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PROOF OF INSURANCE (2021 - 2021) CLOSED4$I I DATE (MMIDDIYYYY', A C't ORV CERTIFICATE OF LIABILITY INSURANCE 06I09I2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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). olaN macs PRODUCER Alis Maynard., NAME: Insurance Solutions PHoc Na. Extr (949) 348-7400 IAI (949) 201-4515 Noy License #0746539 B'MAIL AlisM@ins-solutions.com ADDRESS: 33302 Valle Rd, Suite 200 INSURERS) AFFORDING COVERAGE NAIC # San Juan Capistrano CA 92675 INSURERA: Hiscox Insurance Company Inc. 10200 INSURED INSURER B: California Automobile Insurance Co, i 38342 Counterrisk, Inc., DBA: Michael T LittleINSURER c : 18000 Studebaker Road, Suite 700 INSURER D: 4 INSURER E: NN Cerritos CA 90703 INSURER F: COVERAGES CERTIFICATE NUMBER: 20-21 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 MAYBE 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 AUUL'SUBR POLICY EFF p POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICYNUMBER _LKEM 222 V (MM/DD/YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 CLAIMS -MADE � OCCUR PREMISES (Ea occurrence) $ MED EXP (Any one oerson) $ 5,000 A Y UDC -1993098 -CGL -20 06/07/2020 06/07/2021 PERSONAL &ADV INJURY $ 1,000,000 GEN''LAGGREGAT'E LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRC F7 LOC PRODUCTS - COMP/OPAGG $ 2,000,000 J - $ OT'HE'R AUTOMOBILE LIABILITY 198 ac'tldpr S'OtdGLE LIMIT $ 1,000,000 �'Ea acrudaarriM XANYAUTO BODILY INJURY (Per person) $ __ B OWNED SCHEDULED Y BA040000034276 06/06/2020 06/06/2021 BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS '®m HIRED NON -OWNED PROPERTY DAMAGE $ AUTOS ONLY HAUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR -I EXCESS LIAIIIIR HCLAIMS-MADE DED I, P RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE NIA OFFICER/MEMBER EXCLUDED? El (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below I A Professional Liability Y UDC -1993098 -CGL -20 EACH OCCURRENCE $ AGGREGATE $ S PER ._ STATUTE CRH- E L EACH ACCIDENT S E L DISEASE - EA EMPLOYEE $ E L DISEASE - POLICY LIMIT S Each Claim $1,000,000 06/07/2020 06/07/2021 Aggregate $1,000,000 µDESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of EI Segundo its officials, and employees as "additional insureds" under said insurance coverage and to state that such insurance will be deemed "primary" such that any other insurance that may be carried the City of EI Segundo will be excess thereto 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 ACCORDANCE WITH THE POLICY PROVISIONS. 314 Main Street AUTHORIZED REPRESENTATIVE EI Segundo CA 90245 ©1988-2015 ACORD CORPORATION. All rightse r served. ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD 4 0 H S COX Policy Number: Named Insured: Endorsement Number: Endorsement Effective: UDC -1993098 -CGL -19 Michael Little 8 June 7, 2019 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - AUTOMATIC STATUS 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 any per- sons) or organization(s) for whom you are performing operations or leasing a premises when you and such person(s) or organiza- 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 lia- 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: 1. In the performance of your ongoing opera- tions; or 2. In connection with your premises owned by or rented to you. A person's or organization's status as an addi- tional insured under this endorsement ends when your operations or lease agreement for that additional insured are completed. CGL E5421 CW (02/14) Includes copyrighted material of Insurance Services Office, Inc., with its Page 1 of 1 permission. "MERCURY Policy Number: BA040000034276 INSURANCE Effective Date: 06/06/2020 Renewal Declarations BUSINESS AUTO DECLARATIONS For resolving issues or other information you can contact your agent or Mercury using the below phone numbers: Issued By: California Automobile Insurance Company P.O. Box 10730 Santa Ana, CA 92711-0730 Billing: (888) 637-2176 Claims: (800) 503-3724 Agent: INSURANCE SOLUTIONS# 33302 VALLE ROAD SUITE 200 SAN JUAN CAPISTRANO, CA 92675 Agent Number: 043319 Agent Phone: (949) 348-7400 ITEM ONE GENERAL INFORMATION Named Insured: COUNTERRISK INC DBA MICHAEL LITTLE Mailing Address: 18000 Studebaker Rd, Ste 700 Cerritos, CA 90703-2684 Policy Period: From 06/06/2020 to 06/06/2021 at 12:01 AM Standard Time at your mailing address Business Type: Management Consulting Business Category: Services Form of Business: Corporation Total Policy Premium: $1,938.76 This policy may be subject to final audit. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. ENDORSEMENTS ATTACHED TO THIS POLICY IL 00 17 1198 - Common Policy Conditions MCA 2154 04 19 - California Uninsured Motorists - Bodily IL 00 2109 08 - Nuclear Energy Liability Exclusion MCA AM END 04 19 - Amendatory Endorsement IL 00 03 09 08 - Calculation of Premium MCH VEHSHARE 0619 - Vehicle Sharing Exclusion CA 00 0110 13 - Business Auto Coverage Form CA 01 21 10 13 - Limited Mexico Coverage CA 0143 05 17 - California Changes MIL 02 70 04 19 - California Changes - Cancellation and CA 23 94 10 13 - Silica or Silica Related Dust Exclusion IL N 119 10 15 - California Auto Body Repair Consumer Bill of CA 20 48 10 13 - Designated Insured MCA 23 45 06 19 - Public or Livery Passenger Conveyance MCANONFAC0516 - Permanently Attached Non -Factory MDS030817-CA Page 1 of 4 06/06/2020 12:01 AM PT 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 forthe 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 Name of Agent Policy Number Expiration Date Phone # f (&I 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 5o as to become subject to the workers' compensation laws of California, and agree that, if I should become A ject ta, the workers' compensation provisions of Labor Code § 3700 1 must immediately comply ith those per , v, , ion§ or thea agreement will automatically become void, / 9ApplicantDate Si Signature of �� �... r, g y � P -*% Agreement for: I 1& 1; P� -4 19 Dated; %-).' 0' t T Reviewed by; _"yf _.....� .m: f:.::..................._........_.....................w a�