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PROOF OF INSURANCE (2020 - 2020) CLOSEDDATE ,DD/YYYY) 59Wi� AS A MATTER OF' NNF 02/ 12IgI� �� '�I�IIC�ITI�:1� CERTIFICATE�OF LIA . BILITY S NO RIGHTS U CE INFORMATION ONLY AND CONFER"NSUR I , II _ F FF'IRMAT'IVELY OR NEGATIVELY AIMEND, EXTENT) OR ALTER THE COVERAGE ON THE CERTIFICATE HOLDER. THIS N'OT A I AGE AFFORDED BY THE POLICIES C OII CR " OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED ODUCI"R, AND THE CERTIFICATE HOLDER. holder It n ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If��ertlt'IC�Nb holt II II ?�TIo IS WAIVED, subj the terms and conditions Of the policy, certain policies may require an endorsement. A statement on MIS 2205 tlbt tbl i' . ch endorserrlraurt(s)'»... 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I` LIMITS 12111/2019 1211712020 EACH OCCURRENCE & 1110001000 �a 6100.t1t9t�1.� MED Exp 00 1 KASONAwL a ADV INJORY 6 1,000.000 �Illlllhiilliiiill — one ��� IIII)IIIIIIIIIIIIIIIIIIIIIIIIIIIIIuulolGIEM+NEAALAWAECATe 2 I OII,11I 0 NI huuuuu»»», PRODUCTS -COMPW AGO 1 2000.000 II�'lllIlIl;l' IIIIII I ns iI�Il y IYIII I IIIIII lulullllllllll I S �°JI�II » INGLE UNIT SII �����69 ll IIIIIIIIII IIIIIIIIIIII V IIIIII III I�, I ©ODIC INJURY (Per pcu an) $ 1�I� �`I hIINfl 1 III»NIIIIIIIIIIIIIIIII »»Illllllul INJURY (Per aef dent) S OF d IIIIIIIIII lllllllllllM o u ��II� I lllllll�lu (IIII .. eo nNJ � $ 1' I�I�II h`� ��IIIlllowu Ildl I I Ildlllll� �" I@�I�ti pllulf�;�gIIIIII�lllllllllllllllllllllllllllllll�ll����°� III �� I .. I'I , .. _- I X11 I VIII Illi lllm ll�`1�1�4�l�lll 11'11((( uIIIIdiN II( IIII uuutllU � O�NOE II� 111101 'IIIII (IIII I'I I IIIIIIIIIII°°°°I �H I� 111W�hh01I1�V IIIIII 'I IIII I r �� ' N „�; III h 11!I,'kIIIQI11,1111�1II I IIIIIIII „r, �I JI IIIIIII uuuuulloll � . 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I I „ reserved. POLICY NUMBER: BKW60720456 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 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: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Where required by written contract or agreement. Location(s) Of Covered Operations 8 All Project of the named Insured Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to B. With respect to the insurance afforded to include as an additional insured the person(s) these additional insureds, the following addi- or organization(s) shown in the Schedule, but tonal exclusions apply: only with respect to liability for "bodily in- This insurance does not apply to "bodily in- jury", "property damage" or 'personal and jury" or" property damage" occurring after: advertising injury" caused, in whole or in 1. All work, including materials, parts or part, by: equipment furnished in connection with 1. Your acts or omissions; or such work, on the project (other than ser - 2. The acts or omissions of those acting on vice, maintenance or repairs) to be per - your behalf; formed by or on behalf of the additional in the performance of your ongoing oper- insured(s) at the location of the covered ations for the additional insured(s) at the Io- operations has been completed; or cation(s) designated above. 2. That portion of "your work" out of which However: the injury or damage arises has been put 1. The insurance afforded to such additional to its intended use by any person or or - insured only applies to the extent permit- ganization other than another contractor ted by law; and or subcontractor engaged in performing operations for a principal as a part of the 2. If coverage provided to the additional in- same project. sured is required by a contract or agree- ment, 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. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 I H C. 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. This endorsement shall not increase the ap- plicable Limits of Insurance shown in the Dec- larations. Page 2 of 2 0 Insurance Services Office, Inc., 2012 CG 20 10 04 13 -------- ----------------- INSURANCE IDENTIFICATION CARD - CAUFORNIA t l Policy Number. 00825687-D NAIC Number 11770 I Effective Date: 062012019 Expiration Date: 0612012020 I Policy Type: Commercial insurer_ UNITED FINANCIAL CAS CO 1-80044444.87 PO BOX 94739 CLEVELAND, OH 44101 I Named Insuredls]: ETE FACTORY OUTLET,INC. DBA: EXTREME FITNESS EQUIPMENT Your bmker MONTEB£110INS SVCS 1-323-838-9491 I 3033 W BEVERLY Br#6 _ 8 MONTEBELLO, CA 90640 I Year Make Model • VIN � 2016 CHEVROIF EXPRESSCUiAWAY 1GB6GVCG7G1220462 I Your policy meets the requirements of Section 16056. I I --------------------------- .. � IlPuum ullllllll, CITY OF EL SEGUNDO IIII III, WORKERS' COMPENSATION DECLARATION uluullfll�V`i"I;ul JII Iii hj 11 �I��IV�1 I I RAI III 1 NII 1 I :.,,Iii pPumidl�Nmry�IIIu1II���1�666PV WARNING. FAILURE TO SECURE OYER IO CRIMINAL NAL PEI�IATION 9IS I�1P HUNDRED THOUSAND DOLLARS; AND CIVIL FUNES UP O ONETHU L AND SUBJECTS N EMP ,..III�IIIkA.111I,Y,.,'I�. 111 u� IIIA 1111n�1n1, N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS ',I NIIIIIIII FOR IN LABOR CODE 3706 INTEREST, AND ATTORNEY'S FEES" llllllllll till"��°IIlIpl�ll!.�b h IIVI I I Pp 111^ II ..�wuuuumumll u!I IIII IIIII VN�yi�hll' ������IIIII .. ,wIIIIIIIi�I�i�IiIh ^IIiIV III ��II�I�tlIIpYI�I'!'�Nil�!iM1INh!��11 affirm under penalty of perjury under the laws of California one of the following declare (� I have and will maintain a certificate of consent of self -insure for workers' conip"er i of Industrial Relations as provided for by Labor Code § 3700 for the performance oflllil III0V� with the City of EI Segundo. SII; Ipll,,,IIIIIIIIIIIIII Wl Policy No. �i'I IiNNWu' Illllulllllllll@l'llhll'iliN�4! u I (� 'I have and will maintain workers' compensation insurance as°,regi of the work for which the agreement with the City of EI Segundo ls;a carrier and policy number are: ullllllllllllll pl II I um Ildrrtm IIIIJIIr' Carrier I VIII I I,°Nomlil� II�111}II'II,II��P�� lilulhllu I Name of AgentITT 61P„Ip'IIV"hull �' ;II of I certify that, in the pf employ any person in any agree that, if I should 'bei immediately comply with w Signature of Applican$'IIII4 ,. �IIIII Ij �I����IIIIIIIIIIIIIIIIIIIIIIIIIII�I, ui iiIIiIIIII iIPNjdIIIuVY^Illlliil�l�illl,llllf rum uuuuill VIII I� IIH, iI 1111111 ,I Illi) �I1I �iiiiiVulillllll�l 1 , �I�I VIII �IIIIIIIIIII!I,IIIII�rJ����p�i�h��la�h�!��b' �h�,l�