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PROOF OF INSURANCE (2020 - 2021) CLOSEDJOEMPOL-01 TCHAMPILIN CERTIFICATE OF LIABILITY INSURANCE DATE ) 6/15/2020 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 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). CRINTACT 14 00 SW Barrows Rd PRODUCER (AIC,No, Ext): (866) 276„-3775 IAJC„ Nai:(866) 21.. y+ TAG .......,. ...................... 5................. 9 ,Ste 202-5018 Beaverton, OR 97007 .55 The ACORD name and logo are registered marks of ACORD INS,URER(S,) AFFORDINGC,OVERA„G„E NAIC,,,,,,,, --- I.NSURER A; Scottsdale Insurance Company .... 41297...._ INSURED ,INSI,/,RER,.S.•r. ................ ........... ..,,....................... Joemar Polygraph & Investigative Services Inc .INsIIRER c :...................................... 12939 Banyon INSURER D; Rancho Cucamonga, CA 91739 INSURER..I',,,,,,,,,,,,,,,,,,,,,, ........................... ..... ................., INSURER F: COVERAGES,,,,,,,,,,,,,,,,,,, CERTIFICA E 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, IN,SJ�,,,,VD POLICY NUMBER A TYPE OF INSURANCE P ry POLICYjZ.p,/`,�„',�,�1 IMMIDDIYVI'Vl II EFF 1 POLICY EXP LIMITS$ X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH pQCURRENCE -- CLAIMS -MADE XccuR RBS0033801 X X 0........ D AGE ?0 Rf:mkE'Fi0 7/2912020 7/2912027 ....^_�' .. 5 0 O 0 MEQ„„EXP (Anv one person),,,,,,,,,,,,,,, -............_-- ...�,,,iW].PSi�+',EA�CJ°�GIFCCOl.91:.4�:........{.$ 1,000,000 „PERSQNA„L &„ADV INJURY , . f"E„N'L AGGREGATE LIMIT APPLIES PER:NEIATAG Q ISR', X„J POLICY' �,.� JIET � LOC ..................2,000,000 PRQpDG,,,S,-,CO„MPIOP,AGG_ $—„ 00,000 � ___....� OTHER' $ SINGLE LIMIT AUTOMOBILE LIABILITY ..: EB URp 0')9.............. s.,. .................. ANY AUTO BODILY INUR J,, _ ........... Y (Perperson -„ ........, _ OWNED SCHEDULED AUTOS ONLYE'�� AUTOS Per accident/ $ BODILY,INJU„R,Y„„�„„,,,,,,,_,,,,,,,,___ � r� D ARAMS ALdTK}S�.M ry (PaneCcidnlq�AM'w„$ _ ............... —UMBRELLA LIAB OCCUR I '.. EACH OCCURRENCEm E.........."".,,-- — ....,..... B CLAIMS -MADE EXCESS LIAB A L(p„RE,GATE $ ............ DED RETENTIONg $ .M.. WORKERS COMPENSATION PER ORH AND EMPLOYER EMPLOYERS' BI YIN ..�..5,TATVTE .................. ANY PROPRIETOR/PARTNER/EXECUTIVE Q 'FICC dM -M BER EXCLUDED? NIA -im.4-L,EA�r-H,A,QCI,DENT MF aylnNH) E_I-„DISFAS.E--E?..E„M.PLO„YEE$ If yes, describe under OFOF OPERATIONS below „„E„;I DISEASE - POLICY LIMIT A Errors & Omissions X X RBS0033801 7/29/2020 7/29/2021 each claim 1,000,000 A Errors & Omissions X X RBS0033801 7/29/2020 7/29/2021 aggregate 2,000,000 DESCRIPTION OF OPERATIONS I LOCATION'S I VEHICLE'S (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder is additional insured per attached GLS487 ................... CERTIFICATE HOLDER _.,. — CANCELLATION _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Ci Of EI Segundo City 9 ACCORDANCE WITH THE POLICY PROVISIONS. 348 Main St EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE I ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ENDORSEMENT SCOTTSDALE INSURANCE COMPANY' NO. ATTACHED TO AND ENDORSEMENT EFFECTIVE DATE FORM NG APART OF (12:01 A.M. STANDARDTIME) NAMED INSURED AGENT NO. POLICY NUMBER RBS -0033801 7/29/2020 Joemar Polygraph & Investigative Services Inc 46722 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU INCLUDING PRIMARY OR PRIMARY AND NON-CONTRIBUTORY AND LIMITED WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ERRORS AND OMISSIONS COVERAGE PART A. SECTION II—WHO IS AN INSURED is amended to include as an additional insured any person or organization for whom you are performing operations and you and such person or organization have executed a written contract or agreement prior to the time of an "occurrence" giving rise to a claim that such person or organization be added as an additional insured on your policy. Such person or organi- zation is an additional insured only with respect to liability for "bodily injury," "property damage," "error or omission" or "personal and advertising injury" caused, in whole or in part, by: 1. Your negligent acts or omissions; or 2. The negligent acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: 1. "Bodily injury," "property damage," "error or omission" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or sur- veying services, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and b. Supervisory, inspection, architectural or engineering activities. 2. "Bodily injury" or "property damage" occurring after: a. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or b. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. Includes copyrighted material of ISO Properties, Inc., with its permission. Copyright, ISO Properties, Inc., 2004 GLS -487 (6-15) Page 1 of 2 C. With respect to the insurance afforded to these additional insureds, the following is added to SEC- TION III—LIMITS OF INSURANCE: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contractor agreement you have entered into with the additional insured; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. D. Under SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS; subparagraphs a. Pri- mary Insurance and b. Excess Insurance of paragraph 4. Other Insurance are amended as follows: If you have agreed in a written contract and executed such a contract or agreement prior to the time of an "occurrence" giving rise to a claim, that this policy will be afforded on a primary or primary and non- contributory basis and without right of contribution from any insurance in force for the liability in the performance of your ongoing operations for the additional insured(s), then this insurance will be af- forded on a pri maty or primary and non-contributory basis, and we will not seek contribution from any other such insurance. E. Under SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS, the following is added to paragraph 8. Transfer Of Rights Of Recovery Against Others To Us: We waive any right of recovery we may have against an additional insured if you have agreed in a written contract, and executed such a contract or agreement prior to the time of an "occurrence" giving rise to a claim, but only with respect to liability for "bodily injury," "property damage," "error or omission" or "personal and advertising injury" caused by: 1. The named insured's negligent acts or omissions; or 2. The negligent acts or omissions of those acting on the named insured's behalf; in the performance of the named insured's ongoing operations for the additional insured. All other Terms and Conditions of this Policy remain unchanged. AUTHORIZED REPRESENTATIVE DATE Includes copyrighted material of ISO Properties, Inc., with its permission. Copyright, ISO Properties, Inc., 2004 OLS -487 (6-15) Page 2 of 2 Renewal auto policy declarations IWAIstate,61 Your policy effective date is February 11, 2020 You're in good hang. ;Pag.e,l of �, 6. . Information as of December 20, 2019 Tow Amimig nita;^ +k D . o sod Please review your insured vehicles and verify their VINs are correct. Summary Vehicles covered Premlum Named Insured(s) 1997 Chevy Trk Blazer $462.28 Joe & One Delia 2010 Mercedes -8 E350 681,50 2016 Ram Trucks 1500 2Wd 856.19 California Fraud Assessment Fee 2.64 Total*$2,002.61 Policy number 1024601607 Your blif will be mofled'separatety. Before making a payment please refer to yow Your policy provided by latest WII, which Includes payment options and Installment fee information. If you do Allstate Northbrook indemnity not pay in fall, you will be charged an installment fee(s). Company See the Important payment and coverage Information section for details about Policy period installment fees. B ry 11.2020 through gust ", 20 0 ­ u at li, 202 t 12.01 a.m. standard Discounts (included In your, total premdum) Your Allstate agency is Good Driver (20%) $482.28 Distinguished $334.12 Driver Anti -theft $747 Total discounts... $824.37 Some orall of the Inforritation on your Discounts per yWrto Polley Declarations Is used In the rating (1997 Chevy Trk,Blazer $185.49) . of your Policy or it could affect your, eligibility, for certaincoverages. Please Good Driver (20%) -$97.85 Distinguished $8 744 notify us Immedlateily if you believe that :Driver any Information on y6ur*ollcy 2010 Mercedes -4,050 $282,11s) Declarations Is incorrect. We will rnake Anti -theft $3,63 Good Driver (200,x) $17038 corrections once ypu'6ve notified us, Distinguished $108.17 and any resultlngrk4 adjustments, will Driver be, made only forAho current policy 12016 Ram Trucks ISOO 2Wd $3S& LOJ period or foe future policy (periods. Anti -theft $4,34 Good Driver, (20%) $214,05 Please also nq0iy'usr immediately If you believe any coverages are not listed or Distinguished MUM`- are Inaccurately listed. Driver Listed drivers on yourpolley Ons Dek Joe Delta Excluded drivers from your policy None 82077 Is 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, ATTORNEYS FEES. - I of under penalty of perjury under the laws of California one of the following declarations: (_J I have and will maintain a certificate of consent of self4risure 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 El Segundo. lam (_J I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance of the work for which the agreement with the City of El Segundo is executed. My workers' compensation Insurance carrier and policy number are: Carder i Name of Agent Policy Number Expiration Date Phone# IV' I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not 9mpioy 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 t workers! compensation provisions of Labor Code § 3700 1 must Immediatelfcompllyarwith tho p ovision the agement will automatically become void. t Date —31,cl?,024 Agreement for: rW '��/ L4 Kz, lated: NO Tevi Md_hhiW,