by you; WHO IS AN INSURED under Section C. is (c) Any physical or chemical change amended to include as an additional insured in the product made intentionally the person(s) or organizabon(s) shown in the by the vendor; Declarations as an Additional Insured — (d) Repackaging, unless unpacked Controlling Interest, but only with respect to solely for the purpose of inspection, their liability arising out of: demonstration, testing, or the a. Their financial control of you; or substitution of parts under b. . Premises they own, maintain or control instructions from the manufacturer, while you lease or occupy these premises. and then repackaged in the original container, Form SS 00 08 04 05 Page 19 of 24 BUSINESS LIABILITY COVERAGE FORM This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. 9. Additional Insured — Owners, Lessees Or Contractors — Scheduled Person Or Organization a. WHO IS AN INSURED under Section C. is amended to include as an additional insured the person(s) or organization(s) shown in the Declarations as an Additional Insured — Owner, Lessees Or Contractors, 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 omissions of those acting on your behalf: (1) In the performance of your ongoing operations for the additional insured(s); or (2) In connection with "your work" performed for that additional insured and included within the "products - completed operations hazard", but only if this Coverage Part provides coverage for "bodily injury" or "property damage" included within the "products -completed operations hazard". b. With respect to the insurance afforded to these additional insureds, this insurance does not apply to "bodily injury", "property damage" or "personal an advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: (1) The preparing, approving, or failure to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders, designs or drawings and specifications; or (2) Supervisory, inspection, architectural or engineering activities. 10. Additional Insured — Co -Owner Of Insured Premises WHO IS AN INSURED under Section C. is amended to include as an additional insured the person(s) or Organization(s) shown in the Declarations as an Additional Insured — Co - Owner Of Insured Premises, but only with respect to their liability as co-owner of the premises shown in the Declarations. The limits of insurance that apply to additional insureds are described in Section D. — Limits Of Insurance. How this insurance applies when other insurance is available to an additional insured is described in the Other Insurance Condition in Section E. — Liability And Medical Expenses General Conditions. G. LIABILITY AND MEDICAL EXPENSES DEFINITIONS 1. "Advertisement" means the widespread public dissemination of information or images that has the purpose of inducing the sale of goods, products or services through: a. (1) Radio; (2) Television; (3) Billboard; (4) Magazine; (5) Newspaper, b. The Internet, but only that part of a web site that is about goods, products or services for the purposes of inducing the sale of goods, products or services; or C. Any other publication that is given widespread public distribution. However, "advertisement' does not include: a. The design, printed material, information or images contained in, on or upon the packaging or labeling of any goods or products; or b. An interactive conversation between or among persons through a computer network. 2. "Advertising idea" means any idea for an "advertisement". 3. "Asbestos hazard" means an exposure or threat of exposure to the actual or alleged properties of asbestos and includes the mere presence of asbestos in any form. 4. "Auto" means a land motor vehicle, trailer or semi -trailer designed for travel on public roads, including any attached machinery or equipment, But "auto" does not include "mobile equipment". 5. "Bodily injury" means physical: a. Injury-, b. Sickness; or C. Disease sustained by a person and, if arising out of the above, mental anguish or death at any time. 6. "Coverage territory" means: Page 20 of 24 Form SS 00 08 04 05 Policy Declarations A summary of your Personal Liability Protection coverage Thank you for insuring with us. Here is your renewal Personal Liability Protection policy summary, which is effective as of 08/28/2019. INSURANCE INFORMATION Named Insured Henry Garcia Rhonda D Garcia Mailing Address 461 Green Orchard PI Riverside CA 92506-7590 Total 12 Month Policy Premium: Policy Number LJ1-268-034370-40 Policy Effective Date 08/28/2019-08/28/2020 12:01 AM standard time at the address of the Named Insured as stated in policy. $469.00 We are pleased to offer you a Personal Liability Protection policy through your affiliation with City of Riverside. lokLiberty Mutual INSURANCE QUESTIONS ABOUT YOUR POLICY? By phone 1-909-476-6756 1-855-237-4813 Liberty Mutual Office 355 E Rincon St Ste 302 Corona CA 92879 Sales Representative Daniel D Swanson Visit us online LibertyMutual.com Coverage Information MANAGE YOUR LIMITS ACCOUNT ONLINE Personal Liability $1,000,000 Each Occurrence Sign up for eService LibertyMutual.com/eService Your Underlying Policies TYPES OF INSURANCE INSURER POLICY NUMBER To report a claim Auto LIBERTY MUTUAL A02-261-621041-40 By phone 1-800-2CLAIMS Auto LIBERTY MUTUAL A02-261-930295-40 (1-800-225-2467) Home LIBERTY MUTUAL H37-261-621046-40 General Liability LIBERTY MUTUAL FN2-268-461891-10 If any changes have been made to your underlying policies, please contact us to ensure proper coverage. Required Minimum Liability Limits for Underlying Policies Auto and Other Vehicles $ 250,000 Each Person $ 500,000 Each Accident $ 50,000 Property Damage Or $ 500,000 Combined Single Limit Home $ 100,000 Each Occurrence Watercraft $ 100,000 Each Occurrence Your underlying policies for auto, home and watercraft must have a minimum of the above limits throughout the policy period. Exposure Information Vehicles (automobiles/ 5 Total residences (including primary, 2 motorcycles) rental, seasonal, etc) Recreational vehicles licensed for road use None None Watercraft Miscellaneous vehicles (not registered/licensed for road use) None Operators under age 25 None Liability limits are subject to a retention of $250 on exposures not covered by underlying insurance. PCE 155 03 12 Page 1 of 2 R t,alyt~AM t I , 2. INSURANCE Endorsements — Changes to your policy • LibertyGuard PLP Policy 12/04 (PCE -92 (ED. 12-04)) • Membership in Liberty Mutual Holding Company • Amendment of Policy Definition (PCE -134) Inc. (2340e) • Communicable Disease Exclusion 11/91 (PCE -51) • Explanatory Endorsement - Home Day Care 11/91 (PCE -50) • Sexual Molestation Exclusion 3/94 (PCE -75) • Amendatory Mold Endorsement (PCE -96) Important Messages • Underground Storage Tank Exclusion (PCE -114 R1) If a problem arises concerning your insurance, Liberty Mutual will make every effort to resolve the matter, Call your local sales office for assistance. Whenever the company or its agent has been unable to resolve a consumer complaint affecting this policy, the below listed state agency may be contacted to assist the complainant in pursuing a resolution of the complaint: California Department of Insurance Claims Service Bureau 300 South Spring Street South Tower, Suite 201 Los Angeles, CA. 90013 Toll Free Telephone (800) 927 -HELP (4357) LibertyGuard Personal Liability Protection Policy Declarations This policy, including endorsements Coverage provided and underwritten by Liberty Mutual Insurance Company Boston, MA. listed above, is signed by: Mark C. Touhey Secretary David H. Long President Hamid Mirza Authorized Representative PCE 155 03 12 Page 2 of 2 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. (_J 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 # 6z, 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 those provisioth Signature of Applicant �,, "p � will automatically become void. ns or err _ ,Date f � 3 Print Name 14C&2,62 -If T, Agreement for: WT , Dated: Reviewed by: