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PROOF OF INSURANCE (2020 - 2021) CLOSEDDATE (MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 3/18/2020 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 'CONTACT COMPLETE EQUITY MARKETS INC NAC No,, East): (847)541-0900 I_[n//C Ra), (847)541-044 _ 847 541-0,90,0 E-MAIL 1190 Flex Court _lpPPREss: - Lake Zurich, IL 60047 (1 . INSURERS AFFORDING COVERAGE NAIC # INSURER A: Underwriters at Lloyd's. London INSURED INSURER B: MAK Fire Protection Engineering it ih�l' INSURER C: 12130 Rahn Avenue &Consulting, Inc. u I � �' INSURER D: IN . SURER E : Granada Hills, CA 91344 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO 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�, TR..NSD wV NUMBER M DDfYYYYI� iMM)DDffCY YY.., ....._, TYPE OF INSURANCE d4j DDL S D POLICY N Y9 LIMITS COMMERCIALGENERAL LIABILITY 2,01001000 CLAIMS-MADEXOC SGE T RL-N'0-'U PREM-151"S 0,000...... . MED EXP Aru cnu ( y pexsunp 5 000 e A 1701127 3/16/2020 3/16/2021 PERSONAL a ADV NJURY $ 2000,000 c GENERAL AGGREGATE 5 2,000,000'_ GEN'L AGGREGATE LIMIT APPLIES PER: V POLICY PRO- JECT LOC , PRODUCTS - COMP/OPAC'a0. Sr 2,000y000 _.) 01 HER ll_���Ccl,/��ilY�Np�l(;xLE LIMIT $ AUTOMOBILE LIABILITY Af= .... ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON -OWNED PR,t1"..' ._.�t?AMA F Pk:'1"i f $ AUTOS ONLY AUTOS ONLY pr(')f~iLrjj ynyi UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS -MADE A4'im4' RE E EGAT, 1 $ DLD RETENTq Odl S $ WORKERS COMPENSATION PE.R OTH- u i �— T AND EMPLOYERS' LIABILITY YI N 4 ANY PROPRIETOR/PARTNER/EXECUTIVE �' EACH IDENT ' in BERNH) EXCLUDED? N / A (Mandatory in NH) '"'"') � (Mandatory µ -„ EASECEA F'MI'"L',SYEE $ E.L. DISEASE If ycn, describe under DESCRIPTION OF 4°PPERAI IONS belo�+ E L. DISEASE -POLICY t.tll�,ll'l" $ . Professional Liability 94690 A 61112019 6/1/2020 Each Claim $1,000,000 Aggregate $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Subject to all policy terms, conditions, exclusions and endorsements of each respective policy. City of EI Segundo, its officers, officials, employees, agents and volunteers is an additional insured with Primary/Non-Contributory with 30 -Day Notice of Cancellation but only per the terms & conditions of the endorsement generated for each respective policy and subject to all policy terms, conditions, exclusions and endorsements. Please see pages 2 and 3 for additional information CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of EI Segundo, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Its officers, officials, employees, agents and volunteers Attn: Carol Lynn Anderson AUTHORIZED REPRESENTATIVE 314 Main Street EI Segundo, CA 90245 r-P{Y44— I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD IMPORTANT NOTICE: 1. The insurance policy that you have purchased is being issued by an insurer that is not licensed by the State of California. These companies are called "nonadmitted" or "surplus line" insurers. 2. The insurer is not subject to the financial solvency regulation and enforcement that apply to California licensed insurers. 3. The insurer does not participate in any of the insurance guarantee funds created by California law. Therefore, these funds will not pay your claims or protect your assets if the insurer becomes insolvent and is unable to make payments as promised. 4. The insurer should be licensed either as a foreign insurer in another state in the United States or as a non -United States (alien) insurer. You should ask questions of your insurance agent, broker, or "surplus line" broker or contact the California Department of Insurance at the toll-free number 1-800-927-4357 or internet website www.insurance.ca.gov. Ask whether or not the insurer is licensed as a foreign or non -United States (alien) insurer and for additional information about the insurer. You may also visit the NAIC's internet website at www.naic.org. The NAIC—the National Association of Insurance Commissioners—is the regulatory support organization created and governed by the chief insurance regulators in the United States. 5. Foreign insurers should be licensed by a state in the United States and you may contact that state's department of insurance to obtain more information about that insurer. You can find a link to each state from this NAIC internet website: https://naic.org/state_web_map.htm. 6. For non -United States (alien) insurers, the insurer should be licensed by a country outside of the United States and should be on the NAIC's International Insurers Department (IID) listing of approved nonadmitted non -United States insurers. Ask your agent, broker, or "surplus line" broker to obtain more information about that insurer. 7. California maintains a "List of Approved Surplus Line Insurers (LASLI)." Ask your agent or broker if the insurer is on that list, or view that list at the Internet website of the California Department of Insurance: www.insurance.ca.gov/01-consumers/120-company/07- lasli/lasli.cfm. 8. If you, as the applicant, required that the insurance policy you have purchased be effective immediately, either because existing coverage was going to lapse within two business days or because you were required to have coverage within two business days, and you did not receive this disclosure form and a request for your signature until after coverage became effective, you have the right to cancel this policy within five days of receiving this disclosure. If you cancel coverage, the premium will be prorated and any broker's fee charged for this insurance will be returned to you. D-2 (Effective January 1, 2020) AMENDATORY ENDORSEMENT NO.: 1701127 INSURED: MAK FIRE PROTECTION ENGINEERING & ADDITIONAL PREMIUM: Included CONSULTING, INC. RETURN PREMIUM: N/A EFFECTIVE: March 16, 2020 to March 16, 2021 In consideration of the additional premium paid as shown above, it is hereby 'understood and agreed that Underwriters shall provide a 30 -day written notice of cancellation regarding this policy of insurance to: Ms. Carol 1-ynn Urner City of El Segundo City of El Segundo 314 Main Street El Segundo CA 90245 For correctional purposes only. This endorsement replaces Endorsement #13 attached to Endorsement 1701127 issued March 16, 2020 All other terms, conditions, limits and exclusions remain unchanged. Attached to and forming part of Cover Note/Certificate/Policy No.: NI 9023 Dated: March 26, 2020 AUTHORIZATION NO.: (UMR) B0429BA2001027 AIF 23911 (06/99) (UMR) B0429BA2001027 P14**34 Endorsement #35 UNDERWRITERS AT LLOYD'S, LONDON Complete E uity Markets, ftic. dba Cbiri)Iete iquity Markets Insurance Aptiq, Mc .,CASL#�OD44077) By Lawrence T.P. Molloy AMENDATORY ENDORSEMENT NO.: 94690 ASSURED: MAK FUZE PROTECTION ENGINEERING & ADDITIONAL PREMIUM: CONSULTING, INC. EFFECTIVE: June 1, 2019 to June 1, 2020 FXTFNSION OF COVERAU, BAR IMS-LLOD --11X (Primary) 'It is hereby agreed and understood that Underwriters will pay Damages and Claims Expenses on behalf of the entity/entities listed below for its/their vicarious or imputed liability it; which arises from Claims caused by the negligent errors or omissions of the Named Assureds identified in the Declarations, in the performance of their Professional Services for the below identified Additional Assureds: The City of El Segundo, its officers, officials, employees, agents and volunteers It is further understood and agreed that such liability stated above shall apply only to the listed entity/entities and its/their employees. ployees, This extension of coverage does not increase the Limits of' Insurance nor amend any other provision in the Certificate which shall remain the same. It is further agreed that the coverage provided hereunder to the above-named Additional Assured(s) shall be primary and non-contributory to any insurance or self-insurance mainlained by the Additional Assured(s). (Included) All other terms, conditions, limits and exclusions remain unchanged. Attached to and forming part of Certificate No.: CEM 58 - 19 Dated: May 7, 2019 UNDERWRITERS AT LLOYD'S, LONDON LII 197-3 (08/15) Complete E Ult� Market,s, Inc. V (UMR) B0429BA1901026 dba C y Markets Insurancv Agwicy, In -, (CASL#OD44077) Lib**504 By Lawrence T.P. Molloy Endorsement #13 AMENDATORY ENDORSEMENT NO.: 94690 ADDITIONAL PREMIUM: Included ASSURED: MAK FIRE PROTECTION ENGINEERING & CONSULTING, INC_ EFFECTIVE: June 1, 2019 to June 1, 2020 NOTICE OF CANCELLATION In consideration of the additional premium paid as shown above, it is hereby understood and agreed that if Underwriters cancel this insurance for any reason other than non-payment of premitun, Underwriters shall provide a 30 -day written notice of cancellation to tile following: Ms. Carol Lynn Anderson City of El Segundo 314 Main Street El Segundo CA 90245 All other terms, conditions, limits and exclusions remain unchanged. Attached to and forming part of Certificate No.: CEM 58 -19 Dated: May 7, 2019 UNDERWRITERS AT LLOYD'S, LONDON AIF 2119 (09/08) Complete ESjuity Markets, I'nc. dba Cumplete Equity Markets Insurance Agency, 7 In - CCASL#01)44077) (UMR) B0429BA1901026 Lib*023 revised 7/04 8/04 9/08 By lk6�"- Lawrence T.P. Molloy Endorsement #14 Certificate of Insurance MAK FIRE PROTECTION ENGINEERING & CONSULTING, INC, Policy Number: 94690/1701021 Subject to all policy ternis, canditions, exciusions and endorseinents of �each respective policy. The City of El Segaindo, its officers, officials, ernployees, agents and volunteers H an additional insured but only per the ternis & conditions of' the endorsernent gener;ted f'4 each respective policy and subject to all policy terms, conditions, exclusions and endorsements. ***Primary/Non-Contributory and a 30 -Day Notice of Cancellation only applies to the General Liability Policy. SURPLUS LINES NOTICE TO POLICYHOLDER - PLEASE SEE ATTACHED Lawrence T.P. Molloy binders't'M 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. (_) 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 Name of Agent Policy Number Expiration Date Phone # 41 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 Califomia, and agree that, if I should become ubject to tile e workers' compensation provisions of labor Code § 370 1 must immediately comply with thos islons agreernent will automatically become void. Signature of Applicant Date Agreement for: °� t ' m"� � %" )112�YI i'I,� �' �dh�l t �• n' i Dated:AV Reviewed by: 11>