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PROOF OF INSURANCE (2021 - 2022) CLOSED
.,, CERTIFICATE LIABILITY DATE (MM/DD/YYYY) 12/1812020 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 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). PRODUCER CONTACT NAME: PRESIDIO FIN AND INS SOLUTIONS 72256527 I PHONE (805) 499-7300 FAX (805) 499-7070 31365 OAK CREST DRIVE 225 (A/C, No, Ext): (A/C, No): WESTLAKE VILLAGE CA 91362 E-MAIL ADDRESS: IINSURER INSURED INSURER B; DROP FUSION IV INSURER C: 937 CYPRESS ST i EL SEGUNDO CA 90245-2419 1 INSURER D: INSURER E: INSURER F: INSURER(S) AFFORDING COVERAGE NAIC#f Sentinel Insurance Company Ltd. 11000 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 I POLICY NUMBER POLICY EFF POLICY EXP LIMITS I LTR INSR VAIn fuminnewvvi reaasr - COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OOCCUR X General Liability A Ix GEN'L AGGREGATE LIMIT APPLIES PER: POLICY❑ PRO" ❑ LOC JECT OTHER: AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED _ AUTOS AUTOS HIRED NON -OWNED AUTOS AUTOS _ UMBRELLA LIAR OCCUR EXCESS LIAR CLAIMS - MADE DED1 1 RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY YIN PROPRtETOR/PARTNERIEXECUTIVE Ni A OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe Under DESCRIPTION OF OPERATIONS below EACH OCCURRENCE DAMAGE TO RENTED PRF_MISES IEa omurrence) MED EXP (Anyone person) 72 SBABD7391 02/01/2021 02/01/2022 PERSONAL&ADV INJURY GENERAL AGGREGATE PRODUCTS - COMP/OP AGG COMBINED SINGLE LIMIT 1 {Ea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) { EACH OCCURRENCE AGGREGATE 1 PER {{1 ISTATUTC I IORH E.L. EACH ACCIDENT E.L. DISEASE-EAEMPLDYEE E.L. DISEASE - POLICY LIMIT $2,000,0001 $1,000,0001 $10,0001 $2,000,000+ $4,000,000 $4,000,0001 DESCRIPTION OF OPERATIONS / LOCA TIONS /VEHICLEv (ACORD 101, Additional Remarks Sceedule, maybe attached if more space is required) Those usual to the Insured's Operations. Certificate holder is an additional insured per the Business Liability Coverage Form SS0008, attached to this policy. CERTIFICATE HOLDER CANCELLATION City Of EI 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. AUT14OR1IZEED REPRESENTATIVE O 1988-2015 ACORD CORP TIO . AI fights res ed. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 2,03111, M W11,111,111, %w Me! This endorsement changes the policy effective on the Inception Date of the policy unless another date is indicated below: PollcyNurnber: 72SBA BD7391 SC Named Insured and Mailing Address; DROPFUSION TV 937 CYPRESS ST EL SEGUNDO CA 90245 Policy Change Effective Date: 02/01/21 Effective hour is the same as stated in the Declarations Page of the Policy. Policy Change Number: 001 AgentName. PRESIDIO FIN AND INS SOLUTIONS Code: 256527 POLICY CHANGES: SENTINEL TNSURANCE CO-MPPNY, LIMITED ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING STATEMENT.IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BUNTS ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A BILL. NO PREMIUM DUE AS OF POLICY CHANGE EFFECTIVE DATE LIABILITY AND MEDICAL EXPENSES ARE REVISED LIABILITY AND MEDICAL EXPENSES LIMIT IS CHANGED FROM $1,000,000 EACH OCCURRENCE TO $2,000,000 EACH OCCURRENCE PERSONAL AND ADVERTISING INJURY LIMIT IS CHANGED FROM $1,000,000 TO $2,000,000 PRO RATA FACTOR: 1.000 THIS ENDORSEMENT DOES NOT CHANGE THE POLICY EXCEPT AS SHOWN. Form SS 12 1104 05 T Page ool (CONTINUED ON NEXT PAGE) process Rate: 12/18/20 Policy Effective Date: 02/01/21 Policy Expiration Date: 02/0-1/22 11 This endorsement changes the policy effective on the Inception Date of the policy unless another date is indicated below: Policy Number: 72SBA BD7391 SO Named Insured and Mailing Address; DROPFUSION IV 937 CYPRESS ST EL SEGUNDO CA 90245 Policy Change Effective Date: 02/01/21 Effective hour is the same as stated in the Declarations Page of the Policy. Policy Change Number: 002 AgentNate: PRESIDIO FIN AND INS SOLUTIONS Code: 256527 POLICY CHANGES: SENTINEL INSURANCE COMPANY, LIMITED ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING STATEMENT.IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BANK ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A BILL. NO PREMIUM DUE AS OF POLICY CHANGE EFFECTIVE DATE BUSINESS LIABILITY OPTIONAL COVERAGES ARE REVISED ADDITIONAL INSURED(S) ARE ADDED THE FOLLOWING ARE ADDITIONAL INSURED FOR BUSINESS LIABILITY COVERAGE IN THIS POLICY. LOCATION 001 BUILDING 001 PERSON/ORGANIZATION: SEE FORM IH 12 00 FORM NUMBERS OF ENDORSEMENTS ADDED AT ENDORSEMENT ISSUE: PRO RATA FACTOR: 1.000 THIS ENDORSEMENT DOES NOT CHANGE THE POLICY EXCEPT AS SHOWN. For SS 1211 05 T Page 001 (CONTINUED ON NEXT PAGE) ProcessDate: 12/18/20 Policy Effective Date: 02/01/21 Policy Expiration Date: 02/01/22 Policy Number: 72 SPA BD7391 AGGREGATE LIMITS: PRODUCTS -COMPLETED OPERATIONS AGGREGATE LIMIT IS CHANGED FROM $2,000,000 TO $4,000,000 GENERAL AGGREGATE LIMIT IS CHANGED FROM $28000,000 TO $4,000,000 Form SS 12 1104 05 T Page 002 Prose ssDate: 12/18/20 Policy Effective Date: 02/01/21 Policy Expiration Date- 02/01/22 M i 2,11 7 D, 111,T1,120,11, lll', <.,. r , �.. ADDITIONAL INSURED - PERSON -ORGANIZATION LOC 001 BLDG 001 CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO, CA 90245-3813 Form IH 12 00 1185 T Q. NO. 0 01 Printed in U.S.A. Page 0 01 Process Date; 12/18/20 ExpirationDate: 02/01/22 ACO 12/23/2020 ® CERTIFICATE F LIABILITY INSURANCE I DATE(MM12020 Y, �i- 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 I CONTACT Janet Ramirez NAME: Merriwether &Williams Insurance Services PHONE (213) 258-3096 FAX (213) 258-3096 (AIC, No, Ext): I (AIC, No): License No.: 0001378 I E-MAIL ADDRESS: jramirez@imwiS.com 550 Montgomery St., Suite 550 I INSURER(S)AFFORDING COVERAGE NAIL# San Francisco CA 94111I INSURERA: United Financial Casualty Co. 11770 INSURED INSURER B; DropFusion IV INSURER C : 939 Cypress Street (INSURER D: INSURER E: EI Segundo CA 90245 I INSURER F: COVERAGES CERTIFICATE NUMBER: CL20122316542 REVISION NUMBER: THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FORTHE 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 ADDL'SUBR POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE POLICY NUMBER LTR INSD WVD (MM/DD/YYYY) (MMIDDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ r_1 DAMAGE 10 RENTED ( CLAIMS -MADE OCCUR PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMITAPPLIES PER: I GENERAL AGGREGATE $ POLICY ❑ JECT PRO F-1LOC I PRODUCTS-COMP/OPAGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 ANYAUTO I BODILY INJURY (Per person) $ A OWNED XSCHEDULED Y 03051485-0 12/23/2020 06123/2021 I BODILY INJURY (Per accident) $ AUTOS ONLY HIRED X X AUTOS NON -OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAR OCCUR HCLAIMS-MADE EACH OCCURRENCE $ EXCESS LIAB AGGREGATE $ DED I I RETENTION $ $ _ WORKERS COMPENSATION PER H I STATUTE I I ER AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE NIA ( E.L. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? ❑ I (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) The Certificate Holder is named Additional Insured but only as respects to the Named Insured's operations. f- - 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,its officers,officials,employees ACCORDANCE WITH THE POLICY PROVISIONS. agents, and volunteers AUTHORIZED REPRESENTATIVE 350 Main St. 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 CITY OF EL SEGUNDO I WORKERS' COMPENSATION DECLARATION IRRIM 11 IIIN HUM vtc-�7,n-vf nis V-myv.� aw # N-Awnwc- 9 rYN--- IVIIVRI WAM' with the City of El Segundo. of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone # (_/ certify that, in the performance of the work set forth in the agreement with the City of El 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-, c . ensation provisions of Labor Code § 3700 1 must immediately comply with those provisions" meat will�utomatically become void. Signature of Applicant Date Agreement for: Drop Fusion - Agreement No. 5993 Reviewed by: