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PROOF OF INSURANCE (2021 - 2021) CLOSED40 D CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDD/YVYYI 07/10PZ020 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 terns 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 enCorsement(s). i PRODUCER CONTACT t?9_M.F..... CLIENT CONTACT CFNTER IFEDERATED MUTUAL INSURANCE COMPANY......... " HOME OFFICE: P O. BOX 328 AM No Fxil' 888-333-4949 „ n/cp OWATONNA, MN 55060 b RR?9 AR R? S.COM �MODRESS: CLIENTN URERISITAFFORDINGCOVERAGE ............................................. COVE AGE NAIL 4 INSURER A: FEDERATED MUTUAL INSURANCE COMPANY 13935 "............................................ ---..... ...........,.,.,.,.,.., ..... INSURINSURED 300-577-6 ER e: __..................... " W...................................................... WATERLINE TECHNOLOGIES INC .......... INSURER C: 626 N SANTIAGO ST ......................................................... .............. .... SANTA ANA, CA 92701-3942 INSURER o: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 217 REVISION NUMBER: 0 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 StUR'R' POLICY PBi.YdJEER r POLICY EFF P000 EXP LIMITS LTR INSR N or, MMIDDIYYYYI„ fM Dd7dY"b'YY1 ...,... DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required) SEE ATTACHED PAGE CE'RT'IFICATE HOLDER CANCELLATION 308-577.6 217 0 CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 MAIN ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EL SEGUNDO, CA 90245-3813 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 �I DAMAGE TO RENTED $100,000 CLAIMS -MADE OCCUR P.?ff�.sir.IF,.E,^.Efi4am,^rl............ .......................... MED EXP (Any one person) EXCLUDED A ..........................................................................." Y N 0623485 08115/2020 06/15/2021 PERSONAL IS ADV INJURY .......... $1,000,000 AGGREGATE LIMIT APPLIES PER: GENERA AGGREGATE $2,000,000 ®o,a6o X CI ❑ POLICY j p LOC PRODUCTS WCOM OP AGG .... P ......................................................... $2 0®0`000 ...... . OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000000 IF. a Ide,0 ..__... X ANY AUTO BODILY INJURY IPer person) A �. OWNED AUTOS ONLY � AUTOSULED Y N 0623465 OB/1512020 08/15/2021 BODILY INJURY IF., aceidant) ._.......... AUTOS ONLY AUTOS ON �, ......,..,. . ................. DAE4GzHIRED ,...,r Cl - . ............. X ELLL X OCCUR OCCURRENCE $8 .................... 8, 000, 000 A ExcE L.". S L eLAIMs-MADE N N 0623486 08/15!2620 08l15 AGGREGATE 000,000 _ 'D m"."" �. D DB RETENTION �. "I u� COMPENSATION 07H - IWORKERS AND EMPLOYERS LIABILITY AND v{n —_ E '11 11ERACH T ANY PROPRIETORIPARTNERIEXECUTIVE E.L. ACCIDENT OFFICERIMEMBER EXCLUDED? N �'a' .................................................. E L DISEASE EAEMPEMPLOYEE IManda4ory in NH __„ _____, 11 yes, dascribe under 11 ................ E L DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required) SEE ATTACHED PAGE CE'RT'IFICATE HOLDER CANCELLATION 308-577.6 217 0 CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 MAIN ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EL SEGUNDO, CA 90245-3813 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 308-577-6 ...................... LOC #: ACSRV' `Ift_- ADDITIONAL REMARKS SCHEDULE Page 1 of AGENCY NAMEDINSURED FEDERATED MUTUAL INSURANCE COMPANY WATERLINE TECHNOLOGIES INC ...........m 620 IN SANTIAGO ST POLICY NUMBER SEE CERTIFICATE # 217.0 SANTA ANA, CA 92701-3942 CARRIER NAIC CODE SEE CERTIFICATE # 217.0 EFFECTIVE DATESEE CERTIFICATE # 217 0 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: .. . . . . . . . . ...................... ALL OPERATIONS TO VARIOUS LOCATIONS IN CA. CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSURED UNDER THE GENERAL LIABILITY ON A PRIMARY AND NON-CONTRIBUTORY BASIS. THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED ON GENERAL LIABILITY SUBJECT TO THE CONDITIONS OF THE ADDITIONAL INSURED - OWNERS, LESSEES, OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION ENDORSEMENT. THE CERTIFICATE HOLDER IS A DESIGNATED INSURED ON BUSINESS AUTO LIABILITY SUBJECT TO THE CONDITIONS OF THE DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE. -111111111 .­­­­­­­­­ 1,1111 .......... ............................................ . ......... ACORD 101 (2008101) @ 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 0623485 COMMERCIAL AUTO CA 20 48 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Auto Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: WATERLINE TECHNOLOGIES INC Endorsement Effective: 08-15-2020 63e3:14111144 Name of Person(s) Or Organization(s)- CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO CA 90245 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 10 13 9 Insurance Services Office, Inc., 2011 Page 1 of 1 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. © Insurance Services Office, Inc., 2012 Page 1 of 1 CG 20 01 04 13 Policy Number: 0623485 Transaction Effective Date: 08-15-2020 POLICY NUMBER: 0623485 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Name Of Additional Insured Person(s) Or Organizations: (CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO CA 90245 SCHEDULE Location(s) Of Covered Operations ANY COVERAGE PROVIDED BY THIS ENDORSEMENT APPLIES ONLY WITH RESPECT TO NAMED INSURED'S DELIVERY OF PRODUCTS TO CERTIFICATE HOLDER. ADDITIONAL INSUREDS 'ALSO INCLUDE: CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES AND VOLUNTEERS. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. WATERLINE TECHNOLOGIES INC 620 N SANTIAGO ST SANTA ANA CA 92701 B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. 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 location of the covered operations has been completed; or 2. 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. © Insurance Services Office, Inc., 2012 Page 1 of 2 CG 20 10 04 13 Policy Number: 0623485 Transaction Effective Date: 08-15-2020 C. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; 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. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13 Policy Number: 0623485 Transaction Effective Date: 08-15-2020 0 DATE(MMIDD/YYYY) ACC>R" CERTIFICATE OF LIABILITY INSURANCE 07/13/2020 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 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 Nicole Chow NAME Newfront Insurance Services, LLC PHONE () 415 754-3635 I FAX WC„ No„,Ext)', (AIC, Not 55 2nd Street E-MAIL n ADDR'ESSI icole.c'how t-sllewfront.com Floor 18 INSURER($) AFFORDING COVERAGE NAIC # San Francisco CA 94105 INSURERA: Service American Indemnity Co 39152 INSURED INSURER B 620 N Santiago St Santa Ana �Iiil1011il INSURER C 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 IN EXP WVD POLICYNUNIBER IMMIDONYY'Yk WM'IDWY RLIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S DA'MAGE'Ti:o ,ENI r,lJ, $ CLAIMS -MADE FI OCCUR PRT<'0�J'iISE'S�(F'Irr,�,;.!°ur�rc,,ioe:rri� MED EXP (Aany uno per'Swq S PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER P6TC1• i I °t7t.IC;'r j J,EC'T I O'T'HER: AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS -MADE DEC) RETENTIONS (,WORKERS COMP'ENSAT'ION AND 'EMPLOYERS' LIABILITY YINN A �,ANYPR SPI'aIL-I.4�)4driyARTNE,P.'J'EXECUTIVE `” . v 11"71°'P'Irl;C,9qiPu"E,f,flEple6ik'N.C.II,IJED� IW.,.•, � N/A (Mandatory In NH) .."." If yes, describe under DESCRIPTION OF OPERATIONS below GENERAL AGGREGATE S PRODUCTS - COMP/OP AGO S 's COMOINED SI'NGI.E" )MIT $ I Ea �V'..af ouol) BODILY INJURY (Per person) II BODILY INJURY (Per accident) 5i PROPFRTY'OAMAGE $ (PaT :a:ur ,Yerut,y $ EACH OCCURRENCE $ AGGREGATE $ S X S'TPEA TUT;EER ER E L, EACH ACCIDENT S SAMTWC0031500 07/01/2020 07/01/2021 E L DISEASE - EA'E,MPLOYFE; $ E . DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of Coverage, Waiver of subrogation In favor of City of EI Segundo. 1,000,000 1,000,000 1.000.000 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St AUTHORIZED REPRESENTATIVE EI Segundo CA 90245 f © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 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 per- form 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 otherwise due on such remuneration. Person or Organization 0 . 020% of the California workers' compensation premium Schedule Blanket Waiver of Subrogation as required by writtencontract Job Description Contract This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Date: 0 7 / 01 / 2 0 2 0 Policy No. SAMTWC 0 0 315 0 0 Endorsement No. Policy Effective Date: 07/01/2020 to 07/01/2021 Premium $ Insured: Waterline Technologies, Inc DBA: Carrier Name / Code: Service American Indemnity Company (Method) Countersigned by ,...., WC 04 03 06 (Ed. 4-84) Page 1 of 1