PROOF OF INSURANCE (2021) CLOSEDDATE(MM/DD/YYYY)
AcbRa CERTIFICATE OF LIABILITY INSURANCE
2/3/2021
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 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, Mary Strohman
Kessler Alair Insurance Services, Inc PAhwo Exa: (909) 931-1500 Nd, Isoslssz-zlss
(License # OA 91387 EMAIL'
ADDRESS,mstrohman@kessleralair.com
12487 N. Mainstreet, Ste. 240 INSURER(S) AFFORDING COVERAGE NAIC #
Rancho Cucamonga CA 91739 INSURER A:Philadel hia Insurance
..................._......... ........ ..... p....... ...............
INSURED INSURER_B:Employers Preferred Ins Co (#1709000) 11512
Revenue & Cost Specialists, LLC INSURERC:
1519 E. Chapman Ave., Suite C INSURERDr
INSURER E :
Fullerton CA 92831-3623 INSURERF':
COVERAGES CERTIFICATE NUMBER:2020-21 GL AUTO PROF & WC 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 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 L UBR POLICY EFF POLICY EXP
........... ..............
1.7R TYPE OF INSURANCE POLICY NUMBER MM/DDlVVVV MMdDO/Y tl
LIMITS
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$
1,000,000
AMA "L"U N'T� """.$
A CLAIMS -MADE � OCCUR
PREMISES.._L9a .occurrence),
500,000
X PHBX20001810 12/31/2020 12/31/2021
MED EXP (Any one person)
S
10,000
PERSONAL 8 ADV INJURY
--..............
$
1,000,000
GENLAGGREGAT.E LIMIT APPLIES PER:
GENERALAGGREGATE
$
3,000,000
X PRO.
%{ POLICY JEC,T LOC
uPRODUCTS COMP/OPAGG
S
2,000,000
01HER I
Hired/borrowed
$
1,000,000
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
Ea accident
S
BODILY INJURY (Per person)
$
ANYAUTO
A
ALL OWNED SCHEDULED
AUTOS AUTOS
pHBX20001810
12/31/2020
12/31/2021
BODILY INJURY (Per accident)
S
NON -OWNED
PROPERTY DAMAGE
Per acddanti
$
HIREDAUTOS AUTOS
S
X
UMBRELLALIAB OCCUR
EACH OCCURRENCE
$
1,1000.,000.
A
EXCESS LIAB X CLAIMS -MADE
AGGREGATE
S
1,000,000
X
12/31/2020
12/31/2021
DED RETEN' $ 10,000
PHUB750890
$
WORKERS COMPENSATION
OTH-
X TAT 117 J ER
AND EMPLOYERS' LIABILITY YIN
I
m_
ANY PROPRIETOR/PARTNERIEXECUTIVE
EL EACH ACCIDENT
$
1,,000,000
OFFICER/MEMBER EXCLUDED? ❑NIA
B
(Mandatory in NH)
EIG2980i42-01
12/31/2020
12/31/2021
E.L.DISEASE -EA EMPLOYEE
$
000,000
IF yes, describe under--------�
1_$
DESCRIPTION OF OPERATIONS below
E.L DISEASE - POLICY LIMIT
1 000 000
A
'.. Professional Liability
12/31/2020
12/31/2021
Liability Each Clairn Ind Exp
$1,000,000
''.. Retro Date 04/27/1990
PHSD1509358
$2,500 Ded-Annual Aggregate
$2,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Additional Insured is City of El Segundo, it's officers, officials, employees and
volunteers as per
attached, PI-BOP-001 (01-18),
CERTIFICATE HOLDER
CANCELLATION
pharada@elsegundo.org
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ATTN: Paricia Harada, City Clerks Office ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE pp ,
Mary S t: r Chm n / IA IR Y Y1laS. { C. �7t1sl.rn�+n�
1988.2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INS025 (201401)
Philadelphia Indemnity Insurance Company
PI-BOP-003 (01/18)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
A. SECTION II —LIABILITY, C. Who Is An Insured is amended to include the following as an additional
insured:
Any person(s) or organization(s) for whom you are performing "your work" under a written contract or
agreement, that requires such person(s) or organization(s) to be added as an additional insured on
your policy. Such person(s) or organization(s) is an additional insured only with respect to liability for
"bodily injury", "property damage" or "personal and advertising injury" occurring after the effective date
of such contract or agreement that is caused, in whole or in part by:
a. Your acts or omissions; or
b. The acts or omissions of those acting on your behalf;
in the performance of "your work" for the additional insured.
Coverage for an additional insured under this endorsement ends when "your work" for that additional
insured ends or is put to its intended use by any person or organization.
B. The following is added to SECTION II — LIABILITY, B. Exclusions, 3. Applicable To Both
Business Liability Coverage And Medical Expenses Coverage — Nuclear Energy Liability
Exclusion with respect to this endorsement only:
There is no coverage under this endorsement for loss or expense, including but not limited to the
cost of defense for "bodily injury", "property damage" or "personal and advertising injury"
occurring:
a, After all of "your work", including materials, parts or equipment furnished in connection with
"your work" and performed under the above referenced written contract(s) or agreement(s)
has ended; or
b. When that portion of "your work" out of which the "bodily injury", "property damage" or
"personal and advertising injury" arises and performed under the above referenced written
contract(s) or agreement(s) has been put to its intended use by any person or organization;
whichever occurs first.
PI-BOP-003 (01/18)
Page 1 of 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 § 3706, INTEREST, AND ATTORNEY'S FEES.
I affirm under penalty of perjury under the laws of California one of the following declarations:
O 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 El 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 El Segundo is executed. My workers' compensation insurance
carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone #
( I certify that, in the performa c�. of the work set forth in the agreement with the City of El Segundo, II' will not
mploy any person in any ma ne y so Ms to become subject to the workers' compensation laws of California, and
agree that, if I should bec su j,ec to the workers' compensation provisions of Labor Code § 3700 1 must
9 pp th agreement will automatically become void.
immediately comply with � ose p ov � Date
Signature ofA Applicant o or .._�......_ ._.. me ......... .. . .. .....�
Agreement for:
r'
Dated:..
Reviewed b y,