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PROOF OF INSURANCE (2021 - 2021) CLOSEDALCOR" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/OD/YYYY) I 10/30/2020 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). PRODUCER (CONTACT NAME: Hiscox Inc. d/b/a/ Hiscox Insurance Agency in CA PHONEFAX (A/C. No. Ext1: (ggg ) 202-3007 (A/C, No): 520 Madison Avenue ADDRESS: contact@hiscox.com 32nd Floor New York, NY 10022 INSURED IMGB Solutions 9506 Karmont Ave South Gate CA 90280 INSURER(S) AFFORDING COVERAGE INSURERA: Hiscox Insurance Company Inc I INSURER B: INSURER C: INSURER D: NAIC # 10200 I 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INsn WVn POLICY NUMBER IMM/DD/YYYYI IMM/DD/YYYYI LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR A Y GEN'L AGGREGATE LIMIT APPLIES PER: POLICY [:]PRO [:]LOC JECT OTHER: AUTOMOBILE LIABILITY ANY AUTO OWNEDSCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLALIAB OCCUR EXCESS LAB HCLAIMS-MADE DED I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRI ETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 UDC -1506408 -CGL -20 10/24/2020 10/24/2021 PERSONAL &ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ S/T Gen. Agg. COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTYDAMAGE $ (Per accident) EACH OCCURRENCE $ AGGREGATE $ PER STATUTE EERH E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of EI Segundo is an addtional insured CERTIFICATE HOLDER CANCELLATION City Of EI Segundo 350 Main St SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EI Segundo, CA 90245 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I � ' @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 4AM H I SCOX Policy Number: Named Insured: Endorsement Number: Endorsement Effective: UDC -1506408 -CGL -19 IMGB Solutions 17 October 24, 2019 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) City of EL Segudo, its officers, employees, agents and volunteers 350 Main St EI Segundo,CA 90245 Information required to complete this Schedule, if not shown above, will be shown in the Declarations Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s) or organi- zation(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omis- sions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 C ISO Properties, Inc., 2004 Page 1 of 1 ALCOR" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/OD/YYYY) I 10/30/2020 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). PRODUCER (CONTACT NAME: Hiscox Inc. d/b/a/ Hiscox Insurance Agency in CA PHONEFAX (A/C. No. Ext1: (ggg ) 202-3007 (A/C, No): 520 Madison Avenue ADDRESS: contact@hiscox.com 32nd Floor New York, NY 10022 INSURED IMGB Solutions 9506 Karmont Ave South Gate CA 90280 INSURER(S) AFFORDING COVERAGE INSURERA: Hiscox Insurance Company Inc I INSURER B: INSURER C: INSURER D: NAIC # 10200 I 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INsn WVn POLICY NUMBER IMM/DD/YYYYI IMM/DD/YYYYI LIMITS COMMERCIAL GENERAL LIABILITY = CLAIMS -MADE 1:1 OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY [:]PRO [:]LOC JECT OTHER: AUTOMOBILE LIABILITY ANY AUTO OWNEDSCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLALIAB OCCUR EXCESS LAB HCLAIMS-MADE DED I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRI ETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below A Professional Liability Y EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTYDAMAGE $ (Per accident) EACH OCCURRENCE $ (AGGREGATE $ PER STATUTE EERH E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ UDC -1506408 -EO -20 10/24/2020 10/24/2021 Each Claim: $ 1,000,000 Aggregate: $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City Of EI Segundo is an addtional insured CERTIFICATE HOLDER CANCELLATION City Of EI Segundo 350 Main St SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EI Segundo, CA 90245 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I � ' @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Get your digital proof of insurance & membership card on the AAA App X>IDownload the app. Click AAA.com/app75 Jil i�' � lui tll h,il,"� II u I ��, il,u+ � I i ui it '��,u wl i III ,ii ruu di 'r 9i ;''��„lu ii iw i1 ii",i1i�1,� c;I, li a I,i I i r'ir i II� a d tl ��,� I n i i -i;,, PROOF OF INSURANCE VEHICLES ON POLICY + Interinsurance Exchange of the Automobile Club YEAR MAKE VEH I.®- # ' NAIC#:15598 2012 VLKS NEW JETTASE 3VWDP7AJ1CM377075 I 2012 TYTA PRIUS PHEV JTDKN3DP2C3008610 p Named Insured Policy Number: CAM 07391418 2019 HOND CIVIC EX -L 19XFC1F7XKE202947 GABRIEL BARRIENTOS 2019 VLVO XC90 I � ua w T 0 DRIVERS ON POLICY O BARRIENTOS, GABRIEL rL Effective Date: 06/16/2020 Expiration Date: 06/16/2021 ; KRASIKOVA, VIKTORIIA This policy provides at least the minimum amounts of liability insurance required by the CA VEH CODE SECTION 16056 for the specified vehicles i' and named insureds, Coverage subject to policy terms and limits, ----------------------------------------------------------------------------------------------------------------- IF YOU HAVE AN ACCIDENT CALL OUR 24/7 AAA ACCIDENT ASSIST HOTLINE 1-800-672-5246 After an accident, exchange information with the other party and I follow these 5 easy steps: Step 1: Pull vehicle over to a safe place, Get the names, addresses, Step 4: Take photos of the vehicles involved, damages and and phone numbers of all persons involved in the accident, e , w surrounding area of the accident, if it is safe to do so. pedestrians, witnesses, other passengers, etc. w = Step 5: Call our AAA Accident Assist Hotline at 800-672-5246 to wStep 2: Take photos of or write down the other person's driver's o report the loss, If necessary, we will arrange to have your vehicle towed. a license information and other vehicle's license plate number, Il Our provider's tow trucks always display the AAA emblem, including state of registration Do not admit responsibility for or discuss the circumstances of the accident Step 3: Take photos of or write down the other person's insurance with anyone other than the police or an authorized Auto Club claims card information. representative. Do not disclose your policy limits to anyone I For questions or changes to your policy, call 1-877-422-2100, Monday through Friday from 7 a m to 9 p m or Saturday from 8 a m to 5 p m Place a Proof of Insurance card in each vehicle insured under your policy. In addition, we suggest that each listed driver carry a card. Under California law, Call our AAA Accident Assist drivers and owners of a motor vehicle must be able to show proof of financial Hotline at 1-800-672-5246 responsibility at all times. These cards become invalid and should be destroyed on the expiration or termination date of the policy„ �..----__.._..----_-___-----_____........_..-----------------------......_...----.........._.__ uNCE...... PROOFINSURANCE ®___.__...____ ___---T VEHICLES ON POLICY - .", Interinsurance Exchange of the Automobile Club YEAR MAKE VEH I.D, # VIv,j' NAIC #: 15598 2012 VLKS NEW JETTASE 3VWDP7AJ1CM377075 2012 TYTA PRIUS PHEV JTDKN3DP2C3008610 Named Insured Policy Number: CAA107391418 2019 HOND CIVIC EX -L 19XFC1 F7XKE202947 GABRIEL BARRIENTOS 2019 VLVO XC90 T6 INSCRIPTION YV4A22PL6K1449543 I w w w o r I ❑ DRIVERS ON POLICY r O BARRIENTOS, GABRIEL Effective Date: 06/16/2020 Expiration Date: 06/16/2021 i KRASIKOVA, VIKTORIIA 1 u This policy provides at least the minimum amounts of liability insurance o I required by the CA VEH CODE SECTION 16056 for the specified vehicles i and named insureds Coverage subject to policy terms and limits. I u IF YOU HAVE AN ACCIDENT CALL OUR 24/7 AAA ACCIDENT ASSIST HOTLINE 1-800-672-5246 d I I After an accident, exchange information with the other party and I I n follow these 5 easy steps: w a r Step 1: Pull vehicle over to a safe place, Get the names, addresses, Step 4: Take photos of the vehicles involved, damages and p and phone numbers of all persons involved in the accident, e,g., w surrounding area of the accident, if it is safe to do so pedestrians, witnesses, other passengers, etc- w p = Step 5: Call our AAA Accident Assist Hotline at 800-672-5246 to Step 2: Take photos of or write down the other person's driver's report the loss. If necessary, we will arrange to have your vehicle towed r o license information and other vehicle's license plate number, Our provider's tow trucks always display the AAA emblem Including state of registration, Do not admit responsibility for or discuss the circumstances of the accident v Step 3: Take photos of or write down the other person's insurance with anyone other than the police or an authorized Auto Club claims card information. representative. Do not disclose your policy limits to anyone, I I For questions or changes to your policy, call 1-877-422-2100, Monday through Friday from 7 a m to 9 p rn or Saturday from 8 a m to 5 p.m Iaa2� _�..._��........��_..__.....,.�.�. E2�6152�__.._,___.._-_..__..._...._...._-_---_-_..___..----_.. _--------------------------------------------- _�_�_�_, ..___-- 8165(3/19) 062220 W 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: (_) 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 forthe 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 # (_4X .) 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 th?se provisions or the agreement will automatically become void. Signature of Applicant "o^" µ Date 02/01/19 ��i��' tiil�►n ° ��rv�e� -- gyp,--r� Agreement for- Dated:-3/ or:Dated:-3 Reviewed b :. Y .K�,