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PROOF OF INSURANCE (2020 - 2021) CLOSEDDATE (MM/DD/YYYY) __skw_ CERTIFICATE OF LIABILITY INSURANCE 05/15/2020 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(les) 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' PCF INS SRVCS OF THE WEST LLC/PHS NAME: 72250765 PHONE (866) 467"8730 I AIC, No : FAX (888) 443.6112 The Hartford Business Service Center (A/C, No, Ext): l ) 3600 Wiseman Blvd E-MAIL San Antonio, TX 78251 ADDRESS: DFSC MPTION OF OPERATION'S below DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the Insured's Operations. Certificate holder is an additional insured per the Business Liability Coverage Form SS0008 attached to this ( policy. CERTIFICATE HOLDER CANCELLATION CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 350 MAIN ST BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED EL SEGUNDO CA 90245-3813 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Digitally signed by Joseph Lillio DN: —Joseph Ldlio, o=City of EI Joseph Lillio Segundo, ou=Director of Finance, email=Jlillio@elsegundo.org, c=U5 Date: 2020.05.29 16:16:38 -07'00' INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURERA: Sentinel Insurance Company Ltd. 11000 PSYCHOLOGICAL CONSULTING ASSOCIATES INC. INSURER B: 10940 WILSHIRE BLVD STE 1600 LOS ANGELES CA 90024-3910 INSURER : INSURER D INSURER E: 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 NUMBER POLICY EFF POLICY EXP LIMITS [TR. INSR W„yD,,,Y (.MMIDD/YYYY) IMMIDDII/YYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $2,000,000 CLAUMS MADE X]occuR DAMAGE TO RENTED PREMISES (Ea pr„aurrencel $1,000,000 X General Liability MED EXP (Any one person) $10,000 A X 72 SBM ZB1037 10/07/2019 10/07/2020 I PERSONAL& ADVINJURY $2,000,0001 GEN'L AGGREGATE LIMIT APPLIES PER: II GENERAL AGGREGATE $4,000,000 POLICY PRO- � LOC I PRODUCTS -COMP/OP AGG $4,000,000 ECT OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $2,000,000 ANY AUTO BODILY INIRY (Per person) � SCHEDULED X A �_ 72 SBM ZB1037 10/07/2019 10/07/2020 � BODILY INJURY (Per accident) ALL OWNED HIRED NON -OWNED X X PROPERTY DAMAGE ( AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCURj' EACH OCCURRENCE EXCESS LIAB CLAIMS- AGGREGATE u MADE I E IRETENTION $ WORKERS COMPENSATION u OI ppPTATUTE AND EMPLOYERS' LIABILITY iPER t ANY YIN E L EACH ACCIDENT I PROPRIETOR/PARTNERIEXECUTI VE OFFICER/MEMBER EXCLUDED? C N/A E DISEASE -EA EMPLOYEE I (Mandatory in NH) If yes, describe under E DISEASE - POLICY LIMIT DFSC MPTION OF OPERATION'S below DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the Insured's Operations. Certificate holder is an additional insured per the Business Liability Coverage Form SS0008 attached to this ( policy. CERTIFICATE HOLDER CANCELLATION CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 350 MAIN ST BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED EL SEGUNDO CA 90245-3813 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Digitally signed by Joseph Lillio DN: —Joseph Ldlio, o=City of EI Joseph Lillio Segundo, ou=Director of Finance, email=Jlillio@elsegundo.org, c=U5 Date: 2020.05.29 16:16:38 -07'00' THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGE This endorsement changes the policy effective on the Inception Date of the policy unless another date is indicated below: Policy Number: 72 SBM ZB1037 DX Named Insured and Mailing Address; PSYCHOLOGICAL CONSULTING ASSOCIATES INC. 10940 WILSHIRE BLVD STE 1600 LOS ANGELES CA 90024 Policy Change Effective Date: 05/15/20 Effective hour is the same as stated in the Declarations Page of the Policy. Policy Change Number: 003 Agent Name: PCF INS SRVCS OF THE WEST LLC/PHS Code: 250765 POLICY CHANGES: SENTINEL INSURANCE COMPANY, LIMITED ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING STATEMENT.IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BANK ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A BILL. NO PREMIUM DUE AS OF POLICY CHANGE EFFECTIVE DATE FORM NUMBERS OF ENDORSEMENTS REVISED AT ENDORSEMENT ISSUE., IH12001185 ADDITIONAL INSURED - PERSON -ORGANIZATION PRO RATA FACTOR: 0.403 THIS ENDORSEMENT DOES NOT CHANGE THE POLICY EXCEPT AS SHOWN. 91 - Form SS 1211 04 06 T Page o o 1 Process Date: 05/15/20 Policy Effective Date: 10/07/19 Policy Expiration Date: 10/07/20 POLICY NUMBER: 72 SBM ZB1037 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PERSON -ORGANIZATION REF##- 7057 -15 -FI 300 W 3RD STREET SUITE 302 OXNARD, CA 93030 CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO,CA 90245 THE CITY OF CULVER CITY AND MEMBERS OF IT'S CITY COUNCIL, IT'S BOARDS AND COMMISSIONS, OFFICERS, AGENTS AND EMPLOYEES. 4040 DUQUESNE AVE CULVER CITY, CA 90232 CITY OF LONG BEACH BOARD OF HARBOR COMMISSIONAIRES PO BOX 570 LONG BEACH, CA 90801-0570 Form IH 12 00 11 85 T SEQ. NO. 003 Printed in U.S.A. Page 002 (CONTINUED ON NEXT PAGE) Process Date: 05/15/20 Expiration Date: 10/07/20 POLICY NUMBER: 72 SBM ZB1037 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PERSON -ORGANIZATION COUNTY OF LOS ANGELES CALIFORNIA SHERIFF'S DEPARTMENT 4700 RAMONA BOULEVARD MONTEREY PARK, CA 91754-2169 CITY OF GARDEN GROVE ITS OFFICERS, OFFICIALS, DIRECTORS, EMPLOYEES, AGENTS, CONSULTANTS, AND VOLUNTEERS & GARDEN GROVE POLICE DEPARTMENT 11301 ACACIA PKWY GARDEN GROVE, CA 92840 LOC 002, BLDG 001 CITY OF BURBANK POLICE DEPARTMENT 200 N. 3RD ST. BURBANK, CA. 91502 RE: PROVIDING PSYCHOLOGICAL SERVICES TO THE DEPT. HUNTINGTON BEACH FIRE DEPARTMENT 2000 MAIN ST HUNTINGTON BEACH CA, 92648 CITY OF LONG BEACH POLICE DEPARTMENT ATTN: BENJAMIN PARAMO 400 WEST BROADWAY LONG BEACH, CA 90802 THE CITY OF LONG BEACH, ITS OFFICIALS, EMPLOYEES AND AGENTS ARE ADDITIONAL INSUREDS UNTER THE GENERAL LIABILITY POLICY. LOC 002 BLDG 001 CITY OF OXNARD RISK MANAGER Form IH 12 00 11 85 T SEQ. NO. 003 Printed in U.S.A. Page 001 (CONTINUED ON NEXT PAGE) Process Date: 05/15/20 Expiration Date: 10/07/20 POLICY NUMBER: 72 SBM ZB1037 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PERSON -ORGANIZATION Form IH 12 00 1185 T SEQ. NO. 003 Printed in U.S.A. Page 003 (CONTINUED ON NEXT PAGE) Process Date: 05/15/20 Expiration Date: 10/07/20 Account Number: CA PSYC 1870 Date: 5/21/20 Initials: JA CERTIFICATE OF INSURANCE ALLIED WORLD INSURANCE COMPANY C/O: American Professional Agency, Inc. 95 Broadway, Amityville, NY 11701 800-421-6694 This is to certify that the insurance policies specified below have been issued by the compan indicated above to the insured named herein and that, subject to their provisions and condition such policies afford the coverages indicated insofar as such coverages apply to the occupation or business of the Named Insured(s) as stated. THIS CERTIFICATE OF INSURANCE NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR ALTERS THE COVERAGE(S) AFFORDED BY THE POLICY(IES) LISTED ON THIS CERTIFICATE. Mme and Address of Named Insured:_ PSYCHOLOGICAL CONSULTING ASSOCIATES, INC. 10940 WILSHIRE BLVD SUITE 1600 LOS ANGELES CA 90025 Type of Work Covered: PROFESSIONAL PSYCHOLOGIST Location of Operations: N/A (If different than address listed above) Claim History: Additional Named Insureds: GINA L. GALLIVAN, PH.D Retroactive date is 04115/2002 Policy Effective Expiration Limits of Coverages Number Date Date Liability PROFESSIONAL/ 1,000,000 LIABILITY 5011-2743 4/15/20 4/15/21 3,000,000 NOTICE OF CANCELLATION WILL ONLY BE GIVEN TO THE FIRST NAMED INSURED, WHO SHALL ACT ON BEHALF OF ALL INSUREDS WITH RESPECT TO GIVING OR RECEIVING NOTICE OF CANCELLATION. Comments: THE COMPANY WILL NOTIFY THE CERTIFICATE HOLDER/ADDITIONAL INSURED OF ANY TERMINATION OF COVERAGE AND FAILURE TO RENEW WITHIN 30 DAYS, HOWEVER, FAILURE TO GIVE SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY UPON THE COMPANY OR THE UNDERSIGNED. This Certificate Issued to: Name: CITY OF EL SEGUNDO 350 MAIN ST. Address: EL SEGUNDO CA 90245 APA 00138 00 (06/2014) --ive -�► � CERTIFICATE OF LIABILITY INSURANCE DATE 05/15/2020 Y) . _ 05/15/2020 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 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 NUTMEG INSURANCE AGENCY INC/PHS NAME: 02025657 PHONE (866)467-8730 FAX (888)443-6112 (A/c, No, Ext): (AIC, No): The Hartford Business Service Center 3600 Wiseman Blvd IE -MAIL San Antonio, TX 78251 ADDRESS: INSURER(S) AFFORDING COVERAGE NAICl/ INSURED [ INSURER A: Hartford Accident and Indemnity Company 22357 PSYCHOLOGICAL CONSULTING ASSOCIATES INC. I INSURER B; 10940 WILSHIRE BLVD STE 1600 INSURERC: LOS ANGELES CA 90024-3910 I INSURER D : INSURER E: 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 SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR, INSR WVD IMWODDOM) ImMVOOIY YYY1 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS -MADE ❑ DAMAGE TO RENTED OCCUR PREMISFS IFa occurrence) MED EXP (Any one person) PERSONAL & ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: 'POLICYPRO- LOC JECT OTHER, AUTOMOBILE LIABILITY ANY AUTO ' ALL OWNED SCHEDULED AUTOS AUTOS HIRED NON -OWNED AUTOS AUTOS GENERAL AGGREGATE PRODUCTS - COMP/OP AGG COMBINED SINGLE LIMIT' ffaaccident) BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) OCCUR UMBRELLA LIAB I EACH OCCURRENCE EXCESS LIAB CLAIMS- � I` AGGREGATE MADE DED[ [RETENTION $ WC1kKERS COMPENSATION PER OTH- X (STATUTE I AND EMPLOYERS' LIABILITY I FE_ ANY YIN E L EACH ACCIDENT $1,000,000 A PROPRIETOR/PARTNER/EXECUTIVEr NIA X 02 WEC CR5206 10/03/2019 10/03/2020 $1,000,000 OFFICER/MEMBER EXCLUDED? L �E,L DISEASE -EA EMPLOYEE (Mandatory in NH) If yes, describe under I EL DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS below pp II u DESCRIPTION OF OPERATIONS /LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the Insured's Operations. Waiver of Subrogation applies in favor of the Certificate Holder per the Broad Form Endorsement -Extended Option WC990301, attached to this policy CERTIFICATE HOLDER CANCELLATION CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 350 MAIN ST BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED EL SEGUNDO CA 90245-3813 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Jz_ THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CHANGE IN INFORMATION PAGE INSURER: Hartford Accident and Indemnity Company NCCI Company Number: 10448 Audit Period: ANNUAL Policy Effective Date: 10/03/19 Policy Expiration Date: 10/03/20 Policy Number: 02 WEC CR5206 Endorsement Number: 5 Effective Date: 05/15/20 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PSYCHOLOGICAL CONSULTING ASSOCIATES INC 10940 WILSHIRE BLVD STE 1600 LOS ANGELES CA 90024 FEIN Number: 58-2668663 Producer Name: NUTMEG INSURANCE AGENCY INC/PHS Producer Code: 02025657 It is agreed that the policy is amended as follows: This is NOT a bill. However, any changes in your premium will be reflected in your next billing statement. You will receive a separate bill from The Hartford. If you are enrolled in repetitive EFT draws from your bank account, changes in premium will change future draw amounts. In consideration of an additional premium of $101, it is agreed that: Policy is amended to add the following condition(s): Waiver of Our Right to Recover from Others Endorsement Policy is amended to change the following condition(s): Waiver of Our Right to Recover from Others Endorsement Policy is amended to add the following Endorsement Forms reflecting the changes made to your policy. WC990006A(.2) WC990006A(.1 P) Policy is amended to revise the following Endorsement Forms reflecting the changes made to your policy. WC040306 UL Countersigned by Form WC 99 00 06 A (1) Printed in U.S.A. Process Date: 05/15/20 Authorized Representative Page 1 Policy Expiration Date: 10/03/20 CHANGE IN INFORMATION PAGE (Continued) Policy Number: 02 WEC CR5206 SCHEDULE IT IS AGREED THAT THE POLICY IS AMENDED AS FOLLOWS: CLASS CODE NUMBER AND DESCRIPTION ESTIMATED RATES PER 100 TOTALANNUAL OF REMUNERATION REMUNERATION CA - Location 1 Rating Period: 10/03/2019-05/15/2020 8810 CLERICAL OFFICE EMPLOYEES -N O C Rating Period: 05/15/2020-10/03/2020 8810 CLERICAL OFFICE EMPLOYEES -N O C Rating Period: 10/03/2019-10/03/2020 8810 CLERICAL OFFICE EMPLOYEES -N O C CA - Location 2 Rating Period: 10/03/2019-10/03/2020 8810 CLERICAL OFFICE EMPLOYEES -N O C CA - Location 3 Rating Period: 05/01/2020-05/15/2020 8810 CLERICAL OFFICE EMPLOYEES -N O C Rating Period: 05/01/2020-10/03/2020 8810 CLERICAL OFFICE EMPLOYEES -N O C Rating Period: 05/15/2020-10/03/2020 8810 CLERICAL OFFICE EMPLOYEES -N O C Total State Summary Total Class Premium CA Territorial Differential Waiver charge Form WC 99 00 06 A (1) Printed in U.S.A. Process Date: 05/15/20 ESTIMATED ANNUAL PREMIUMS 52,331.00 0.510000 267 32,794.00 0.510000 167 85,125.00 0.510000 -434 100.00 0.510000 -'1 1,033.00 0.510000 5 11,435.00 0.510000 -58 10,402.00 0.510000 53 -1 0.00 1.104900 0 0.00 100 Page 2 Policy Expiration Date: 10/03/20 CHANGE IN INFORMATION PAGE (Continued) Policy Number: 02 WEC CR5206 SCHEDULE IT IS AGREED THAT THE POLICY IS AMENDED AS FOLLOWS: CLASS CODE NUMBER AND DESCRIPTION Small Policy Credit Expense constant Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement CA User Fund CA Fraud CA Uninsured Employers Benefit Trust Fund CA Subsequent Injuries Benefit Trust Fund Assessments CA Occupational Safety & Health Fund CA Labor Enforcement & Compliance Fund California Total Cost Form WC 99 00 06 A (1) Printed in U.S.A. Process Date: 05/15/20 ESTIMATED RATES PER 100 ESTIMATED TOTALANNUAL OF ANNUAL RENUMERATION RENUMERATION PREMIUMS 0.00 3 -3 0.00 0 0.00 0.020000 1 0.00 1.447900 2 0.00 0.287800 1 0.00 0.083100 1 0.00 0.273700 0 0.00 0.376500 0 0.00 0.343100 0 101 Page 3 Policy Expiration Date: 10/03/20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number: 02 WEC CR5206 Endorsement Number: 5 Effective Date: 05/15/20 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: PSYCHOLOGICAL CONSULTING ASSOCIATES INC 10940 WILSHIRE BLVD STE 1600 LOS ANGELES CA 90024 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 % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE Person or Organization Job Description CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO, CA 004 90245 Countersigned by Authorized Representative Form WC 04 03 06 (1) Printed in U.S.A. Process Date: 05/15/20 Policy Expiration Date: 10/03/20