PROOF OF INSURANCE (2021 - 2021) CLOSEDDATE (MMIDD/YYYY)
7/29/2020
THIS CERTIFICATE IS ISSUED ASA FATTER 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 CONTRACTBETWEEN 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 AlDITIO.NAL 1NSURdED 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($),
PRODUCER I CONTACTE.., Lynette Eye
PIA Select insurance Solutions PHONE Extt: 805-975-3531 FAX No):
1100 Industrial Rd., 43 t: -WAIL
ADDRESS: tynn.eye,ca piasclect.com
INSURER(S) AFFORDING COVERAGE NAIL #
San CarlosCA 94070 INSURER A : Hiscox Insurance Company
INSURED
1INSURERB: Scottsdale Indemnity Company
Mark Groh I INSURER C:
5481 V'aliecito Ave.
I+ INSURER E:
Westminster CA 92483-2836 IINSURERF:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF'INSURANCE LISTED BELOW HAVE BEEN ISSUED T6 THE INSURED NAMED AEOVE'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 AWULaODU ' ' POLICY EFF POLICY EMP
LTR TYPE OF INSURANCE INSO WVD POLICY NUMBER (MMIDD/YYYY) (MM/DDNYYY) I LIMITS
COMMERCIAL GENERAL LIABILITY
--7CLAIMS-MADE 7XOCCUR
A 'Y SBGL000805-00
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY [7 PRO-
JECT 7 LOC
OTHER:
AUTOMOBILE LIABILITY
ANY AUTO
A OWNED SCHEDULED
AUTOS ONLY AUTOS SBGL000805-00
— HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
UMBRELLA LIABOCCUR
EXCESS LIAB HCLAIMS-MADE
DED I RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y I N
ANY PROPRIETOR/PARTNERtEXECUTiVE
OFFICER/MEMBER EXCLUDED? [:]N / A
(Mandatory in NH)
if yes, describe under
DESCRIPTION OF OPERATIONS below
B Professional Liability EK13336439
EACH OCCURRENCE
$ 1,000,000'
UAMA(.xt I U KCN I tU
PREMISES (Ea occurrence)
$ 100,000
MED EXP (Any one person)
$ 5,000
07i06/2020 07/06/2021 PERSONAL 8 ADV INJURY
$ Excluded
I GENERAL AGGREGATE
S 2,000,000'
PRODUCTS - COMP/OP AGG
$ 2,000,000
S
CUMBINED SINGLt LIMI I
(Ea accident)
$ 1,000,000
BODILY INJURY (Per person)
S
07/06/2020 07/06/2021 BODILY INJURY (Per accident)
S
PRUHEtt I Y UAMAGt
(Per accident)
I Aggregate limit:
1,000,000
1 EACH OCCURRENCE
$
AGGREGATE
$
SPhR
TATUTE I IER
I E.L. EACH ACCIDENT
S
E.L. DISEASE - EA EMPLOYEE
$
E.L. DISEASE - POLICY LIMIT
S
Limit:
S1,000,000
07/11/2020 07/11/2021 Deductible:
$2,500
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
The City of El Segundo and its officers, employees, elected officials, volunteers, and members of boards and commissions are included as
additional insureds, but only insofar as the operations under this agreeent or contract are concerned per endorsement CGL E5421 CW
attached. This policy includes a blanket Waiver of subrogation.
CERTIFICATE HOLDER
City of El Segundo
350 Main Street
I El Segundo CA 90245
Mamrt
A , .. z •. AA z. -
AUTHORIZED REPRESENTATIVE
(D 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Jy
J,,ie,10!
HISCOX
?I'olicy Number:
Named Insured:
11.1 IR
Mark L Groh
0
07/06/2020
R11 1! F V ! M11 W1 i R I Ta qpisrp�� q� �,', pil
A. Section 11 — Who Is An Insured is amended
to include as an additional insured any per-
son(s) or organization(s) for whom you are
performing operations or leasing a premises
when you and such person(s) or organize-
tion(s) have agreed in writing in a contract or
agreement that such person(s) or organiza-
tion(s) be added as an additional insured on
your policy. Such person or organization is
an additional insured only with respect to
bility for "bodily injury", "property damage" or
"personal and advertising injury" caused, in
whole or in part, by your acts or omissions or
the acts or omissions of those acting on your
behalf:
I In the performance of your ongoing opera=
t�
:ions; or
2, In connection with your premises owned by or
rented to you,
3= �
CGL E5421 CW (02/14) Includes copyrighted material of Insurance Services Office, Inc., with its Page 1 of 1
permission.
VA
HISCOX Hiscox Insurance Company Inc.
Policy Number: SBGL000805-00
Named Insured: Mark L. Groh
Endorsement Number: 0
Endorsement Effective: 07106/2020
The following is added to Paragraph 8. Transfer Of
Rights Of Recovery Against Others To Us of
Section IV — Conditions:
CGL E5402 CW (03/10)
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
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 ATTORNEY'S FEES.
I affirm under penalty of perjury under the laws of California one of the following declarations:
(_) I have and will maintain a certificate of consent of self -insure 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 EI Segundo.
Policy No.
(_) 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 EI Segundo is executed. My workers' compensation insurance
carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone #
( I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not
employ 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 the workers' compensation provisions of Labor Code § 3700 1 must
immediately comply with those provisions or the agreement will automatically become void.
blglnlly signed by M.,k Gwh
Mur. -Mark Goh,—h,de d -Hearing Offl—,ou,
Signature of Applicant ems. f,.�� k�,��„g.�Ma��.�,M Date
NrOa'.4FAttMU WMJ"� un'M" "
^r
Agreement for: �/1G;� �- �,hYWVA,,""
Dated:
..
Reviewed b