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PROOF OF INSURANCE (2021 - 2021) CLOSEDDATE(MMIDD/YYYY) ACCOR" CERTIFICATE OF LIABILITY INSURANCE 01/03/2020 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 Sharon Price NAME Jacobs- 11 (361) 293-3557 Yoakum, TX 77995, spree@jacobs-weber.com F New" (361) 293-3074 P.O. Box 67 111 tis. Ell: I ° ................ PHONE ..................................................... Patrick Hull1 NAIC it INSURER(S) AFFORDING COVERAGE INSURER Arch Insurance Company 11150 ..........__. INSURED Western Extrication Specialists, Inc. INSURERB: 4350 Adam Rd Simi Valley, CA 93063 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. pp INSR TYPE OF. INSURANCE...,., IA S.R..L........................... POLICY NUMBER .....i. tMPIMIDD YY!l IMMDOIYYYY) 4 ............,., LTR LIMITS A ,COMMERCIAL GENERAL LIABILITY Y Y MFPK08576000 101/01/2020 01/01/2021 y,E,-_,,,,„ �c 000 EACH OCCURRENCE $ ,000,000 Q AMAr;�"i`iSRENTEb 1...01000 CLAIMS -MADE OCCUR PRFMIS)mR_(fmac �nence) MED EXP (Any one person) $ 10,000 PERSONAL BADV INJURY ..$ .............................1,000,000 ..G'EN'L LIMIT APPLIES AGGREGATE . P.....................,. ICY = PER: � GENERAL AGGREGATE $ 2,000,000 "m ... ECT LOC OTHER AUTOMOBILE LIABILITY .._-..., ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY A V. UMBRELLA LIAB occuR Y Y MFUN410015200 ....M...,. ,EXCESS LIAB _. ....... �„ CLAIMS -MADE ...... DEO RETENTMN $ 0 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N / A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below A Property In -Transit / Off Premise Y Y MFPK08576000 .Sd�GM/oG.9... 2,000,000 . $ COMBO EoE pT $ �tE��,Acrca�en�C9 BO DILY INJURY (Per person) $ BODILY INJURY (Per accident) $ _.05k6_ALA.W b4MAG.E $ .......................... 01/01/2020 01/01/2021 O CURRENCE OD $ �m,m,m ....0 , ................... ATE AGGREGATE 000, 0 1,000,000 $ Ol) ER STATUTE gR.H...... ...$....... E.,L: EACH ACCIDENT $ E.L. DISEASE- EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ 01/01/2020 01/01/2021 I $250,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 701, Additional Remarks Schedule, may be attached if more space is required) Digitally signed by Joseph Lillio J o s e L I 1 1 I O CIN: cn=Joseph Lillio, o=City of FI Segundo, ou=Director of Finance, email=jlillio@else(4undo.org, c=US Date: 2020.09.28 13:19:08 -07'00' CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of EI Segundo, its officers, officials, employees, ACCORDANCE WITH THE POLICY PROVISIONS. agents and volunteers 350 Main Street AUTHORIZED REPRESENTATIVE EI Segundo, TX 902453813 i ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD JL POLICY NUMBER: MFPK08576000 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. we Nk .0 M, This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations Any Person or Organization when you are specifically All contracted locations required by a written contract or agreement to include as an additional insured for the "products -completed operations hazard". Any Person or Organization does not include engineers, architects or surveyors. 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" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". 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. B. 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. CG 20 37 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 �7L POLICY NUMBER: MFPK08576000 COMMERCIAL GENERAL LIABILITY CG 20 33 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATU'S WHEN REQUIRED, IN CONSTRUCTION I AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured any person or additional insureds, the following additional organization for whom you are performing exclusions apply: operations when you and such person or This insurance does not apply to: organization have agreed in writing in a contract or agreement that such person or organization be 1. "Bodily injury", "property damage" or "personal added as an additional insured on your policy. and advertising injury" arising out of the Such person or organization is an additional rendering of, or the failure to render, any insured only with respect to liability for "bodily professional architectural, engineering or injury", "property damage" or "personal and surveying services, including: advertising injury" caused, in whole or in part, by: a. The preparing, approving, or failing to 1. Your acts or omissions; or prepare or approve, maps, shop drawings, 2. The acts or omissions of those acting on your opinions, reports, surveys, field orders, change orders or drawings and behalf; specifications; or in the performance of your ongoing operations for b. Supervisory, inspection, architectural or the additional insured. engineering activities. However, the insurance afforded to such This exclusion applies even if the claims against additional insured: any insured allege negligence or other wrongdoing 1. Only applies to the extent permitted by law; in the supervision, hiring, employment, training or and monitoring of others by that insured, if the 2. Will not be broader than that which you are "occurrence" which caused the "bodily injury" or required by the contract or agreement to " property damage", or the offense which caused provide for such additional insured. the "personal and advertising injury", involved the rendering of or the failure to render any A person's or organization's status as an professional architectural, engineering or additional insured under this endorsement ends surveying services. when your operations for that additional insured are completed. CG 20 33 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 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 location 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. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or 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. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 33 04 13 u7L COMMERCIAL GENERAL LIABILITY CG 20 38 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS FOR OTHER PARTIES WHEN REQUIRED IN WRITTEN CONSTRUCTION AGREEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured: 1. Any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy; and 2. Any other person or organization you are required to add as an additional insured under the contract or agreement described in Paragraph 1. above. Such person(s) or organization(s) is an additional insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: a. Your acts or omissions; or b. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured. However, the insurance afforded to such additional insured described above: a. Only applies to the extent permitted by law; and b. Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. A person's or organization's status as an additional insured under this endorsement ends when your operations for the person or organization described in Paragraph 1. above are completed. 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" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying 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; or b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of, or the failure to render, any professional architectural, engineering or surveying services. 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 location of the covered operations has been completed; or CG 20 38 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 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. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement described in Paragraph A.1.; or 2. Available under the applicable Limits Insurance shown in the Declarations; whichever is less. This endorsement shall not increase applicable Limits of Insurance shown in Declarations. of the the Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 38 04 13 POLICY NUMBER:MFPK08576000 uZ COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF FIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Any Person or Organization when you are specifically required by a written contract or agreement to include as an additional insured onto your policy and waive any right of recovery arising out of your ongoing operations or "your work" and included in the "products - completed operations hazard". Any person or organization does not include engineers, architects or surveyors. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products - completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 Ilnterinsurance Exchange of the Automobile Club Automobile Insurance Policy Coverages and Limits Renewal Declarations We are pleased to offer you a renewal for your automobile insurance policy. To renew your policy, send at least the minimum payment on or before the due date. Insurance is in effect only for the vehicles, coverages, and limits of liability shown on this declarations page and as set forth in the insurance policy and endorsements. These declarations, together with the contract and the endorsements in effect, complete your policy. If any change to your policy or to the information we have on file results in a premium decrease during the policy period, the Interinsurance Exchange reserves the right to apply any refund due to your outstanding balance. NAMED INSURED (Item 1.) DANEJACKSON 4350 ADAM RD SIMI VALLEY CA 93063-2344 AUTO POLICY NUMBER: CAA 065793673 ................................... POLICY PERIOD (PACIFIC STANDARD TIME) POLICY EFFECTIVE DATE: 04-06-20 12:01 A.M. COVERAGES AND LIMITS Coverage is not in effect unless a premium or the word "included" is shown. COVERAGES LIMITS OF LIABILITY Liability o Bodily Injury $500,000 each person/ $500,000 each occurrence Property Damage $100,000 each occurrence Medical Physical Damage (Actual Cash Value unless otherwise stated, less deductible) Vehicle 3 Vehicle 4 Vehicle 7 Vehicle 8 Vehicle POLICY EXPIRATION DATE: VEHICLES ACV $90000 (Less Deductible) $500 ....... $500 $250 VEH. YEAR MAKE MODEL IDENTIFICATION VEHICLE GARAGE ANNUAL— NO, Car Rental Expense NUMBER USE ZIP CODE MILES 3 2007 HARL HARLEY COMMUTE 93063 1 - 500 4 2003 FORD F250 CREW C CREW Uninsured & Underinsured Vehicles PLEASURE 93063 17,501 - 20,000 7 2014 HARL FLHTK ULTRA LIMITED poliu'l ud. !!o •,;., . „. COMMUTE 93021 3,501 - 4,500 8 2012 NW M BAY STAR 3302 PLEASURE 93021 2,501 - 3,500 COVERAGES AND LIMITS Coverage is not in effect unless a premium or the word "included" is shown. COVERAGES LIMITS OF LIABILITY Liability o Bodily Injury $500,000 each person/ $500,000 each occurrence Property Damage $100,000 each occurrence Medical Physical Damage (Actual Cash Value unless otherwise stated, less deductible) Vehicle 3 Vehicle 4 Vehicle 7 Vehicle 8 Vehicle Comprehensive ACV ACV ACV $90000 (Less Deductible) $500 $250 $500 $250 Collision ACV No Coverage ACV $90000 (Less Deductible) $500 No Coverage $500 $500 Car Rental Expense (Per Day) No Coverage No Coverage No Coverage No Coverage Uninsured Motorist Bodily Injury - $100,000 each person/ $300,000 each accident Uninsured & Underinsured Vehicles Uninsured Deductible Waiver Uninsured Collision Total Premium 04-06-21 12:01 A.M. ANNUAL PREMIUMS VERIFIED SALVAGE MILEAGE VERIFIED VERIFIED NO VERIFIED VERIFIED Vehicle 3 Vehicle 4 Vehicle 7 Vehicle 8 Vehicle $ 106 $ 386 $ 80 $ 99 $ 26 $ 262 $ 20 $ 64 1 V' 1. jNo Coverage No Coverage ; No Coverage ; No Coverage e 1 e $ 82 $ 97 $ 38 a $ 192 I tl 1 4 $ 114 No Coverage $ 130 $ 355 1 o 0 d No Coverage No Coverage! No Coverage No Coverage! E 9 I I I w $112 a $159 $140 ! $29 o 9 a Included No Coverage a Included Included 1 No Coverage, No Coverage No Coverage No Coverage; $ 440 $ 904 $ 408 $ 739 PREMIUM DISCOUNTS No Coverage" indicates coverage not purchased. Please refer to the enclosed document entitled "Premium Discounts Applied to Your Automobile Policy." Total Annual Premium* * (Includes all applicable discounts.) $ 2491 If at any time you choose to pay less than the full balance outstanding, finance charges of up to 1.5% per month of the balance outstanding will apply Less Policyholder Savings Dividend $ 335 as explained in your billing statements, which are part of these declarations. Net11 P 11 remium * N $ 2156 ** To see the annual mileage for your expiring policy, please refer to the ,"Notice of AnnualMileage" P a y page contained m our renewal package. E20190107 PROCESS DATE 02-26-20 PLEASE ATTACH TO YOUR POLICY (SEE REVERSE) 022620 DATE(MM/DD/YYYY) �-- CERTIFICATE OF LIABILITY INSURANCE 09/01/2020 .............. 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(les) must be endorsed. If SUBROGATIONIS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer R rights to the certificate holder in lieu of such endorsement(s). __ ..... PRODUCECONTACT NAME:: AP INTEGO INSURANCE GROUP LLC ( PHONE 289-2939 FAX (888) 289-2988 76250846 (AIC, No, Ext): (A/c, Na): 375 WOODCLIFF DRIVE STE 103 FAIRPORT NY 14450 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIL# INSURER A: Hartford Fire and Its P&C Affiliates 00914 INSURED GENERAL AGGREGATE I INSURER B: PRODUCTS - COMP/OP AGG WESTERN EXTRICATION SPECIALISTS, INC.lNSURERC: OTHER: 1 PO BOX 1065 _..._..................................................... ... COMBINED SINGLE LIMIT ............................. ...�........................... IEa accident) ANY AUTO BODILY INJURY (Per person) llvsuRERD: BODILY INJURY (Per accident) SIMI VALLEY CA 93062-1065 HIRED NON -OWNED PROPERTY DAMAGE .�.AUTOS AUTOS (Per accident) .........................................._.._......................................... INSURER E: ............................................... EACH OCCURRENCE _............................................... ........_._._._ . EXCESS LIAB CLAIMS- AGGREGATE 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. YNSI�ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WWD POLICY NUMBER _tMNUDDIYY,YY),,,,,,,,. JRMCDD/Y, nM_ LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE ............ OCCUR DAMAGE TO RENTEEN�_:.................................... CLAIMS -MADE � ED MED EXP (Any one person) PERSONAL & ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE POLICY 0 PRO F—] LOC PRODUCTS - COMP/OP AGG JECT OTHER: .................................... _ AUTOMOBILE LIABILITY _..._..................................................... ... COMBINED SINGLE LIMIT IEa accident) ANY AUTO BODILY INJURY (Per person) ° ALL OWNED SCHEDULED BODILY INJURY (Per accident) AUTOS AUTOS HIRED NON -OWNED PROPERTY DAMAGE .�.AUTOS AUTOS (Per accident) .........................................._.._......................................... .... OCCUR UMBRELLA LIAR ............................................... EACH OCCURRENCE _............................................... ........_._._._ . EXCESS LIAB CLAIMS- AGGREGATE MADE ED 1 RETENTION $ WORKERS COMPENSATION WORKERS COMP N ........................ _............... X V PER OTH-' AND LIABILITY STATUTE ANY YIN E L EACH ACCIDENT $1,000,0001 A PROPRIETOR/PARTNER/EXECUTIVE NIA X 76 WEG AFOM4H 01/16/2020 01/16/2021 1 OFFICER/MEMBER EXCLUDED? [ EL DISEASE -EA EMPLOYEE $1,000,000 (Mandatory in NH) I If yes, describe under E L DISEASE - POLICY LIMIT $1,000,000 m,,,,,,,,,,,,,,,,_ DESCRIPTION OF OPERATIONS below .--........... .... ................................. ..m.m.... r DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACO.:D 101, Additional Remarks Schedule, may be attached if more space Is required) Those usual to the Insured's Operations. Blanket Waiver of Subrogation applies in favor of the Certificate Holder per the Waiver of Our Right to Recover from Others Endorsement WC040306 , attached to this policy. CERTIFICATE HOLDER CANCELLATION City of EI Segundo, its officers, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED officials, employees, agents and BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Volunteers�� 350 MAIN ST AUTHORIZED REPRESENTATIVE EL SEGUNDO CA 90245-3813 U ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number: 76 WEG AFOM41-1 Endorsement Number: 2 Effective Date: 03/10/20 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: Western Extrication Specialists, Inc. PO BOX 1065 SIMI VALLEY CA 93062 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 % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE Person or Organization Job Description Any person or organization from whom you are required by written contract or agreement to obtain this waiver of rights from us Countersigned by Form WC 04 03 06 (1) Printed in U.S.A. Process Date: 03/10/20 Authorized Representative Policy Expiration Date: 01/16/21