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PROOF OF INSURANCE (2020 - 2020) CLOSEDOP ID: DR 14 1X CERTIFICATE OF LIABILITY INSURANCE � DATE(M Q 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(les) must be endorsed, If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endoreement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s), PRODUCIERCONMichelle A Nowell Mgt` S insurance Sery N� _ 6 N�,p 764171.5378 Alliance 5 Viae Veru Crux:O'T AOOR a. 760.471'-'7T 1 PAX MichMelleA.NoWe'iI' VII' FBM#, ...,,. µcorn - Can a tl Broke9207$ 0737966 amieC9. o —.. c WYATT�2 tlga...tive Services . I�NStMA:Acca tan a_._C, IT _._. ualty_ ns C Camp -1-0 349 GarenWya NS 301100 1h Street Nuevo, CA 92567 , , INSU_LKSLI.. INSURER_._ ............. ... .__..., „ ....... _.r..._.._._,. F COVERAGE$ 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 'ro 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. POILICT_ - F n POLICY NuIY 'r L0]MUVWWP 41401 Fw Yr (du t usrrs ,...._ ._ LTR TYPE of INSURANCE 140 44 GENERALLuuR.ITY ! X CP44962336 4713112019 47131/2424 �AIC'aNCn�Si6�EEN1"Eb"1,04444, A X COMMERCIAL GENERAL LIABILITY „. Mo.�___E_.........,m! .d:_..�.., I CLAIMS -MADE t x r OCCUR X Errors 14 Omission Ij, 3 NL, AGGREGATE UNIT APPLIES PER: A I POLICY 71 TRPT- F Loc AUTOMO'B'ILE LIABILITY ANYAUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NO"WNEDAUTOS N d it UMBRBLLA LAS i u OCCUR �.. V ^ DEDUCTIBLEEXCESS f:J.AttdbSt4tArlEj f i RETENTION S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PRmte-rOt'+A"ART'NERIEXEoLmve YIN MIA, OFFiCE"EMBER EXCLUDE("' (MendetalY In NH) iwy� bit L Ud dBd DES RttPTION OF OPERATIONS WOW ED EXP 'An ......_m,...mm..,,,, P . MSADIIRNJiURY ....�..{ I 44,44 ------ GENERAL. AGGREGATE GENERAL i 3 111 5,044,04 PRWUCTS-COMPri7PA0G 1, 44,44( f $ COMBINED SINGLE LIMIT $ (Ea ecatdertt} BODILY INJURY (Per pemon) ,It kDILY INJURY (Per eacM _,.,. _.-- ....._ . .............ant) S PROPERTY DAMAGE $ (PER ACCIDENT) $ EACH,OCCURRENCI!,. S 1S. WCSTATU- O'TH•! _TDRY,LIMff$1 -CA E L EAL.H ACCIDENT S E.L. DkSEAS'E - EA EMPLOYEE $ _T A E.L. DISEASE -POLICY LIMIT S OESC'R)P"DDN GF OPEPATIONS I LOCA'MNS I VENCLEB(Adsch ACORD ,101 Addklvn*l Romrkw SchedWe, N mom spew in requlred) 4/1 / /LULU Ceit of�i �iJndo, te% off(; ia�offic nSpa nant errst(oy s are named �Ittdi Dna insure +Aw'th res t to true W r rforme b tt a name Digitally signed by Joseph Lillio nsure DN: cn=Joseph Lillio, o=City of EI Investigations, CA _ Joseph Lillio Segundo, ou=Finance Department. —1" 'o elseoundo.or%c=US CERTIFICATE HOLDER, CANCELLATION Date: zozo.oa.I r 15:22:04 -07'00' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE VIIITH THE POLICY PROVISIONS. City of EI Segundo 350 Matin Street I AUTNOKMD REPRESENTATIVE EI Segundo, CA 90245 (t} 1"8-2009 ACORD CORPORATION. AN rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD POLICY NUMBER- CP00962336 COMMERCIAL GENERAL LIABILITY CO 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE AddlMonal Insured Perrv6nfs .. Name Of. ,rganlxateon(so) .. �. .. .... .... .. .... ,.. Automatic Status Included Where Required by Written Contract. All Where Required by Written Contract Section it — Who Is An Insured Is amended to In- clude as an additional insured the person(s) or organl- xation(s) shown in the Schedule, but only wM 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 om s- s'lons of those acting on your behalf A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CO 20 26 07 04 0 180 Properties, Inc., 2004 Page 1 of 1 JL 4/17/2020 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 forthe 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 # l I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not I' 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 thos provision or twill will automatically become void. l Signature of Applicant Date `'t I 1 z�b Agreement for: Garon Wyatt - Agreement Dated 4/17/2020 Digitally signed by Joseph _1 Is, Joseph Lillio o��-,ot .I=j 1,. ydEI5d.0 ou=F a e Reviewed by: I-202ot 17152lh807l qundo orq,c=US oa,e zq=gga,�,=zb2a.q�qq PERSONAL AUTOMOBILE POLICY AMENDED DECLARATION Amended Declaration effective Oct 17, 2019 Supersedes any previous declaration bearing INSWUNCIP the same policy number for this policy term. ARON D ittYATT WAWANESA INSURANCE 9050 FRIARS RD STE 101 SAN DIEGO CA 92108-5865 Telephone: 1-800-640-2920 Policy Number Account Number Policy Period 12:01 A.M. standard time at the address of the 12762210 4070411-1 �1 From Oct 17, 2019 to Apr 17, 2020 Named Insured as stated herein Named Insured's Phone Number: 951-928-3569 Named Insured's Email Address: gwyatt.828@gmail.com Your previous 6 month premium was $1,497.83. Your amended 6 month premium is $1,635.55. Refer to the breakdown of premiums below. The change in premium for the remainder of the policy period is $137.72 (pro rated). Description of Owned Vehicle(s) Vehicle Year Make Model Vehicle Identification Number Premium per Vehicle ($) 1 Q 2009 Toyota COROLLA BASE/S/LE/XLE 114.65 850.09 2 12014 BMW 3281 8.96 395.71 3 2017 Chevrolet SILVERADO 1500 CREW 37.51 389.75 �i 134.74 CAB LT 24.64 23.30 2.01 1.61 1.61 Premium Subtotal for Vehicles 1635.55 Insurance is provided only with respect to the coverage's for which a Premium is stated, subject to all conditions of the policy. Coverage and Limits of Liability See Policy for Coverage Details Bodily Injury Liability $250,000 per person/$500,000 each occurrence Property Damage Liability $100,000 each occurrence Medical Payments $5,000 each person Comprehensive $500 deductible Collision $500 deductible Uninsured/Underinsured Motorists Protection $30,000 per person/$60,000 each occurrence Uninsured Motorists Collision Deductible Waiver Total Premium per Vehicle ($) All Premiums listed are for the full 6 month term. Premiums per Vehicle ($) 1 2 3 356.97 104.53 V I 114.65 233.40 69.22 69.24 14.80 8.96 8.70 15.56 23.50 37.51 199.39 V 163.25 134.74 27.96 24.64 23.30 2.01 1.61 1.61 860.09 395.71 389.75 Oct 07, 201911:44 CT `°Wawanesa Insurance" is a trademark of Wawanesa General Insurance Company