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PROOF OF INSURANCE (2020 - 2021) CLOSEDD"A"TE YYYY) ..1..1 /0 ...- �at c�;►�ci CERTIFICATE OF LIABILITY INSURANCE (MMIDDI 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... n....__ ....................... ............m............................. older is an ADDITIONAL INSURED, the policy(ies) 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 rights to the certificate holder in lieu of such endorsement(s). ....AUTO CLUB (NSU.. . CONTACT (866 )467 ) 72253682 RANCE AGENCY LLC/PHS PHONE 873.... ..... _ .w-------------- AIc,..N.... 888 443-6112 m NAM A/C, No, Ext):( o): The Hartford Business Service Center 3600 VUseman Blvd E-MAIL San Antonio, TX 78265 ADDRESS' INSURED David Ebeling 3456 LOTUS ST IRVINE CA 92606-2117 INSURER(S) AFFORDING COVERAGE?NAIC# r . .............. SerYtinL-'U........_.............................. ...................................,........ INSURER A ._L. ....... n..s....... ranCe u Company 11000 ............. INSURER B : .............................. _,................ . -_... INSURERC: 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 INSR� ........ AODL SUBR POLICY NUMBER POLICY EFF POLICY EXP ...................�.................................................IM"I'."S............_......................_.......,_____._...�. - LTRW.wr_.... ....CIOAL.GENE.RANC....LIABILITY NSR WD IMMID,)�,YYY,).,,,,,•,,,-EACH OCCURRENCE•"••LI•MITS $2.000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Fa pCCurrenGe) $1^^000 ___ ,000 ..... ..__... X General Liability MED EXP (Any one person) $10,000 n�._.•.,_.. A 72 SBM BC9401 11/07/2019 11/07/2020 PERSONAL & ADV INJURY .................. .•.. $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $4,000,000 LOC TS CO MP/OPAGG ....- PR........_..._.... $4,000,000 — L..-.._d...JECT .......... ................ OTHER .—..�. _ .........__. .....................m_����..._.m... AUTOMOBILE LIABILITY ._ww.................................................._.ODUC ........ COMBINED SINGLE LIMIT ....., ( a ar .j•ent ANY AUTO BODILY ALL OWNED�.mm, SCHEDULED (Per acdent) (mBODILY accident) AUTOS AUTOS •,w,m,,,,,,, HIRED' NON-OWNEDPROPERTY DAMAGE AUTOS AUTOS (Per accident) —......-......u.. ......... 8.................._.� UMBRELIAB _-�...�...........,,.u..........................._____..�..........._............................................................______....__......_______............_......... OCCUR EACH OCCURRENCE EXCESS CLAIMS - [MADE AGGREGATE mAND k"L'V ..........hRETENTION $ .............. .................... KERS COMPENSATION WCR ,�"""`"""'""""'..____..........___........................__________. PER OTH- (STATUTE .....................p EMPLOYERS' LIABILITY IER ANY Y/N� 4 E L EACH ACCIDENT PROPRIETOR/PARTNER/EXECUTIVE NIA OFFICER/MEMBER EXCLUDED C E L DISEASE -EA EMPLOYEE (Mandatory in NH) _..w,w..w.................._,.W..............�.........___................_ If yes, describe under E L DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if, more space is required) Those usual to the Insured's Operations.THE CITY OF EL SEGUNDO its officers, officials, employees and volunteers is additional insured per the Business Liability Coverage S,Iaatttacched tothisHOLDER pol cyCANCELLATION CERTIFICATE SEO008rm SS0008 attached to this policy Coverage is primary and per the Business Liablli6 overage Form "THE CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 350 MAIN ST BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED EL SEGUNDO CA 90245-3813 IN ACCORDANCE WITH THE POLICY PROVISIONS. ................................ AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 72 SBM BC9401 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - VENDOR CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO CA 90245 Form IH 12 00 11 85 T SEQ. NO. 001 Printed in U.S.A. Page 00.1. Process Date: 11/0s/19 Expiration Date: 11/07/20 M THE HARTFORD BUSINESS SERVICE CENTER THE 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 THE CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO CA 90245-3813 Account Information: Policy Holder Details : David Ebeling November 5, 2019 %Q Contact Us Business Service Center Business Hours: Monday - Friday (7AM - 7PM Central Standard Time) Phone: (866) 467-8730 Fax: (888) 443-6112 Email: 29�gficv.services@thehartford.com Website: httr)s./Ibusiness.thehartford,com Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team WLTR005 PROOF OF INSURANCE Interinsurance Exchange of the Automobile Club NAIC #: 16698 Named Insured Policy Number: CAA 071832643 EBELING, KATHLEEN & DAVID Effective Date: 07-28-20 Expiration Date'. 07-28-21 This policy provides at least the minimum amokints of hability insurance requirad by the CA VEH CODE SECT fON 16056 for the specifiod vehictes and named insureds. Coverage subject to policy lerms and limits. VEHICLES ON POLICY YEAR MAKE 2013 VLKS 3VVV2K7,AJ9DW89II0 DRIVERS ON POLICY EBELING, KATHLEEN A EBELING, DAVID EBELING, KAILA EBELING, HANNAH DATEM/DDIYYYY) A<7f? CERTIFICATE OF LIABILITY INSURANCE V rr.r•"'" ll(/114/2019 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 Bonnie Ayersman NAME: SPIB Insurance Agency, Inc PHONE (949) 582-5220FA (949) 582-3512 WC. No. Ex'll° AV'C, Nay License Number 0719264 E'-M'AIL bonnie@spib,com ADDRESS' 26441 Crown Valley Parkway#200 INSURERI'S) AFFORDING COVERAGE NAIC # Mission Viejo CA 92691 INSURERA: RLI Insurance Company AM Best Rating A+ 13056 .....................................................................-_.............� INSURED INSURER B: Ebeling Communications, DBA: E -Link com INSURER C 3456 Lotus St INSURER D INSURER E Irvine CA 92606 INSURER F: W COVERAGES CERTIFICATE NUMBER: MASTER 2019-2020 REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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 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 TYPE OF INSURANCE ADDL �SUBR POLICY NUMBER 0bLI6Y FF�-T��1"Ei`E"V'E=7i....-........................�......................... LIMITS LTR INSD WVD (MMIDOIYYYY) (MMIDDlYYYY)„ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR GEN'LAGGREGATELIMITAPPLIES PER: POLICY PRO LOC JECT OTHER. AUTOMOBILE LIABILITY ANY AUTO .._ OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY __,__ ......... ..... UMBRELLA LIABV I OCCUR EXCESS LABCLAIMS-MADE DED II I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE NIA OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below PROFESSIONAL LIABILITY A RTP0017308 11/07/2019 11/07/2020 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER. CITY OF EL SEGUNDO 350 MAIN STREET ELSEGUNDO I ACORD 25 (2016103) CANCELLATION EACH OCCURRENCE S UAMAUF 10 REN I EU PRF..MISFS �,Ea occurrence) $ MED EXP (Any one person) s PERSONAL &ADV INJURY S GENERALAGGREGATE S PRODUCTS - COMP/OPAGG S S COM204ED S'BNGLE OJWIT' S tlEa acvdnon BODILY INJURY (Per person) s BODILY INJURY (Per accident) $ PROPERTY DAMAGE S (Per accident) $ EACH OCCURRENCE $ AGGREGATE $ hPER RS V STATUTE FH E L EACH ACCIDENT $ E L DISEASE - EA EMPLOYEE $ E L DISEASE - POLICY LIMIT S PL 1,000,000 OCC 1,000,000 AGG DED 1,000 r�- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE CA 90245 �'� ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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. affirm under penalty of perjury under the laws of California one of the following declarations: L_) 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. U 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 # p 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 or the agreement will automatically become void. "F. ... ..... ... _Signature A licant Date ........... Print Name Agreement for: ` I rv� Dated: Reviewed by: 17 r►,