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PROOF OF INSURANCE (2021 - 2021) CLOSEDDATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 05/19/2020 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 Sparrow Nanci Sparrow Sparrow General Insurance Agency 2629 Manhattan Ave. #281 I (A//C, N , EXtr 310-379-0605 (AJ , No,: 310-379-0631 Hermosa Beach CA 90254 I E-MAIL ADDRESS: nanci@SparrowGeneral.com INSURER(S) AFFORDING COVERAGE NAIC # Phone: 310-379-0605 Fax: 310-379-0631 I INSURERA: Travelers Insurance Company INSURED INSURER B : South Bay Vital Signs, Inc. 1001 E. Franklin Ave. I INSURERC: EL SEGUNDO CA 90245 I INSURER D: I INSURER E: I 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYYI (MM/DD/YYYYI X COMMERCIAL GENERAL LIABILITY = CLAIMS -MADE I X I OCCUR A Y GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO ❑ LOC JECT OTHER: AUTOMOBILE LIABILITY ANY AUTO A OWNED SCHEDULED AUTOS ONLY AUTOS x HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLALIAB OCCUR EXCESS LIAB HCLAIMS-MADE DED 1 1 RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N AANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of EI Segundo, its officials, and employees are named as Additional Insured CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Citof EI Se undo —Cit Clerk THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN y g y ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street, Room 5, EI Segundo, CA 90245-3813 AUTHORIZED REPRESENTATIVE 4#w +wwl © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300 000 PREMISES (Ea occurrence) $ MED EXP (Any one person) $ 5,000 680 003J470245 4/28/2020 04/28/20211 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 COMBINED SINGLE LIMIT $ (Ea accident) 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ 680 003J470245 4/28/2020 04/28/2021 PROPERTY DAMAGE $ (Per accident) EACH OCCURRENCE $ (AGGREGATE $ x 1 PER STATUTE EERH E.L. EACH ACCIDENT $ 1,000,000 UB7N204530 05/22/2020 05/22/20211 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of EI Segundo, its officials, and employees are named as Additional Insured CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Citof EI Se undo —Cit Clerk THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN y g y ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street, Room 5, EI Segundo, CA 90245-3813 AUTHORIZED REPRESENTATIVE 4#w +wwl © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. XTEND ENDORSEMENT FOR SMALL BUSINESSES This endorsement modifies insurance provided under the following: •uu ON I 011"IrM • 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 C. Who Is An Insured — Newly Acquired Or Formed Limited Liability Companies D. Incidental Medical Malpractice E. Blanket Waiver Of Subrogation PROVISIONS b. An organization other than a partnership, joint A. WHO IS AN INSURED — UNNAMED venture or limited liability company; or SUBSIDIARIES c. A trust; The following is added to SECTION II — WHO IS as indicated in its name or the documents that AN INSURED: 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. 2. 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 S. 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. S. 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 © 2018 The Travelers Indemnity Company. All rights reserved. CG D8 42 02 19 Includes copyrighted material of Insurance Services Office, Inc., with its permission. of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: If the insured has agreed in a contract or agreement to waive that insured's right of recovery against any person or organization, we waive our right of recovery against such person or organization, but only for payments we make because of: COMMERCIAL GENERAL LIABILITY a. "Bodily injury" or "property damage" that occurs; or b. "Personal and advertising injury" caused by an offense that is committed; subsequent to the execution of the contract or agreement. 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. TRAVELERS J� WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 89 06 14 (00) - POLICY NUMBER: UB -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: A W _ TRAVELERS 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 DATE OF ISSUE: 04-09-20 ST ASSIGN: Page 1 oft