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PROOF OF INSURANCE (2020) CLOSEDAte"' CERTIFICATE OF LIABILITY INSURANCE DATE CERTIFICATE 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 CANrACt THIMBLE j'pt,},pss //support,thimble.com/ Thimble Insurance Services PHONE C, 14%s E%1) IA/ No) 174 West 4th Street, Suite 204 EMAIL ort New York, NY 10014 ADORESS. su l?p @thYimble.Com https://support.thimble.com/ INSURER(S) AFFORDING COVERAGE NAIC # INSURER A:, Markel, Insurance Company 38970 INSURED INSURER B: Ronnie Po INSURER C : Morpheon Corporation d/b/a ACME Time Machine INSURER D: purchasing@morpheon corn INSURER E 91103 INSURER _ .....",_https;//www.thimble.com/check-policy-statu,s/ 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 _NSR ADDLTYPE OF INSURANCE SU POLICY NUMBER (MMIDDfYYYY) (MMIDD(YYYY) LIMITS IN,$D POLICY EFF POLICYEXP L,TR JNSD wVD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES (,Ea occurrence) , $ 100,MQ,,,,,,,.,,, A Y Y VFMK-F3GD9QXXR GEN't AGGREGATE LIMIT APPLIES PER X POLICY i t CT it CT � LOC OTH'F R 6:00 AM 7:00 PM AUTOMOBILE LIABILITY $ 1,000,000 ANY AUTO GENERAL AGGREGATE OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS -MADE DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? U N1. (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below 05/02/2020 05/02/2020. MED EXP (Any one nerson) s 5,000 6:00 AM 7:00 PM PERSONAL & ADV INJURY $ 1,000,000 PDT PDT GENERAL AGGREGATE $ 1,000,000 PRODUCTS - COMP/OP AGG $ 1,000,000 COPASINEDSINGI.r. LIMIT' ;6 I:Fa acc,dev'( ., BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ e(:9r'111"TY DA'MiAGE. II,, ('k AiC,W ildePN1,i 16 EACH OCCURRENCE $ AGGREGATE 'I, PSIS "�H $ LY 'STAgTUTE FIR E,,L,EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY IANVI' $ EACH OCCURRENCE $ AGGREGATE $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space isrequired) CE'R'TIFICATE HOLDER The City of EI Segundo, its officers, officials, employees, agents, and volunteers mpalacios@elsegundo.org (con't on form Acord 10 1) 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: purchasing@morpheon.com LOC #: 1 ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Thimble Insurance Systems Ronnie Po POLICY ......... .................... PoP .... ......... Y NUMBER MorP heon Corporation d/b/a ACME Time Machine VFMK-F3GD9QXXRpurchasing@morpheon com cARRIER NAIC CO Markel Insurance Company 38970DE........- 91103 p y EFFECTIVE DATE: 05/02/2020 6:00 AM PDT ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER:!'.?,?FORM TITLE: Certificate of Liability Insurance Description of Operations (con't) Products and Completed Operations coverage (VFMK-GL-0203-0318) for policy number VFMK- F3GD9QXXR until 05/02/2021 5:59 AM PDT ACORD 101 (2008/01) @ 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Amended auto policy declarations Your policy effective date is November 8, 2019 Total Amount Due for the Policy Period Please review your insured vehicles and verify their VINs are correct. WAllstate, You're in good hands. Page 1 of 6 Information as of November 27, 2019 Summary Vehicles covered _.... Identification Number (VIN) ...................... Premium ....._...................._._...................._ Named Insured(s) .................�..-..-.................... 2019 Honda Pilot 5FNYF5H12KB010786 $669.59 Ellen PO, Ronald T PO 2012 Honda Odyssey 5FNRL5H28CB064455 498.65 Mailing address 2000 Nissan Pathfinder JN8AR07SOYW410800 1,822.99 3580 Greenhill Rd California Fraud Assessment Fee and any resulting rate adjustments, will 2.64 Pasadena CA 91107-2140 Total* period or for future policy periods. $2,993.87 Policy number believe any coverages are not listed or Multiple Policy $37.22 1967 729 605 * Your bill will be mailed separately. Before making a payment, please refer to your latest bill, which includes payment options and installment fee information. If you do not pay in full, you will be charged an installment fee(s). See the Important payment and coverage information section for details about installment fees. Discounts (included in your total premium) Anti -theft $2.64 Good Driver (20%) $274.34 Multiple Policy $59.36 Distinguished $252.68 Driver Good Student $192.81 Total discounts . k , Discounts per vehicle (2019 Honda Pilot Anti -theft $1.76 Multiple Policy $12.08 2012 Honda Odyssey Anti -theft $0.88 Multiple Policy $10.06 2000 Nissan Pathfinder Good Student $192.81 Listed drivers on your policy Ellen PO Ronald PO Jason PO $781.83 Your policy provided by Allstate Northbrook Indemnity Company Policy period Beginning November 8, 2019 through May 8, 2020 at 12:01 a.m. standard time Your policy changes are effective November 28, 2019 Your Allstate agency is W Smith Ins Sery 1968 Lake Ave #101 Altadena CA 91001-3038 (626) 791-7636 WilbertSmith@allstate.com Some or all of the information on your Policy Declarations is used in the rating of your policy or it could affect your y $302.761 eligibility for certain coverages. Please Good Driver (20%) $149.68 notify us immediately if you believe that Distinguished $139.24 any information on your Policy Driver Declarations is incorrect. We will make $249.04 corrections once you have notified us, Good Driver (20%) $124.66 and any resulting rate adjustments, will Distinguished $113.44 be made only for the current policy Driver period or for future policy periods. - Please also notify us immediately if you $230.03) believe any coverages are not listed or Multiple Policy $37.22 are inaccurately listed. Amended auto policy declarations Policy number: 1967 729 6051 Policy effective date: November 8, 2019 Excluded drivers from your policy None Page 2 of 6 POLICY NUMBER: VFMK-F3GD9QXXR COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON ORORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Designated Person or Organization (including its departments and attached agencies, its directors, officers, officials, employees, representatives and agents): The City of EI Segundo, its officers, officials, employees, agents, and volunteers E -Mail Address: mpalacios@elsegundo.org A. SECTION II — WHO IS AN INSURED 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" 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; or 2. In connection with your premises owned by or rented to you. 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 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. C. If this policy is cancelled or nonrenewed for any reason, we will deliver notice of the cancellation or non- renewal to any Designated Person or Organization shown in the SCHEDULE above at the e-mail address shown above. D. This endorsement shall not increase the applicable limits of insurance shown in the Declarations. All other terms and conditions remain unchanged, VFMK-GL-2001-0318 © 2018 Verifly Insurance Services, Inc. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc,, with its permission COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY Y - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following,- COMMERCIAL ollowing; COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 0413 C Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: VFMK-F3GD9QXXR COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: The City of El Segundo, its officers, officials, employees, agents, and volunteers mpalacios@elsegundo.org Information required to complete this Schedule, if not shown above, will be shown in the Declarations The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products - completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 0 Insurance Services Office, Inc., 2008 Page 1 of 1 0 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. 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 # (—\/) 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 t s_e visio nt will automatically become void. 2/11/2020 DateSignature of Applicant Print Name Ronald T Po Agreement for: Dated: "rR Reviewed by: �,: