PROOF OF INSURANCE (2021 - 2022) CLOSEDDATE (MMIDDIYYYY)
C" CERTIFICATE OF LIABILITY INSURANCE 02/01/2021
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 endorsements .
PRODUcER CONTACT Elizbaeth Flinders
Flinders/DePalma Insurance Agency PHONE """ _" .. .. TFAz
P.O. Box 510 (818)843-8600 (818)566 9841
e%C No,.Eafl
E•MAiL liz@flindersins.com
Burbank CA 91503- Atat�Es — Ire O�tlh.ndersl... ........ .. .... T
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 ADDL SR. -w__ ....,.... .... .... - .. POLICY EFF ...........------. .....� �.........._
INSURANCE POLICY EXP LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
CCP938084
02/06/2021
2/06/2022
EACH oCCURRENCE �, 2,000,000
X
DAMAGE RENT
TO 100,000
CLAIMS -MADE OCCUR
uQ); g _
�
5,000
MEDEXPtAny,anepe{song �
.—
._._,_.
.e......
1 000 000
PIy,RSONAL. BADV INJURY $ 0
� ...
N"sIEI�YL
__ ......
'LIMIT APPLIES PER
AGGREGA.IE LIMIT
,, GP�I�IERALAGGREGATE $ 2,000,000
. _ $
�X
PRO- �
LOC
F 1.�0DY J5CPIR
included
'—OMPIOI? AGG $._.__ .....
deductible 500
B AUTOMOBILEGLE
06342952-3
4
11/22/2020
'11/22/2021
COMBINEDSINGLE LIMIT1,000,000
$ __
ANYAUTOABILITY
Y
BODILY INJURY (Per person)
..__
$ ..
OWNED SCHEDULED
BODILY INJURY (Per accident)
$
— AUTOS ONLY .. AUTOS
NON -OWNED
--
PROPERTY
nt)DAMAGE
""""HIRED
$
AUTOS ONLY AUTOS NLY
=cd
LIAB (
$
UMBRELLA OCCUR
1 EXCE: SLIAB — C,LAIMS,MADE
,......._ _.. II
EGCH OCCURRENCE ......--
AAGREGATE,,, ___�
$ .,..,.,.. ...
�.
WORKERS COMPENSATION
PER OTH
STATUSE. EFL..._
_...__ .....
AND EMPLOYERS' LIABILITY
.....
ANY PROPRIETOR/PARTNER/EXECUTIVE
E:l.. EACH AQGIRENT
S ___
OFFICERIMEMBER EXCLUDED?
(Mandatory in NH)
N / A
- ... E
E ( IIJSE&K_.EA EMPLQXE,,,
_-
If yes, describe under glow-
E.L. DISEASE - POLICY LIMIT
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
City of El Segundo is named as an additional insured on the General Liability policy as per written contract. Endorsement attached.
tl'-'.Ahrf^=l 1 A.'RIi fx!
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of El Segundo
ACCORDANCE WITH THE POLICY PROVISIONS.
348 Main Street
ElSegundo CA 90245-
AUTHORIZED REPRESENTATIVE
v
i
V 1VOU-LUT0AUUKU VUKYUKAIwIN. Au rlgmlLS reserves.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
Policy # CCP938084
COMMERCIAL GENERAL LIABILITY
CG 20 10 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES O
CONTRACTORS - SCHEDULED PE SO O
ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
_._......� �........ ... __.....�. _.
Name Of Additional Insured Person(s)
Or Oreanizai ions yy Location(s) Of Covered Operations
I,
Information r wired to com lete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II — Who Is An Insured is amended to
include as an additional insured the person(s) or
organization(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:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your
behalf;
in the performance of your ongoing operations for
the additional insured(s) at the location(s)
designated above.
However:
1. The insurance afforded to such additional
insured only applies to the extent permitted by
law; and
2. If coverage provided to the additional insured is
required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
B. With respect to the insurance afforded to these
additional insureds, the following additional
exclusions apply:
This insurance does not apply to "bodily injury" or
"property damage" occurring after:
1. All work, including materials, parts or
equipment furnished in connection with such
work, on the project (other than service,
maintenance or repairs) to be performed by or
on behalf of the additional insured(s) at the
location of the covered operations has been
completed; or
2. That portion of "your work" out of which the
injury or damage arises has been put to its
intended use by any person or organization
other than another contractor or subcontractor
engaged in performing operations for a
principal as a part of the same project.
CG 20 10 04 13 0 hisurance Services Office, inc., 2012 (page 1 of 2
C. With respect to the insurance afforded to these
additional insureds, the following is added to
Section III — Limits Of Insurance:
If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the
applicable Limits of Insurance shown in the
Declarations.
IPage 2 of 2 C insurance Services Office, Inc,,I2012 CO 20 10 04 1
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 § 37016, 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 try Labor Code § 3700 for the performance of the work set forth the agreement
with the City of El Segundo.
Policy No.
(„ ) I have and will maintain workero' compensation insurance as required by Labor Code § 3700 for the performance
of the worts for which the agreementwith 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 #
(,,,'1 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 ro ns or Ore agreement will automatically become void.
Signature p�ii�arrylth those I�rovrsi rrs. �,��,. ,,.;mod- � _. Date /
Agreement for:
Dated:
Reviewed by: