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PROOF OF INSURANCE (2020 - 2020) CLOSEDDATE (MMIDD1YYYY) Ac"Ro CERTIFICATE OF LIABILITY INSURANCE 10112912020 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. 11 the certificate holder is an ADDITIONAL INSURED, the pollcy(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 CONIAC I Nanci Sparrow sparrow General Insurance Agency N PHONE 310-379-0605 FA �310 2629 Manhattan Ave. #281A.D I've yn)_ -379-0631 n�incMAILi@Spirr�r)wGe,,ieral.com Hermosa Beach CA 90254 D. INSUR ApI Phone: 310-379-0605 Fax: 310-379-0631 INSURER A: Travelers Insurance Company INSURED South Bay Vital Signs, Inc. 1001 E. Franklin Ave, EL SEGUNDO CA 90245 ,!NAPRER E t INSURER F 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 ........ . . . . . gwj- LIMITS OR TYPE OFINSURANCE NumBER tumfooiywyl jwxtp�yyp X COMMERCIAL GENERAL LIABILITY EACH CCCURRENCE S x . ....... . . . . . 300,060 CLAIMS -MADE OCCUR 5,000 04/2812019�0412812020, PFIRSONAL & ADV INJURY 2,000,000 0 0000 Y 680 003J470245 GENL AGGREGATE LIMIT APPLIES PER GENERAi.AGCRE`GA'rE_ . ....... "POLICY L I C Y 7, JPERCOT. 4,000,000 X P: C�O�JC r S, COMPIOP AQ�5 1 S LOC AUTOMOBILE LIABILITY COMMBEDS rNULC LIM0 2,000,000 ANY AUTO BODILY INJtr URY IPaT person) 5 OWNED SCHEDULED BODILY INJURY (Per accident) 8 AUTOS ONLY AUTOS __�44YF """ " — ­ A HIRED X NON -OWNED 680 003J470245 0412812019 04Y2W2020: 'P;�&wthxv INJURY (der 5 X,_ AUTOS ONLY AUTOS ONLY UMBRELLAUAB OCCUR EACH OCCURRENCE FXCESS UAS p�I CLA MADE I AGGREGATE V DED i I REIENHUN5 WORKERS COMPENSATION ............ . I I PFR I I 015T ]is f AND EMPLOYERS'LIABILITY YIN ANYPROP R M1 ORPART NE WE X EVU t IVE NIA 05122/2019 05/2212020[C 1'-1-.__'_____ S 1,0()0,000 J51 UB7N204530 E.L,DlJ3FASE,EALO.IPLe)"EE�S 1,000,000 (Modtialory in NH) If Lit under 0 C RIPTION OF OPERATIONS bclow !LL-ONEASSE -POLICYLIMIT:S 1,000.000 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schodula, may be attached it more space Is required) The City of El Segundo, its officials, and employees are named as Additional Insured CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE City of El Segundo— City Clerk ACCORDANCE WITH THE POLICY PROVISIONS. WILL BE DELIVERED IN 350 Main Street, Room 5, El Segundo, CA 90245-3813 AUTHORIZED REPRESENTATIVE 17A. -Al *1114pa- I O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. XTE D ENDORSEMENT FOR SMALL BUSINESSES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART GENERAL DESCRIPTION OF COVERAGE — This endorsement broadens coverage. However, coverage for any injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or limited by another endorsement to this Coverage Part, and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by such an endorsement. The following listing is a general coverage description only. Read all the provisions of this endorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered. A. Who Is An Insured — Unnamed Subsidiaries B. Who Is An Insured — Employees And Volunteer Workers — Bodily Injury To Co -Employees And Co -Volunteer Workers PROVISIONS A. WHO IS AN INSURED — UNNAMED SUBSIDIARIES The following is added to SECTION II — WHO IS AN INSURED: C. Who Is An Insured — Newly Acquired Or Formed Limited Liability Companies D. Incidental Medical Malpractice E. Blanket Waiver Of Subrogation b. An organization other than a partnership, joint venture or limited liability company; or c. A trust; as indicated in its name or the documents that govern its structure. Any of your subsidiaries, other than a partnership B. WHO IS AN INSURED — EMPLOYEES AND or joint venture, that is not shown as a Named VOLUNTEER WORKERS — BODILY INJURY Insured in the Declarations is a Named Insured TO CO -EMPLOYEES AND CO -VOLUNTEER if: WORKERS a. You are the sole owner of, or maintain an ownership interest of more than 50% in, such subsidiary on the first day of the policy period; and b. Such subsidiary is not an insured under similar other insurance. No such subsidiary is an insured for "bodily injury" or "property damage" that occurred, or "personal and advertising injury" caused by an offense committed: a. Before you maintained an ownership interest of more than 50% in such subsidiary; or b. After the date, if any, during the policy period that you no longer maintain an ownership interest of more than 50% in such subsidiary. For purposes of Paragraph 1. of Section II — Who Is An Insured, each such subsidiary will be deemed to be designated in the Declarations as: a. A limited liability company; The following is added to Paragraph 2.a.(1) of SECTION II — WHO IS AN INSURED: Paragraphs (1)(a), (b) and (c) above do not apply to "bodily injury" to a co -"employee" while in the course of the co -"employee's" employment by you or performing duties related to the conduct of your business, or to "bodily injury" to your other "volunteer workers" while performing duties related to the conduct of your business. C. WHO IS AN INSURED — NEWLY ACQUIRED OR FORMED LIMITED LIABILITY COMPANIES 1. The following replaces the first sentence of Paragraph 3. of SECTION II — WHO IS AN INSURED: Any organization you newly acquire or form, other than a partnership or joint venture, and of which you are the sole owner or in which you maintain an ownership interest of more than 50%, will qualify as a Named Insured if CG D8 42 02 19 © 2018 The Travelers Indemnity Company. All rights reserved. Page 1 of 3 Includes copyrighted material of Insurance Services Office, Inc., with its permission. COMMERCIAL GENERAL LIABILITY there is no other similar insurance available to that organization. The following replaces the last sentence of Paragraph 3. of SECTION II — WHO IS AN INSURED: For the purposes of Paragraph 1. of Section II — Who Is An Insured, each such organization will be deemed to be designated in the Declarations as: a. A limited liability company; b. An organization other than a partnership, joint venture or limited liability company; or c. A trust; as indicated in its name or the documents that govern its structure. D. INCIDENTAL MEDICAL MALPRACTICE 1. The following replaces Paragraph b. of the definition of "occurrence" in the DEFINITIONS Section: b. An act or omission committed in providing or failing to provide "incidental medical services", first aid or "Good Samaritan services" to a person, unless you are in the business or occupation of providing professional health care services. 2. The following replaces the last paragraph of Paragraph 2.a.(1) of SECTION II — WHO IS AN INSURED: Unless you are in the business or occupation of providing professional health care services, Paragraphs (1)(a), (b), (c) and (d) above do not apply to "bodily injury" arising out of providing or failing to provide: (a) "Incidental medical services" by any of your "employees" who is a nurse, nurse assistant, emergency medical technician, paramedic, athletic trainer, audiologist, dietician, nutritionist, occupational therapist or occupational therapy assistant, physical therapist or speech-language pathologist; or (b) First aid or "Good Samaritan services" by any of your "employees" or "volunteer workers", other than an employed or volunteer doctor. Any such "employees" or "volunteer workers" providing or failing to provide first aid or "Good Samaritan services" during their work hours for you will be deemed to be acting within the scope of their employment by you or performing duties related to the conduct of your business. 3. The following replaces the last sentence of Paragraph 5. of SECTION III — LIMITS OF INSURANCE: For the purposes of determining the applicable Each Occurrence Limit, all related acts or omissions committed in providing or failing to provide "incidental medical services", first aid or "Good Samaritan services" to any one person will be deemed to be one "occurrence". 4. The following exclusion is added to Paragraph 2., Exclusions, of SECTION I — COVERAGES — COVERAGE A — BODILY INJURY AND PROPERTY DAMAGE LIABILITY: Sale Of Pharmaceuticals "Bodily injury" or "property damage" arising out of the violation of a penal statute or ordinance relating to the sale of pharmaceuticals committed by, or with the knowledge or consent of, the insured. 5. The following is added to the DEFINITIONS Section: "Incidental medical services" means: a. Medical, surgical, dental, laboratory, x- ray or nursing service or treatment, advice or instruction, or the related furnishing of food or beverages; or b. The furnishing or dispensing of drugs or medical, dental, or surgical supplies or appliances. 6. The following is added to Paragraph 4.b., Excess Insurance, of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: This insurance is excess over any valid and collectible other insurance, whether primary, excess, contingent or on any other basis, that is available to any of your "employees" for "bodily injury" that arises out of providing or failing to provide "incidental medical services" to any person to the extent not subject to Paragraph 2.a.(1) of Section II — Who Is An Insured. E. BLANKET WAIVER OF SUBROGATION The following is added to Paragraph 8., Transfer Of Rights Of Recovery Against Others To Us, Page 2 of 3 C 2018 The Travelers Indemnity Company. All rights reserved. CG D8 42 02 19 Includes copyrighted material of Insurance Services Office, Inc., with its permission. COMMERCIAL GENERAL LIABILITY of SECTION IV — COMMERCIAL GENERAL a. "Bodily injury" or "property damage" that LIABILITY CONDITIONS: occurs; or If the insured has agreed in a contract or b. "Personal and advertising injury" caused by agreement to waive that insured's right of an offense that is committed; recovery against any person or organization, we subsequent to the execution of the contract or waive our right of recovery against such person agreement. or organization, but only for payments we make because of: CG D8 42 02 19 © 2018 The Travelers Indemnity Company. All rights reserved. Page 3 of 3 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Amok TRAVELERV ONE TOWER SQUARE HARTFORD CT 06183 CHANGE EFFECTIVE DATE: 04-06-20 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CHANGE DOCUMENT WC 99 99 98 ( A) POLICY NUMBER: UB -7N204530 -19-42-G NCCI CO CODE: 13579 INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA INSURED'S NAME: SOUTHBAY VITAL SIGNS, INC. This change is issued by the Company or Companies that issued the policy and forms a part of the policy. It is agreed that the policy is amended as follows: An absence of an entry in the premium spaces below means that the premium adjustment, if any, will be made at time of audit. ADDITIONAL PREMIUM $ 250 ADDITIONAL NON -PREMIUM $ 8 STATE OF CA LOCATION 001 WAIVER OF SUBROGATION SEE ATTACHED ENDORSEMENT CLASSIFICATION SPECIFIC WAIVER WAIVER CALCULATION IS BASED ON CLASS CODE (S) PREMIUM X RATE RETURN PREMIUM $ RETURN NON -PREMIUM $ PREM. CODE BASIS RATE 0930 545 .05 3 The following endorsementg added on the STATE OF CA LOCATION 001 TERRITORY WAIVER OF SUBROGATION SEE ATTACHED ENDORSEMENT ISO NAH DATE OF ISSUE: 04-09-20 NA CHANGE NO: 2 PAGE 1 OF 2 POL. EFF. DATE: 05-22-19 POL. EXP. DATE: 05-22-20 OFFICE: BREA/LA/ORANGE CA 189 PRODUCER: SPARROW GENERAL INS AGCY DBQ73 COUNTERSIGNED AGENT TRAVEL S ONE TOWER SQUARE HARTFORD CT 06183 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CHANGE DOCUMENT WC 99 99 98 ( A) POLICY NUMBER: UB -7N204530 -19-42-G PREM, ANNUAL CLASSIFICATION CODE BASIS RATE PREMIUM SPECIFIC WAIVER 0930 545 ,05 3 Specific Waiver Minimum Premium is added as follows: STATE MINIMUM PREMIUM CA 247 Tax and Assessment charges are changed as follows: STATE DESCRIPTION STAT CODE PERCENTAGE CA LABOR ENFORCEMENT AND COMPLIANCE FUND ASSESSMENT 0069 0.343 m CA OCCUPATIONAL SAFETY AND HEALTH FUND ASSESSMENT 9714 0.376 m CA SUBSEQUENT INJURY BENEFIT TRUST FUND ASST 9716 0.273 m CA UNINSURED EMPLOYERS BENEFIT TRUST FUND ASST 9715 0.083 °s CA STATE FRAUD SURCHARGE 9713 0.287 0 CA WC ADMIN REVOLVING FUND ASSESSMENT 9712 1.448 d CHANGE NO: 2 PAGE 2 OF 2 Aalk TRAVELER ' J WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 89 06 14 (00) — POLICY NUMBER: Us -7N204530 -19-42-G POLICY INFORMATION PAGE ENDORSEMENT Item 3.D. Endorsement numbers is changed to read: WC 04 03 06 01 ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. DATE OF ISSUE: 04-09-20 ST ASSIGN. TRAVELERV WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 04 03 06 (01) — 001 POLICY NUMBER: UB -7N204530 -19-42-G WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 5.00% OF THE CALIFORNIA WORKERS' COMPENSATION PREMIUM OTHERWISE DUE ON SUCH REMUNERATION. PERSON OR ORGANIZATION THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS, AND VOLUNTEERS CITY CLERK , 350 MAIN STREET, ROOM 5,EL SEGUNDO, CA 90245-3813. SCHEDULE JOB DESCRIPTION WRAPPING UTILITY BOXES LOCATED ON THE SIDEWALKS OF MAIN ST. IN EL SEGUNDO, CA 90254 BETWEEN HOLLY AND FRANKLIN AVENUES 9 DATE OF ISSUE: 04-09-20 ST ASSIGN: Page 1 of 1