PROOF OF INSURANCE (2020 - 2021) CLOSEDAC CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDfYYYY)
0611012020
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 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
No Hassle Insurance AgencyNHowz JERRY MACIAS FAX
1400 E. Cooley Dr. Ste. 202-A � , 9 tl• lase}44o�osa _.. Acs: I909')' '8 w7'9oD
AIL
Colton, CA 92324Ball._ _jimacias( nohassleins.not
License #: OE74924 INSURER($) AFFORDING COVERAGE mmV NAIC k
.....................
iNSURED INSURERA: United Statp L18bi1_.its/�r-ryI.Ja.f).,EQ,_i.,m0111p8n,)(-. „'
Christopher Heppell DBA: Precision Reef
Systems INSURER B:
INSURER C;
3537 Torrance Blvd, #24 INSURERA „. .................. _..... .
Torrance, CA 90503 ,INsURERE:
INSURER F :
COVERAGES CERTIFICATE NUMBER: 00004050-18094 REVISION NU'M'BER: 9
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 CONTRACTOR 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.
fhsit ADUL 4J RPWD4JCY EFF '� POLICY EXP - --- -- ......��
1.1kTYPE OF INSURANCE W111 -an POLICV NUMBER iMVMDfYY t IMM(DDIYYYYi LIMITS
A X COMMERCIAL GENERAL LIABILITY Y CL 1757885D 06111/2020 06111/2021 EACH OCCURRENCE S 1.00Q,WOOO
CLAIMS -MADE L �J OCCUR AAC,k TO RENTED
..EM4s�s t��'� s 100,000
MED EXP (Any one pereon .® $ 6 000
PERSONAL& ADVINJURY_ $ 1,000 000
GE"""�ppp6'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGRE'O TE $ 2,000,000
POLICY JECT FI LOC PRODUCTS -COMPIOPAGG $ 2,000 0, 00
- OTHER' Deductible $ 0
AUTOMOBILE LIABILITY 'COMBINED SINGLE LIMIT'
ANY AUTO BODILY INJURY (Per person) $
OWNEDSCHEDULED
AUTOS ONLY AUTOS BODILY INJURY (Par accident)J S HIRED NON -OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Parr acardenl'S
S
UMBRELLA LIAR OCCUR EACH OCCURRENCE S
EXCESS LIAR CLAIMS -MADE AGGREGATE S
DED B RETENTION S $
ANDEMPLOYERS" LIABILITY
WORKERS COMPENSATION g PER 1OTH-
AI S7ATUTA= .... .L��i...._�... .....-..
YPROPRIETORIPARTNERIEXECUTIVE YIN E,L EACHACCIDENT S
OFFICERIMEMBER EXCLUDED? N I A � --- ---
(Mandatory In NH) E.L. DISEASE - EA EMPLOYEE S
If yyoob, describe under
OESC'RIPTION OF OPERATIONS below E.L DISEASE • POLICY LIMIT $
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H mors epau k required)
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
The City of EI Segundo and its employees ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE
(J�
01988-20'15�A4:'ORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
Printed by JMA on June 10, 2020 at 03:42PM
Harada, Patricia
From: Kristina Kora-Beckman
Sent: Thursday, August 20, 2020 12:14 PM
To: Harada, Patricia
Cc: Shilling, Mona; Le May, Jessie; Lillio, Joseph
Subject: Precision Reef System - General Liability Endorsement Insurance Waiver
Importance: High
Hi Patricia,
Hope you and your family are well.
Regarding Precision Reef System's insurance, Joe Lilio has approved waiving the GL endorsement this time (please see
email below).
Please let me know if anything else is needed to process the waiver.
Thank you,
Kristina Kora-Bechman
Senior Librarian, Youth Services
EI Segundo Public Library
111 W. Mariposa Avenue
EI Segundo, CA 90245
(310) 524-2772
www.elsegundoiibrar.pr,
From: Lillio, Joseph
Sent: Thursday, August 20, 2020 9:58 AM
To: Kristina Kora-Beckman
Cc: McCollum, Melissa
Subject: RE: Insurance Cost Relative to Service Agreement Value
The liability exposure seems very low. I am okay with waiving the endorsement this time.
The reason I asked about the technician being supervised is, there is risk of kids in the library being exposed to the
technician's equipment or chemicals and possibly being injured. I would like to have assurance that staff is taking a
proactive approach and ensuring curious children are not permitted near the tank while it is being cleaned. If the
company had the endorsement, I would not be asking this question.
Thanks!
1
DATE (LIMIDOLYYYY)
ARD CERTIFICATE OF LIABILITY INSURANCE
06/19/2020
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
s 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 . CT�5l
sl�eFMBrent K WhiWck Insurance Agency inc PHONE310-821-0864 r_N0 310-541-619904.
28441 Highrldge Rd Ste 503 EMAIL melissa..san+dersisak@statefarm.co'm
Rolling Hills Estates, CA 90274 INSURERISs AFFORDING COVERAGE MAIC 0
INSURER A: State Fara! Mutual Automobile Insurance Company 25178
INSURED INSURERS
Christopher Happell INSURERS; pp
7712 Goddard Ave INSURER D. d
Los Angeles, CA 90045 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.
f I A7y'DI'w;Susn POUCYEFF PO'UCYEXP
{ TYPE OF INSURANCE A122 M POLICY NUMBER tMM)00P vyyY ,,,I1IwDD1YYYYB UIMTS
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE F-1 OCCUR
QEN"L AGGREGATE LIMIT APPLIES PER:
POLICY ❑ JEC1 LOC
OTHEW
TOMOBILEUABIUTY 612 9574-C14-75
ANY AUTO
A OWNED SCHEDULED
AUrOONLY 1^1
AUTOS
HIRED EO
AUTOS ONLY AUTOS ONLY
UMBRELLA LJAaOCCUR
EXCESS LIAO H CLAIMS -MADE
DED Ig
@ RETENTION s
WORKERS COMPENSATION
AND EMPLOYERS' UABIUTY YIN
ANY PROPRIETORIPARTNERIEXECUTIVE —I N f A
OFFICERIMEMBER EXCLUDED?
(Maedatory in NH)
tf yyees, dascribo under
DESCRIPTION OF OPERATIONS below
s rhftl
EACH OCCURRENCE S
EIMTEO
PR M' re", 0womneab S
MED EXP (Any one person! S
PERSONAL d ADV INJURY 15
GENERALAGGREGATE $
PRODUCTS - COMPIOP AGG $
03114)2020 09114/2020 COMStNED Sw6w Lima $
BODILY INJURY (Per perom) I f 1,000,000
BODILY INJURY(Per accldem)d $ 1,000,000
PROPERTYDAMAGEAL3EAeg(s 1,000,000
�a
EACH OCCURRENCE S
AGGREGATE $
I s
NE NOr
ER
[EL7EACIHT4ACCIDENT 1q S
E.L. DISEASE -EA EMPLOYEd $
E.L. DISEASE - POLICY LIMIT M S
DESCRlPT10N OF OPERATIONS I LOCATIONS 1 VEHICLES
(ACORD 101, AddNlohel Remarks Schedule, maybe attached If mors space Is required)
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
The City of EI Segundo and its employees ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street '
AUTHORIZED REP A
Tr< 14
RPORATION. All rights reserved
The ACORD name and logo are registered marks of ACORD 1001466 13284912 03-16-2016
EI Segundo, CA 90245
ACORD 25 (2016/03)
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 #
(XI 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 thus , rovisions or the reemen 'ill automatically become void.
Signature of Applicant � Date
Print Name L ��(_' . .
J
Agreement for:
Dated:
Reviewed by: (��e