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PROOF OF INSURANCE (2020 - 2021) CLOSED............
� DATE (MM/DD/YYYY)
:....................... _ _.... m
CERTIFICATE C LIABILITY NSURANCE........03/13/2020
THIS CERTIFICATE ISI ASF �CAOER OFINFORMATION ON� CONFERS NO RIGH
Y AND mmmm
TS 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 be endorsed. If SUBROGATIONIS 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
BIN INSURANCE HOLDINGS LLC/PHS °-•-••••••••••
46505301 PHONE (866) 467.8'730 FAX AIC No): (888)443-6112
(A/C, No, Ext):
The Hartford Business Service Center
3600 Wiseman Blvd E-MAIL
San Antonio, TX 78251 ADDRESS:
....... _.........
.
INSURERS AFFORDING COVERAGE NAI
INSURED INSURERA: Sentinel Insurance Company Ltd. 1 1 000
.. W ............................
PROGRESSIVE SOLUTIONS INSURERS
PO BOX 783... .. ..._..__....
INSURER C.'
BREA CA 92822-0783 ...................... .. ...............
INSURER D
.......
INSURER E
INSURER F::
w._ ...... _.................... ..................
COVERAGES, CERTIFICATE NUMBER: REVIS147NL_UMBER-
.....
...
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.
INSR� .................._ ADDL SUER .. ..�. .POLICY EFF POLICY EXP ... .-.......................................... .............
IAL GENERAL LI POLICY NUMBER LIMBS
TYPE OF INSURANC ABILITY R WVD f,,,MMIDD/XYYYj_ ,AMM/DD1Y Yl'Y,),_, EACH OCCU ENCE 2,000,0
LTR COMM ....-- INS �. ................_........__
.. DAMAGE S IER�IN f I'Emi
00
X.. ell�eraN LialailakyOccuR , $1,000,000
ll CLAIMS-MAOE
.._. ll MED EXP (Any one
u,person) V $10,000
A X 46 SBA RI9399 04/10/2020 04/10/2021 PERSONAL & ADV INJURY $2,000,000
GEN'LAGGREGATE LIMIT APPLIES PER:
POLICY LX...� JEPRC I I LOC
(OTHER: LL -11
..........
ITAUTOMOBILE LIABILITY
ANY AUTO
..........
' ALLOWNED SCHEDULED
A
AUTOS AUTOS
X HIRED I� NON -OWNED
X AUTOS X AUTOS
w.._.
.... _._....,_. ...........
RELLA LIAB OCCUR
EXCESS LIAR CLAIMS -
J! MB MADE
.........➢:7Ci�lJ.............,.w....................
RETENTION$ ....-...._.......
... _.....� w......... ......... ...... —
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY
ANY YIN
PROPRIETOR/PARTNERlEXECUTIVE NIA
OFFICERIMEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
46 SBA RI9399
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGG
COMBINED SINGMTIMIT
�F Pmt)..... ................................. - .
BODILY INJURY (Per person)
04/10/2020 04/10/2021 BODILY INJURY (Per accident)
PROPERTY DAMAGE
(Per accident)
................................................ �.
—.,,_.-...............................
EACH OCCURRENCE
AGGREGATE
........... ..........................mm..... I ...._......_....
PER OTH-
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EL DISEASE -EA EMPLOYEE
E. L. DISEASE - POLICY LIMIT
$4,000,000
...........
$4,000,000
$2,000,000
..,, ...._,..._w ......._....................... .... _.,.,.,, w .,.,.,., ....... ...............................�
.............................................. ................................. P ......m.. ..,
TIONS /LOCATIONS / VEN/CLES (ACORD 101, Additional Remarks Schedule, may be attached if more ace is
OE"�r"CIi'IPTdON'�'OFOPERA..�.�� squired)
Those usual to Insured's operations. Certificate holder is named as Additional Insured.
OfficteofThe C CTIFICATE le kCP'R .----^^^......5 OULDCANOANY OFIITHE ABOVE DESCRIBED POLICIES BE CANCELLED
Patti AdlenELIVERED
350 Main Street IN ACCORDANCE WITH THE POLICY PROVISIONS.
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL
EI Segundo CA 90245-3895 AUTHORIZED REPRESENTATIVE
due`s
mm... ©1988-2015 ACORD CORPORATION. All rights reserved,
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
cv
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POLICYNUMBER:46 SBA RI9399
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - PERSON -ORGANIZATION
OFFICE OF THE CITY CLERK
350 MAIN ST.
EL SEGUNDO, CA 90245
COUNTY OF SNOHOMISH
3000 ROCKEFELLER AVENUE
EVERETT, WA 98201
LOC 001 BLDG 001
CITY OF ALHAMBRA
111 SOUTH FIRST STREET
ALHAMBRA, CA 91801
CITY OF ONTARIO
303 EAST B STREET
ONTARIO, CA 91764
CITY OF PLEASANTON
200 OLD BERNAL AVENUE
PLEASANTON, CA 94566
CITY OF SANTA BARBARA
735 ANACAPA STREET, ROOM 3
SANTA BARBARA, CA 93101-2203
CITY OF SAN BUENAVENTURA
501 POLI STREET, RM #107
VENTURA, CA. 93001
Form IH 12 00 1185 T SEQ. NO. 001 Printed in U.S.A. Page 001 (CONTINUED ON NEXT PAGE)
Process Date: 01/23/19 Expiration Date: 04/10/20
6124 Progressive Solutions Inc CenfliraW� Or Inswar*e 8/27/201911:03:68 PM
OATB/27/2 IMMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 8/27/2019
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 riahts to, the certificate holder in lieu of such andorsoment(s),
PRODUCER CONTACT
NAME:
:000 PHONE F -AX
Tech insurance ASC. (800).668-7020 No, 877-82,15-W87
AN—
—"Techinsurance ADD;JE6S;
30 N LaSalle, 25th Floor, Chicago, IL 60602 jhlsyjkR6p) AFFORDING COVERAGE NAIC N
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER;
HIS 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
IN" 1`0106�'QF.'FOUCYEXP
TYPE OF iNSURAN09 POLICY NUMBER imw Oqyyy� PAV1101311YYYY1 LIMITS
COMMERCIAL GENERAL LIABILITY EACH LX;CURRENCE S 21000.000
'tw"G� rc REN I 6D
0; S 1.000.0®0
tqSUIRER,A t _ BeOzley InsPrarkce Iqqmp;kray j[Lc. !_375A0
INSURED
MAIURERA $qeylind ln%4rarlpp. Compan, Lirnftd 11000
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Progressive Solutions Inc
INSURER
Po Box 783, Brea, CA, 92822
0 H14E RAL A G�G,R CA T E
POLICY Ll LOC
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I INSURER F •
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER;
HIS 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
IN" 1`0106�'QF.'FOUCYEXP
TYPE OF iNSURAN09 POLICY NUMBER imw Oqyyy� PAV1101311YYYY1 LIMITS
COMMERCIAL GENERAL LIABILITY EACH LX;CURRENCE S 21000.000
'tw"G� rc REN I 6D
0; S 1.000.0®0
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
ice of The City Clerk
City of EI Segundo/Off THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Attn: Tracy Weaver ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE
01988-2014 ACORD CORPORATION. All nights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
.WP or -3.
MED EXP (Any one Person)
Sr
Yes 46SBAR193SYJ i 100QUM 4MM,��nvu
pFW,,0tYAL & ADV INJURY
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AUTOMOBILE LIABILITY
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EL DISEASE - 9000Y LIMIT
1,
A Prolesclunal Liability (Errors and Omissions) V15UE5191101 7f7,2019 71712020
Occurrence/Aggregate
$1,000,0001 S1,000,000
DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 11111, Additional Remarks Schedule, maybe allwichod it more space in required)
Certificate Holder is named as Additional insured as their interests may appear in regards to general liability
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
ice of The City Clerk
City of EI Segundo/Off THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Attn: Tracy Weaver ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE
01988-2014 ACORD CORPORATION. All nights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
BUSINESS LIABILITY COVERAGE FORM
2. Applicable To Medical Expenses Coverage
We will not pay expenses for "bodily injury":
a. Any Insured
To any insured, except "volunteer workers".
b. Hired Person
To a person hired to do work for or on behalf
of any insured or a tenant of any insured.
c. Injury On Normally Occupied Premises
To a person injured on that part of
premises you own or rent that the person
normally occupies.
d. Workers' Compensation And Similar
Laws
To a person, whether or not an
"employee" of any insured, if benefits for
the "bodily injury" are payable or must be
provided under a workers' compensation
or disability benefits law or a similar law.
e. Athletics Activities
To a person injured while practicing,
instructing or participating in any physical
exercises or games, sports or athletic
contests.
f. Products -Completed Operations Hazard
Included with the "products -completed
operations hazard".
g. Business Liability Exclusions
Excluded under Business Liability Coverage.
C. WHO IS AN INSURED
1. If you are designated in the Declarations as:
a. An individual, you and your spouse are
insureds, but only with respect to the
conduct of a business of which you are the
sole owner.
b. A partnership or joint venture, you are an
insured. Your members, your partners, and
their spouses are also insureds, but only with
respect to the conduct of your business.
c. A limited liability company, you are an
insured. Your members are also insureds,
but only with respect to the conduct of your
business. Your managers are insureds, but
only with respect to their duties as your
managers.
d. An organization other than a partnership,
joint venture or limited liability company, you
are an insured. Your "executive officers" and
directors are insureds, but only with respect
to their duties as your officers or directors.
Your stockholders are also insureds, but only
with respect to their liability as stockholders.
e. A trust, you are an insured. Your trustees
are also insureds, but only with respect to
their duties as trustees.
2. Each of the following is also an insured:
a. Employees And Volunteer Workers
Your "volunteer workers" only while
performing duties related to the conduct of
your business, or your "employees", other
than either your "executive officers" (if you
are an organization other than a
partnership, joint venture or limited liability
company) or your managers (if you are a
limited liability company), but only for acts
within the scope of their employment by
you or while performing duties related to
the conduct of your business.
However, none of these "employees" or
"volunteer workers" are insureds for:
(1) "Bodily injury" or "personal and
advertising injury":
(a) To you, to your partners or
members (if you are a partnership
or joint venture), to your members
(if you are a limited liability
company), or to a co -"employee"
while in the course of his or her
employment or performing duties
related to the conduct of your
business, or to your other
"volunteer workers" while
performing duties related to the
conduct of your business;
(b) To the spouse, child, parent,
brother or sister of that co -
"employee" or that "volunteer
worker" as a consequence of
Paragraph (1)(a) above;
(c) For which there is any obligation
to share damages with or repay
someone else who must pay
damages because of the injury
described in Paragraphs (1)(a) or
(b) above; or
(d) Arising out of his or her providing
or failing to provide professional
health care services.
If you are not in the business of
providing professional health care
services, Paragraph (d) does not apply
to any nurse, emergency medical
technician or paramedic employed by
you to provide such services.
(2) "Property damage" to property:
(a) Owned, occupied or used by,
Page 10 of 24 Form SS 00 08 04 05
(b) Rented to, in the care, custody or
control of, or over which physical
control is being exercised for any
purpose by you, any of your
"employees", "volunteer workers",
any partner or member (if you are
a partnership or joint venture), or
any member (if you are a limited
liability company).
b. Real Estate Manager
Any person (other than your "employee" or
"volunteer worker"), or any organization
while acting as your real estate manager.
c. Temporary Custodians Of Your
Property
Any person or organization having proper
temporary custody of your property if you
die, but only:
(1) With respect to liability arising out of the
maintenance or use of that property; and
(2) Until your legal representative has
been appointed.
d. Legal Representative If You Die
Your legal representative if you die, but
only with respect to duties as such. That
representative will have all your rights and
duties under this insurance.
e. Unnamed Subsidiary
Any subsidiary and subsidiary thereof, of
yours which is a legally incorporated entity
of which you own a financial interest of
more than 50% of the voting stock on the
effective date of this Coverage Part.
The insurance afforded herein for any
subsidiary not shown in the Declarations
as a named insured does not apply to
injury or damage with respect to which an
insured under this insurance is also an
insured under another policy or would be
an insured under such policy but for its
termination or upon the exhaustion of its
limits of insurance.
3. Newly Acquired Or Formed Organization
Any organization you newly acquire or form,
other than a partnership, joint venture or
limited liability company, and over which you
maintain financial interest of more than 50% of
the voting stock, will qualify as a Named
Insured if there is no other similar insurance
available to that organization. However:
a. Coverage under this provision is afforded
only until the 180th day after you acquire
or form the organization or the end of the
policy period, whichever is earlier; and
BUSINESS LIABILITY COVERAGE FORM
b. Coverage under this provision does not
apply to:
(1) "Bodily injury" or "property damage"
that occurred; or
(2) "Personal and advertising injury"
arising out of an offense committed
before you acquired or formed the
organization.
4. Operator Of Mobile Equipment
With respect to "mobile equipment" registered in
your name under any motor vehicle registration
law, any person is an insured while driving such
equipment along a public highway with your
permission. Any other person or organization
responsible for the conduct of such person is
also an insured, but only with respect to liability
arising out of the operation of the equipment, and
only if no other insurance of any kind is available
to that person or organization for this liability.
However, no person or organization is an insured
with respect to:
a. "Bodily injury" to a co -"employee" of the
person driving the equipment; or
b. "Property damage" to property owned by,
rented to, in the charge of or occupied by
you or the employer of any person who is
an insured under this provision.
5. Operator of Nonowned Watercraft
With respect to watercraft you do not own that
is less than 51 feet long and is not being used
to carry persons for a charge, any person is an
insured while operating such watercraft with
your permission. Any other person or
organization responsible for the conduct of
such person is also an insured, but only with
respect to liability arising out of the operation
of the watercraft, and only if no other
insurance of any kind is available to that
person or organization for this liability.
However, no person or organization is an
insured with respect to:
a. "Bodily injury" to a co -"employee" of the
person operating the watercraft; or
b. "Property damage" to property owned by,
rented to, in the charge of or occupied by
you or the employer of any person who is
an insured under this provision.
6. Additional Insureds When Required By
Written Contract, Written Agreement Or
Permit
The person(s) or organization(s) identified in
Paragraphs a. through f. below are additional
insureds when you have agreed, in a written
Form SS 00 08 04 05 Page 11 of 24
BUSINESS LIABILITY COVERAGE FORM
contract, written agreement or because of a
(e) Any failure to make such
permit issued by a state or political
inspections, adjustments, tests or
subdivision, that such person or organization
servicing as the vendor has
be added as an additional insured on your
agreed to make or normally
policy, provided the injury or damage occurs
undertakes to make in the usual
subsequent to the execution of the contract or
course of business, in connection
agreement, or the issuance of the permit.
with the distribution or sale of the
A person or organization is an additional
products;
insured under this provision only for that
(f) Demonstration, installation,
period of time required by the contract,
servicing or repair operations,
agreement or permit.
except such operations performed
at the vendor's premises in
However, no such person or organization is an
connection with the sale of the
additional insured under this provision if such
product;
person or organization is included as an
additional insured by an endorsement issued
(g) Products which, after distribution
by us and made a part of this Coverage Part,
or sale by you, have been labeled
including all persons or organizations added
or relabeled or used as a
as additional insureds under the specific
container, part or ingredient of any
additional insured coverage grants in Section
other thing or substance by or for
F. — Optional Additional Insured Coverages.
the vendor; or
a. Vendors
(h) "Bodily injury" or "property
damage" arising out of the sole
Any person(s) or organization(s) (referred to
negligence of the vendor for its
below as vendor), but only with respect to
own acts or omissions or those of
"bodily injury" or "property damage" arising
its employees or anyone else
out of "your products" which are distributed
acting on its behalf. However, this
or sold in the regular course of the vendor's
exclusion does not apply to:
business and only if this Coverage Part
provides coverage for "bodily injury" or
(i) The exceptions contained in
"property damage" included within the
Subparagraphs (d) or (f); or
"products -completed operations hazard".
(ii) Such inspections, adjustments,
(1) The insurance afforded to the vendor
tests or servicing as the vendor
is subject to the following additional
has agreed to make or normally
exclusions:
undertakes to make in the usual
This insurance does not apply to:
course of business, in
connection with the distribution
(a) "Bodily injury" or "property
or sale of the products.
damage" for which the vendor is
(2) This insurance does not apply to any
obligated to pay damages by
insured person or organization from
reason of the assumption of
whom you have acquired such products,
liability in a contract or agreement.
or any ingredient, part or container,
This exclusion does not apply to
entering into, accompanying or
liability for damages that the
containing such products.
vendor would have in the absence
of the contract or agreement;
b. Lessors Of Equipment
(b) Any express warranty
(1) Any person or organization from
unauthorized by you;
whom you lease equipment; but only
with respect to their liability for "bodily
(c) Any physical or chemical change
injury", 'property damage" or
in the product made intentionally
"personal and advertising injury"
by the vendor;
caused, in whole or in part, by your
(d) Repackaging, except when
maintenance, operation or use of
unpacked solely for the purpose of
equipment leased to you by such
inspection, demonstration, testing,
person or organization.
or the substitution of parts under
instructions from the manufacturer,
and then repackaged in the
original container;
Page 12 of 24 Form SS 00 08 04 05
BUSINESS LIABILITY COVERAGE FORM
(2) With respect to the insurance afforded
e. Permits Issued By State Or Political
to these additional insureds, this
Subdivisions
insurance does not apply to any
(1) Any state or political subdivision, but
"occurrence" which takes place after
only with respect to operations
you cease to lease that equipment.
performed by you or on your behalf for
c. Lessors Of Land Or Premises
which the state or political subdivision
(1) Any person or organization from
has issued a permit.
whom you lease land or premises, but
(2) With respect to the insurance afforded
only with respect to liability arising out
to these additional insureds, this
of the ownership, maintenance or use
insurance does not apply to:
of that part of the land or premises
(a) "Bodily injury", "property damage"
leased to you.
or "personal and advertising
(2) With respect to the insurance afforded
injury" arising out of operations
to these additional insureds, this
performed for the state or
insurance does not apply to:
municipality; or
(a) Any "occurrence" which takes
(b) "Bodily injury" or "property damage"
place after you cease to lease that
included within the "products -
land or be a tenant in that
completed operations hazard".
premises; or
f. Any Other Party
(b) Structural alterations, new
(1) Any other person or organization who
construction or demolition
is not an insured under Paragraphs a.
operations performed by or on
through e. above, but only with
behalf of such person or
respect to liability for "bodily injury",
organization.
"property damage" or "personal and
d. Architects, Engineers Or Surveyors
advertising injury" caused, in whole or
(1) Any architect, engineer, or surveyor, but
in part, by your acts or omissions or
only with respect to liability for "bodily
the acts or omissions of those acting
injury", "property damage" or "personal
on your behalf:
and advertising injury" caused, in whole
(a) In the performance of your
or in part, by your acts or omissions or
ongoing operations;
the acts or omissions of those acting on
(b) In connection with your premises
your behalf:
owned by or rented to you; or
(a) In connection with your premises;
(c) In connection with "your work" and
or
included within the "products -
(b) In the performance of your
completed operations hazard", but
ongoing operations performed by
only if
you or on your behalf.
(i) The written contract or written
(2) With respect to the insurance afforded
agreement requires you to
to these additional insureds, the
provide such coverage to
following additional exclusion applies:
such additional insured; and
This insurance does not apply to
(ii) This Coverage Part provides
"bodily injury", "property damage" or
coverage for "bodily injury" or
"personal and advertising injury"
"property damage" included
arising out of the rendering of or the
within the "products -
failure to render any professional
completed operations hazard".
services by or for you, including:
(2) With respect to the insurance afforded
(a) The preparing, approving, or
to these additional insureds, this
failure to prepare or approve,
insurance does not apply to:
maps, shop drawings, opinions,
"Bodily injury", "property damage" or
reports, surveys, field orders,
"personal and advertising injury"
change orders, designs or
arising out of the rendering of, or the
drawings and specifications; or
failure to render, any professional
(b) Supervisory, inspection,
architectural, engineering or surveying
architectural or engineering
services, including:
activities.
Form SS 00 08 04 05
Page 13 of 24
CERTHOLDER COPY
P.O. BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 12-31-2019
CITY OF EL SEGUNDO SP
DEPT OF BUILDING & SAFETY
350 MAIN ST
EL SEGUNDO CA 90245-3813
GROUP:
POLICY NUMBER: 9033101-2019
CERTIFICATE ID: 30
CERTIFICATE EXPIRES. 12-31-2020
12-31-2019/12-31-2020
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer,
We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy.
Authorized Representative President and CEO
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2018-12-31 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED:
CITY OF EL SEGUNDO
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 12-31-2012 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2019-12-31 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME:
CITY OF EL SEGUNDO
ENDORSEMENT #1651 - GLENN VODHANEL, CEO - EXCLUDED.
EMPLOYER
PROGRESSIVE SOLUTIONS, INC. SP
PO BOX 783
BREA CA 92822
M0408
PRINTED : 11-18-2019
(REV.7-2014)
SP
WAIVER OF SUBROGATION NOTICE
Enclosed is your co y of a certificate of insurance on which the certificate holder
required a waiver o subrogation:
2. To apply the % surcharge, you must also agree to maintain accurately
segregated payroll records for employees engaged in work on job/'s for the
certificate holder who has the waiver. The payroll records are subject to
verification by an auditor.
Example:
Payroll for job:
Sample Rate:
Regular Premium equals:
Surcharge:
Additional Waiver charge:
Total premium equals
$5,000.00
13.30%
$ 665.00
3.00%
$ 19.95
$ 664.95 (665.00 + 19.95)