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PROOF OF INSURANCE (2022 - 2022) CLOSED2281189 Mainstream Unlimited Certificate Of Insurance 2/9/2021 5:34:59 PM Ate0 DATE (MMIDDIYYYY) ' CERTIFICATE OF LIABILITY INSURANCE 2/9/2021 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 riahts to the certificate holder in lieu of such endorsement(s). I --] PRODUCER NAM1=, th (800) 688-1984 FAX No)c 877 826 9067 insureon E-MAIL Insureon (BIN Insurance Holdings LLC.) ADDRESS ..... 30 N. LaSalle, 25th Floor, Chicago, IL 60602 INsuRERIS) AFFORDING COVERAGE ......... NAIC # ... _ INSURER A : Ph„iladel hia, Indemny Insurance Company p it .. INSURED INSURERB: HISCOX ..... .................... Mainstream Unlimited INSURER_C 37159 Galena Cir, Burney, CA, 96013 INSURER D : INSURER E INSURER F : i f'r%A. te=D A r11:0- f C{7T6CIr A.T= hIllill Pf:VI:C'Ir Ni NIIMRrr Pti 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. ....... ..........TYPE OF INSURANCE 1 POLICY.... iAlibr wSO R' ..� .... PlyLl�'Y E P...... IPd1Ld �...�......,. e........ ,,.. ... t INSR NUMBER MMIDD/YYYY I MPDTDPYYYY LIMITS LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE i $ 2,000 000 CLAIMS -MADE 1 ✓m OCCUR P,R.¢N.. r wPrrane). $ 50,000 MED EXP (Any one person) $ 5 000 ...,. ,.,,..., g _. ...... ................... ---- ..........ee. I .......................... 2,000000 Yes PERSON UDC-1694215-CGL-21 2/3/2021 2/3/2022 AL & $ . . ADV.. _...�,......^1. GEN'L ... .. AGGREGATE LIMIT APPLIES PER GENERAAGGREGATE $ 2,000000 LOC .INJU...R.Y.. 2,000 000PO- $POLICY E ..m.. e- ... .. OTHER' 1 $ AUTOMOBILE LIABILI N LE LIMIT $ I �TY 9OmMEC�IcNucfFeOnt5. ANY AUTO PODILY INJURY Per person I $ ALL J SCHEDULED i, ODILYINJURY (Per AUTOS y .- ,-I NON -OWNED ..- ! RPPFFYY CTAMAE' ........ �. $ HIREDAUTOS AUTOS Per,al,:a;u rrc{ 1 ..t;. ._.� € $ J UMBRELLA LIAR OCCUR { EACH OCCURRENCE ,yy $ ...... ......... ... ---- ........I EXCESS LIAB CLAIMS -MADE" 1 AGGREGATE $ ............ ,,,, ...�., - ----� f DED RETENTION $ I 1 $ WORKERS COMPENSATION '- PER Ulm - AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE — OFFICER/MEIMBEREXCLUDED? J J EL EACH ACCIDENT I$ NIA (Mandatory in DISEASE -EA . E, fgy�esadeswitefundsp ,O 'SCRtlPTIONOFOP'E'R'ATIONSoebw EL DISEASE-POLIC'EL YLIOMIT $ A Professional Liability (Errors and Omissions) i PHSD1587686 2/4/2021 21412122 Occurrence/Aggregate $1,000,0001$2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more apace is required) Certificate Holder is named as Additional Insured as their interests may appear in regards to general liability. This insurance is primary and non-contributory to any other insurance provided as respects general liability coverage. CERTIFICATE HOLDER k ANctL.L.A I [Uri City of El Segundo 350 Main Street El Segundo, CA 90245 attn:Liana Osborne SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 19BB-2014 ACORD CORPORATION. All rights reserveo. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Policy Number: Named Insured: Endorsement Number: Endorsement Effective U DC-1694215-CGL-19 Mainstream Unlimited 8 February 03, 2019 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - AUTOMATIC STATUS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any per- son(s) or organization(s) for whom you are performing operations or leasing a premises when you and such person(s) or organiza- tion(s) have agreed in writing in a contract or agreement that such person(s) or organiza- tion(s) be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to lia- bility 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 omissions of those acting on your behalf: 1. In the performance of your ongoing opera- tions; or 2. In connection with your premises owned by or rented to you. A person's or organization's status as an addi- tional insured under this endorsement ends when your operations or lease agreement for that additional insured are completed. CGL E5421 CW (02/14) Includes copyrighted material of Insurance Services Office, Inc., with its Page 1 of 1 permission. Am H J CO Policy Number: Named Insured: Endorsement Number: Endorsement Effective UDC-1694215-CGL-19 Mainstream Unlimited 16 February 03, 2019 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. go, 9-2-ROA, • • ' • This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE 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 © ISO Properties, Inc., 2004 Page 1 of 1 DATE (MM/DD/YYYY) A � CERTIFICATE OF LIABILITY INSURANCE e 02/09/2021 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 endorsement(s). PRODUCER CONTACT NAME. _ FA7C Hiscox Inc. d/b/a/ Hiscox Insurance Agency in CA (HONE (888) 202-3007 Arc N > _fA1-�Cka�.xt4s C..r�. p... . _. 520 Madison Avenue EMAIL contact@hiscox.com 32nd Floor ADr_IaE_ss ..._.._._ °�.. New York, NY 10022 NAIc u_ INSURERA: Hiscox Insurance Company IncG.E.................................................m._....,.... 10200 INSURED Mainstream Unlimited 37159 Galena Cir Burney, CA 96013 INSURER B INSURER C INSURER D :. INSURER E t INSURER F : 1" n%1=17AP CQ CFRTIFICATF NI IMRPR• REVISION NUMRFR' 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���-... POLICYEFFf PO ICY' E7tP 'L7R TYPE OF INSURANCE r I POLICY NUMBER �:MMIDD/YYYY MMIOD/YYYY LIMITS COMMERCIAL GENERAL ,( CEreaa�,y.ea... 0.......- ....-._. X I 100,000 nX CLAIMS -MADE OCCUR PS $ Any one parson) $ 5,000 t UDC-1694215-CGL-21A Y 02/03/2021 02/03/2022 PERSONAL BADVINJURY $2. ,mm0m00 000 ._ AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 _GEN°L X.,. POLICY �._...,...] Cif .....I LOC PROCJUGTS COMP/OP AGG $S/T Gen. Agg...m OTHFR' $ LIABILITY { COMBINEDAUTOMOBILE QC m asq r SINGLE L.IiMOT $...... ._ ANY AUTO BODILY INJURY (Per person) $ OWNED h I SCHEDULED AUTOS ONLY ,� AUTOS HIRE l NON-OWNED 1 UDC-16942 5- -2 I 0 accident) OAMA%E $ X ONLY ONLY (WCh'PERT"d Peo ti c ieYll $ 4a GDItl NLYI(Per . _. _ rco�c $ 1,000,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE .AGGREGATE $ ULD RETENTION $ $ WORKERS COMPENSATION L... STA„TLITFOR_,H AND EMPLOYERS' LIABILITY Y / N 1, .-,.-- .....--... „ ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? N / A ,E.L EACH ACCIDENT - $ — „�... (Mandatory in NH) i I E.L DISEASE - EA EMPLOYEE $ ...... .. If yes, describe under DESCRIPTION OF OPERATIONS below i J, EL, DISEASE- POLICY LIMIT $ I I I i DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule, may be attached if more space is required) Consulting CERTIFICATE HOLDER CANCELLATION City of El Segundo City of El Segundo CA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©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 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 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 # (X) I 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 workers' compensation provisions of Labor Code § 3700 1 must immediately comply with t r visions or the agreement will automatically become void. Signature of A is nt ' Date % Z z / 9 Print Name Agreement for: : �� my Dated: y Reviewed by: