PROOF OF INSURANCE (2021) CLOSED11� 0 DATE (MM/DD/YYYY)
C40RO CERTIFICATE OF LIABILITY INSURANCE
11/12/2620
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. USUBROGATION 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 NAME:
FounderShield, LLC I PHONE (A/C No. Ext): 646-554-1058 R FAX (A/C No):
122 W 26th Street, 2nd Floor 6 E-MAIL ADDRESS: coi@foundershield.com
New York, New York, 10001
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A: TWIN CITY FIRE INSURANCE CO 29459
INSURED INSURER B: AXIS INSURANCE COMPANY 37273
INSURER C:
Elued
INSURER D
2261 Market Street 14009
San Francisco, California, 94114 INSURER E:
V 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR � I .. (MM/DD/YYYY) (MM/DD/YYYY) .
IVSD WVD
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000.00
CLAIMS MADE itIOCCUR
DAMAGE TO RENTED
$1,000,000.00
PREMISES (Ea occurrence)
MED EXP (Any one person)
$10,000.00
A GEN'L AGGREGATE LIMIT APPLIES PER:
IOSBMBA1724 09/21/2020 09/21/2021 I PERSONAL & ADV INJURY
S1,000,000.00
��POLICY LOC
IGENERALAGGREGATE
52,000,000.00
_ PROJECT
(PRODUCTS- COMP(OPAGG
$2,000,000.00
OTHER
I
$
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
(Ea accident)
ANY AUTO
I BODILY INJURY (Per person)
OWNED AUTOS SCHEDULED
ONLY
I BODILY INJURY (Per
accident)
HIRED AUTOS ONLY NON -OWNED AUTOS
HIRED
PROPERTY DAMAGE (Per
ONLY
accident)
UMBRELLA LIAR
OCCUR
EXCESS LIAR
CLAIMS -MADE
WORKERS COMPENSATION AND EMPLOYERS' LIABILITY
ANYP ROPRIETOR/PARTNER/EXECUTIV Y/N
OFFICER/MEMBER EXCLUDED" N
(Mandatory in NH)
11 -yes, describe under DESCRIPTION OF OPERATIONS below N/A
Each occurence
Aggregutc
PERSTATUTE_
OTHER
V E.L. EACH ACCIDEN
E.L. DISEASE - EA
EMPLOYEE
E.L. DISEASE - POLICY
LIMIT
B Cyber Liability,Errors & Omissions,Privacy ITTN-200074-03 09/21/2020 09/21/2021 S 1,000,000 per occ $1,000,000 in agg
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The Certificate Holder is included as an Additional Insured on the above referenced policy where required by written contract.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE
CITY OF EL SEGUNDO THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
350 MAIN STREET,
EL SEGUNDO CA 90245
AUTHORIZED REPRESENTATIVES'
1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: 10 SBM BA1724
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - PERSON -ORGANIZATION
LOC:001 BLDG:001
CITY OF EL SEGUNDO
350 MAIN STREET,
EL SEGUNDO CA 90245
THE CITY OF NEW YORK TOGETHER WITH ITS OFFICIALS AND EMPLOYEES
1 POLICE PLAZA
1 POLICE PLAZA PATH
NEW YORK, NY 10038
COVERAGE IS PRIMARY AND NONCONTRIBUTORY PER THE BUSINESS LIABILITY
COVERAGE FORM SS0008, ATTACHED TO THIS POLICY.
Form IH 12 0011 85 T SEQ. NO. 001 Printed In U.S.A. Page 001
Process Date: 07/08/20 Expiration Date: 09/21/21
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:
(_J 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
Name of Agent
Policy Number Expiration Date
Phone #
vtj 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 thoor the agreement will automatically become void.
08/26/2019
Signature of Applicant . Date
Agreement for: Elucd Inc
Dated:
Reviewed by.
DOC ID: ac367d81314539524eag6bate5ab69905d012d8a