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PROOF OF INSURANCE (2021) CLOSEDSEACLEA-01 TIMH HC vKL! CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `.� 6/24/2020 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 NAME: H&S Insurance Services, Inc. PHONE FAX 887 Patriot Drive, Ste. D (A/C, No, Ext): (805) 212-4890 (A/C, No):(805) 212-4891 Moorpark, CA 93021 ADDRESS: DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) *30 days notice of cancellation except 10 days for non-payment of premium. The City of EI Segundo is named as additional insured as required by written contract. A waiver of subrogation applies to the Workers' Compensation policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cit of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Y 9 ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St. EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: United National Insurance Company 13064 INSURED INSURER B : Metropolitan Direct Property and Casualty Insurance Company 25321 National Union Fire Insurance Company of Pittsburgh, Pa. 19445 Sea Clear Pools, Inc. 23316 S Normandie Ave #B INSURER C: INSURER D: Pacific Compensation Insurance Company 11555 Torrance, CA 90502 1 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 CONTRA:T OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLIC ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH 'OLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY 'AID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER LTR INSD WVD POLICY EFF POLICY EXP (MM/DD/YYYYI (MM/DD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,0001 CLAIMS -MADE FIV -1 OCCUR X L7219632 -H 7/1/2020 7/1/2021 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,0001 01 MED EXP (Anv one person) $ 1,000,0001 PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2'000'0001 POLICY JECT LOC PRODUCTS - COMP/OP AGG $ 2'000'000 OTHER $ 1 B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,0001 X ANY AUTO CA044844P2020 7/1/2020 7/1/2021 BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ 1 X HIRED X NON -OWNED PROPERTY DAMAGE 1 AUTOS ONLY AUTOS ONLY (Per accident) $ X Comp Ded $1,000 X Coll Ded: $1,000 1 C X 5,000,0001 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ X EXCESS LIAB CLAIMS -MADE EBU 067960856 7/1/2020 7/1/2021 AGGREGATE $ 5,000,0001 DED I I RETENTION $ $ 1 D WORKERS COMPENSATION X IPER AND ROPRIETOR/P RTNEY WA -004676-02 ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑ X STATUTE EORH 7/1/2020 7/1/2021 1,000,0001 OFFICER/MEMBER EXCLUDED? N / A E.L EACH ACCIDENT $ (Mandatory in NH) E.L DISEASE - EA EMPLOYEE $ 1,000,0001 If yes, describe under 1,000,0001 DESCRIPTION OF OPERATIONS below E.L DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) *30 days notice of cancellation except 10 days for non-payment of premium. The City of EI Segundo is named as additional insured as required by written contract. A waiver of subrogation applies to the Workers' Compensation policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cit of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Y 9 ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St. EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: L7219632 -H COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, CONTRACTORS - (FORM This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: AS REQUIRED BY WRITTEN CONTRACT LESSEES OR B) (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" for that insured by or for you. CG 20 10 11 85 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 ❑ WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) 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 2_5% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Blanket Waiver of Subrogation As respects to all CA jobs performed by the named insured during the policy period where by written contract a waiver of subrogation is required prior to the commencement of work. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherw is stated (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 07-01-2020 Policy No. WA004676-02 Endorsement No. 1 Insured Insurance Company: Sea Clear Pools, Inc. (A Corp) Pacific Compensation Insurance Co. Countersigned By 8rrtok&- HcLrfti`fv ©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved.