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PROOF OF INSURANCE (2020 - 2021) CLOSEDClient#: 198888 50JUVAREHOLD DATE (MMIDD/YYYY) ACORDTM CERTIFICATE OF LIABILITY INSURANCE 5/05/2020 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 ELOW. 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Amber Zell J Smith Lanier & Co Newnan PHbNEPAXWq,.N770-683-1000 o, AM,: �, (+�4 ,.r? ), 010 P. O. Box 71429 E MAIL APDRFSS.azell@js,,mithIanier.com AFFORDING COVERAGE# ll) sm 47 Postal Parkway s e NAIc ......................................................_.............................. Newnan, GA 30271-1429 INSURER A : American Casualty Co. of Reading PA 20427 .................................................. INSURED INSURER B: Continental Insurance Company 35289 ESi Acquisition, Inc— INSURER C: Columbia Casualty Company 31127 235 Peachtree Street, NE; Suite 2300 Transportation Insurance ................... 20494 INSURER D : P Atlanta, GA 30303 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 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 3Y PAID CLAIMS LNSR TYPE OF INSURANCE ADOLSUBR PaLICY EFF POLICY EXt RA POLICY NUMBER �MMWDIYYYY MMIDDIYYY I .!...W............... UINSR MyVM... L.(....... LIMITS A X COMMERCIAL GENERAL LIABILITY X X 6083191715 05/08/2020 05/08/2021 EACH OCCURRENCE $1,000,000 DAMMqq��E TO RENTED CLAIMS -MADE XI OCCUR ?REM,ISFS(FR,raccurrence) $1,000,000 MED EXP (Any one person) $15,000 PERSONAL & ADV INJURY $17009,090 GEN'L AGGREGATE LIMIT APPLIES PER PRO. POLICY ❑ JECT' LOC AU OTHER: AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED _ AUTOS ONLY AUTOS X OWNED AUTOS ONLY X AUTOS ONLY B X ... EXCESS AUMBRELLA .BAB OCCUR DE MS -MA -- DED X R �...... X ..., :.. E N- E'°r �'r9N s100OO WORKERS COMPENSATION AND EMPLOYER'S" LIABILITY Y / N ANY PRS'.uPRIET'ORMARTNERFEXECUTIVE❑ h'DFFICERWEMBF'R EYCLUDE&."N"+ (MaodaWry In NH) If yes, describe under TIONS below .,DESCRIPTION OF OPERA............ . C Technology E&O Cyber Liability GENERALAGGREGATEs2,000,000 000,000 RODUC CS YCIOMP/OPAGG $2,000,000 X X 6083192136 C I a auc de J sIN 5/08/2020 05/08/2021 GLE L /. gnrS ......5.1,000,0,00 ....................... BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ Per accidepl) $ 6083234885 05/08/2020 05/08/2021 EACH OCCURRENCE 5,000 e.0 AGGREGATE $ ,00 .w..,.,_. _,....,.,., ............................... $ 1A.T�IT. ............. . ER N / A ... CCIDENT................................ $ E L, DISEASE - EA EMPLOYEE $ DISEASE - POLICY LIMIT $ ....,....................�,,...,m,,,......................_.,........�..�...._.......-,.._,._......... ..................._. E...... ................................,.,.,.,.,.,.., 651995465 05/08/2020 05/08/2021 SIR:$100,000 $10,000,000 Limit DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) (GL) Additional Insured status applies on a Primary & Non -Contributory basis per Form CNA74872XX115. (GL) Waiver of Subrogation applies per Form CNA74872XX115. (CAU) Additional Insured status applies on a Primary & Non -Contributory basis per Form CNA8370OXX102015. (CAU) Waiver of Subrogation applies per Form CNA8370OXX102015. (See Attached Descriptions) CERTIFICATE HOLDER City of EI Segundo 350 Main Street EI Segundo, CA 90245 CANCELLATION 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) 1 of 2 The ACORD name and logo are registered marks of ACORD #S4861640IM4861584 SZT DESCRIPTIONS (Continued from Page 1) ICity of EI Segundo, its officials, and employees are included as additional insured with respect to general liability where required by written contract. This insurance is primary and non-contributory over any 'sting insurance and limited to liability arising out of the operations of the named insured and where equired by written contract with respect to general liability. I SAGITTA 25.3 (2016/03) 2 Of 2 #S4861640/M4861584 T3-UTU 0 Ip DATE (MMIDDMIYY) CERTIFICATE OF LIABILITY INSURANCE IIuII 6/26/2019 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(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 .... 1. 1. PHONE Risk .. (866443-8489 nagernent Department....a..................m....... Inc . 8... ..................... ......... ADDR ss.: Work.Comp@Trinet.com ... ..... Commercial Ines ) ......_1 .................. L�_ '.fit )........00 889 0021 USI Insurance Services LLC E-MAIL 2601 South Bayshore Drive, Suite 1600 INSURERS) AFFORDING COVERAGE NAIC # Coconut Grove, FL 33133 INSURERA: ACE American Insurance Company 22667 _......�..................................._......_........-........................._................_... ................. .............. ..... . ...... ............................................. INSURED INSURER B TriNet HR III, Inc. INSURERC: L/C/F EMSystems, LLC dba Juvare INSURER D..... _................................................... ............... ...... -.........................- ESI Acquisition Inc. INSURER E: ....................... m... ............ 9000 Town Center Parkway, Bradenton, FL 34202 INSURER F: COVERAGES CERTIFICATE NUMBER: 14362339 REVISION NUMBER: See below 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. I145R At5'bl_'i,SY.T15.A� .............P10.LI.CY EFF POLICY EXP...._.............,..............,...,.,.,.,.,.....,......................._,.............. LTR TYPE OF INSURANCE INSO wan POLICY NUMBER fMMIDDIYYYYt (MMIDDIYYYYI LIMITS CLAIMS -MADE AL ( OCCURRENCE S _ ,. COMMERCIAL GENERAL LIABILITY EACH ................_..li �,...., P OCCUR PREMISES (Es occurrence) _.....�.. I I I II DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Workers' Compensation is limited to worksite employees of EMSystems, LLC dba Juvare through a co -employment contract with TriNet HR III, Inc. CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo CA 90245 AUTHORIZED REPRESENTATIVE The ACORD name and logo are registered marks of ACORD ©1988-2015 ACORD CORPORATION. All rights reserved, ACORD 25 (2016/03) 111111111 lHill 1H 1111 VIII 111 H11 11111 I 1111 1111111111111111111111 II 1111 °crao.mo..021021010l010' MED EXP (Any one person) S PERSONAL & ADV INJURY S P:E'N'kP.GREEO'r APPLIES A E LOC PRODUCTSGCOMP/OP A..ITG.............................-ww...............---............... OTHFR, I AUTOMOBILE LIABILITY COMBINED SINGLE LWI'rS GEa ae;caderul9 ANY AUTO BODILY INJURY (Per person) I s OWNED SCHEDULED BODILY INJURY (Per accident) S —II AUTOS ONLY AUTOS HIRED NON-OWNED�I Pfi Yf"EFI liq C E S AUTOS ONLY AUTOS ONLY jPem.,.4arc�i�rlercoCl L't5 N Y V $ UMBRELLALIAB OCCUR EACH OCCURRENCE 5 —� N EXCESS LIAB 0 CLAIMS„MADE AGGREGATE S DED RETENTIONS ..m.__..___..._ S A WORKERS COMPENSATION WLR 066199113 7/1/2019 7/1/21)20 X STATUTE I EORH AND EMPLOYERS' LIABILITY YIN _ ANYPROPR4ETORY PARTNER/EXECUTIVE E L EACH ACCIDENT 5 2,000,000 OFF "ICERWE'MBEREXCLUDED? C NIA -------..-.�.. IMandatory in NHp E DISEASE - EA EMPLOYEE S 2,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below 2,000,000 E DISEASE - POLICY LIMIT ^ $ I II I I I II DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Workers' Compensation is limited to worksite employees of EMSystems, LLC dba Juvare through a co -employment contract with TriNet HR III, Inc. CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo CA 90245 AUTHORIZED REPRESENTATIVE The ACORD name and logo are registered marks of ACORD ©1988-2015 ACORD CORPORATION. All rights reserved, ACORD 25 (2016/03) 111111111 lHill 1H 1111 VIII 111 H11 11111 I 1111 1111111111111111111111 II 1111 °crao.mo..021021010l010'