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PROOF OF INSURANCE (2021 - 2021) CLOSEDAUC `�o CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) , 'Ill 12/11/2020 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). CONTACT Lin D Diaz PRODUCER NAME: D&C Insurance Solutions W No, Ext); 888.457.4426 FAX Nap, 323.576 4552 E -MAUL ADDRESS; ConlaCl,@)dci-Insurance.com 300 Sr Atlantic Blvd„ Ste 201-B INSURER(S) AFFORDING COVERAGE NAIC# Monterey Park CA 91754 INSURERA: Western World Insurance Company 13196 INSURED INSURER B: Tillmann Forensic Investigations, LLC. INSURER C: INSURER D PO Box 4373 INSURER E: Covina CA 91723 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 ... ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCEINSD MND POLICY NUMBER (MMIDD/YYYVi (MMIDD.IYYVV) X COMMERCIAL GENERAL LIABILITY A NPP8622746 12/17/2020 12/17/2021 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR„d ) w��RE'PJInSEs Ea� rlaac�arrrnc�a $ 100.000 GEN'L AGGREGATE LIMIT APPLIES PER l PRO X r0l_lc`r' ` -1 5ECT LOC, OTHER $ 1,000,000 AUTOMOBILE LIABILITY $ 2,000,000 ANY AUTO $ Included OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EXCESS LAB CLAIMS -MADE DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANYPROPRIETOR/PARTNER/EXECUTIVE ”' OFFICERIMEMBEREXCLUDED? (Mandatory in NH) N I A If yes, describe under DESCRIPTION OF OPERATIONS below MEQ EXP (Anv one Gerson) $ 5,0013 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGO $ Included Errors & Omissions $ Included ,CCINI.9NNED SINGLE: 1. MI r $ (Err vxid*n?) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Pcr I,accideno EACH OCCURRENCE AGGREGATE $ $ PER Oily STATUTE L', l'? E L EACH ACCIDENT $ EL DISEASE - EA EMPLOYEE $ E,L DISEASE -POLICY LIMIT .$ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Regarding the above referenced General Liability Insurance policy, the certificate holder is included as additional insured, but only with respect to the negligent acts, errors or omissions of the named insured. i 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 348 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE Lin Dau Diaz ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD COMMERCIAL LIABILITY COVERAGE PART DECLARATIONS Policy Number: NPP8622746 Effective Date: 12 / 17 / 2 0 2 0 12:01 AM, Standard Time COMMERCIAL GENERAL LIABILITY - LIMITS CE INSURANCE General Aggregate Limit (Other Than Products -Completed Operations) $ 2,000,000 Products - Completed Operations Aggregate Limit $ Included t Personal and Advertising Injury Limit $ 1,000,000 Any One Person or Organization Each Occurrence Limit $ 1,000,000 Damage to Premises Rented to You $ 100,000 Any One Premises Medical Expense Limit $ 5,000 Any One Person Each Professional Incident Limit (if applicable) $ Included t If the Limit is shown as Included, Products -Completed Operations are subject to the General Aggregate Limit. PREMIUM' Premium I Rate Advance Premium Classification Code No. Basis Pr/Co I All Other Pr/Co I All Other p.w i a,,<a,r9�i„j�n„!I I'n„�, i,uv ,.:,,',,; ,,"„'.i rl lo• Irrl F1Ij ,.•,I Il i,t.11r i,Vi!.I Total Advance Premium $ soo.00 I=OIR1 S AND ENDORSE MEII Forms and Endorsements applying to this coverage part and made part of policy at time of issue: See Schedule of Forms and Endorsements THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD. WVV232 (01/12) a,.;. CALIFORNIA w INSURANCE CARD State Farm Mutual Automobile Insurance Company PO Box 853919 Richardson, TX 75085-3919 INSURED TIE ANN, STEV MUTL VOL POLICY NUMBER INVOOPPIWANOP EFFECTIVE YR 2019 MAKE JEEP SEP 29 2020 TO MAR 29 2021 MODEL WRANGLER VIN AUNT MER E?ITFI THOMPSON 1317-AED PHONE- MAIC 25178 COVERA0 FR V1L1EC BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAM. COVERAGES A C U1000 G1000 H U U1 SEE REVERSE SIDE FOR AN EXPLANATION, 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 § 3705, 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 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 # 1 certify that,, in the performance of the work setforth 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 0. should become object tri the workers' compensation provisions of Labor Code § 3700 1' must immediate) comply with those r V e a� ent w will' automaticaGly become void Y pY p Signature of Applicant dons orf Date I " $ Print Namena�� Agreement for: p 19 ('r�on R�in,s V t, Dated: Reviewed by: .x° .