PROOF OF INSURANCE (2020 - 2021) CLOSED (2)A� ® CERTIFICATE OF LIABILITY INSURANCE I DATE(MMIDDIYYYY)
10/26/2020
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 I CONTACT Mary Pojar
NAME:
ISU - Dunlap Agency I PHONn o. Extr (714) 838-3158 I FAX(AJC Not: (714) 922-6157
fAJ700 West 1st St., Suite 8 I E-MAIL mary@dunlapins.com
ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
Tustin CA 92780 INSURER ASentinel Insurance Co
INSURED INSURER B: Preferred Employers Ins. Co.
Matrix Imaging Products, Inc. I INSURER C: United States Liability Co
18445 Amistad I INSURER D:
INSURER E:
Fountain Valley CA 92708 I INSURER F :
COVERAGES CERTIFICATE NUMBER: 2020-2021 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 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.
INSR ADDL SUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1'000'000
RENTED
CLAIMS -MADE FX OCCUR I PREM SESDAMAGE TO(Ea occurrence) $ 1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The City of EI Segundo, its officials. and employees are named as additonal insured. Insurance on the Certificate is Primary. Thirty (30) days notice of
Cancellation required.
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.
350 Main St.
AUTHORIZED REPRESENTATIVE
EI Segundo CA 90245
I
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
I MED EXP (Any one person)
$ 10,000
_
A
72SBABD3913 DX
10/17/2020
10/17/2021 (PERSONAL &ADV INJURY
$ 11000'000
GEN'LAGGREGATE LIMITAPPLIES PER
I GENERAL AGGREGATE
$ 2'000'000
POLICY El—]LOC❑LOC
JECT
I PRODUCTS - COMP/OP AGG
$ 2,000,000
OTHER:
Employee Benefits
$ 2,000,000
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
$ 1,000,000
(Ea accident)
ANYAUTO
I BODILY INJURY (Per person)
$
A OWNED SCHEDULED
72SBABD3913 DX
10/17/2020
10/17/2021 I BODILY INJURY (Per accident)
$
AUTOS ONLY AUTOS
X HIRED�/ NON -OWNED
I PROPERTY DAMAGE
$
AUTOS ONLY /� AUTOS ONLY
(Per accident)
X UMBRELLA LAB OCCUR
EACH OCCURRENCE
$
A EXCESS LAB
72SBABD3913 DX
10/17/2020
10/17/2021 I
CLAIMS -MADE
AGGREGATE
$
DED I XI RETENTION $ 10'000
$
WORKERS COMPENSATION
XI I I
AND EMPLOYERS' LIABILITY Y/ N
SPER TATUTE EORH
B ANY PROPRIETOR/PARTNER/EXECUTIVE � N/A
WKN157011-6
12/01/2019
12/01/2020 I E.L. EACH ACCIDENT
1,000,000
$
OFFICER/MEMBER EXCLUDED
1,000,000
(Mandatory in NH)
I E.L. DISEASE - EA EMPLOYEE
$
If yes, describe under
1,000,000
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$
Deductible: $2,500
$1,000,000
Professional Liability
C Network Security
TK1553465
06/17/2020
06/17/2021 Deductible: $2,500
$250,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The City of EI Segundo, its officials. and employees are named as additonal insured. Insurance on the Certificate is Primary. Thirty (30) days notice of
Cancellation required.
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.
350 Main St.
AUTHORIZED REPRESENTATIVE
EI Segundo CA 90245
I
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
MATRIX IMAGING PRODUCTS, INC
POLICY NUMBER: 72ABABD3913DX COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED -OWNERS, LESSEES OR
CONTRACTORS (Form B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
CITY OF EL SEGUNDO,
ITS OFFICIALS AND EMPLOYEES
Primary Wording/Non-Contributory
It is further agreed that such insurance as is afforded by the policy for the benefit of the above
Additional Insured(s) shall be primary insurance but only as respects any claims, loss or liability
arising out of the Named Insured(s) shall be excess and non-contributing.
(If no entry appears above, information required to complete this endorsement will be
shown in the Declaration as applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or
organization shown in the schedule, but only with respects to liability arising out of your
work preformed for that insured.
CG 20 10 07 04 Copyright, Insurance Services Office, Inc. 2004
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 0313
(Ed, 4-84)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
We have the right to recover oar payments from anyone liab* 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 cnly to the extent that you
perform work under a written contract that req uass you to obtain this agreement Prom us.)
This agreement shall not operate directly or Indirectly to benefit anyone not named in the Schedule,
Schedule
The City El Segundo,
Its officials and employees
This endorsement changes the polity to which It is attached and is effective on the date issued unless otherwise stated.
(The Information below Is required only when this endorsement 4 issued: subsequent to preparation of the pollrayj
Endorsement Effective:,
Insuwd: MATRIX WAGING PRODUCTS, INC.
Insurance Company. Employers
WC 00 0313
(Ed. 4-84)
Policy No. WKN157O1I
Countersigned by _,P§A_n ALnlitp
Copyright 1963 National Council on Compensation Insurance,
Endorsement No. I
Premium $0