PROOF OF INSURANCE (2021 - 2022) CLOSED2/5/2021
Policy Number: uDc-47296e4 Date Entered °2/5/2021nv Y)
CERTIFICATE OF LIABILITY INSURANCE
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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 NANTACT
ME, Eugene J Solomon
Solomon Insurance Agency
(PHONE' AX
(310)414-9409
(310)414 37
840 Apollo
PCIA Mp . yc, N
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ADDRESS: eugene@eugenesolomon. com
Suite306._....��_
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INSURER(S) AFFORDING COVERAGE
NAIC A
El Segundo, CA 90245
Insurance Company
INSURER AHiscox
INSURED IM Consulting LLC
INSURER B:
Kristen Bergevin
INSURER C„
1142 S Holt Ave
INSURERD:
Unit 3
INSURER E:
Los Angeles, CA 90035
INSURER F:
COVERAGES CERTIFICATE NUMBER'.
REVISION NUMBER:
THIS IS TO CERTIFY THA11 T 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
LTR'''
TYPE OF INSURANCE
'lid Si
VJV
POLICY NUMBER
POLICYIFP
MMI00/YYYY
POLICY EXP
MMIDDlYYYY
LIMITS
A
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
S 2,000,000
CLAIMS -MADE ® OCCUR
X
'UDC-4729684
02/OS/2021
02/OS/2022
PREM. SES Ea occurrence.
100,
S 000
m, I
MED EXP (Any one person)
$ 5,000
PERSONAL & ADV INJURY
5
GENT AGGREGATE LIMIT APPLIES PER
GENERAL AGGREGATE
S 2,000,000
POLICY PRO [— ECT ) LOC
J
PRODUCTS - COMPIOP AGG
S 2,000,000
t3THElfi:.
$
AUTOMOBILE LIABILITY
CUM — NFU uINCLL O WT
(F'ra ea CCs�plr0)
$
ANY AUTO
BODILY INJURY (Per person)
$
....m� OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per accident)
5
HIRED NON -OWNED
$
AUTOS ONLY AUTOS ONLY
(Per accdent)
S
UMBRELLA LIA.B'. OCCUR
EACH OCCURRENCE
5
1.—d
EXCESS LIAB CLAIMS -MADE
AGGREGATE
S
I DED I RETENTIONS
S
WORKERS COMPENSATION
H
STATUTE ER
AND EMPLOYERS' LIABILITY Y / N
ANY PRO PRIETO RIPARTN ERIEXEC UTIVE
E.L EACH ACCIDENT
S
OFFICER/MEMBER EXCLUDED? NIA
�--i
(Mandatory in NH)
E,L DISEASE EA EMPLOYEE( S
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE POLICY LIMIT
S
A Professional Liability X UDC-4729684
02/05/2021 02/05/2022
1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Public Relations Consulting
Certificate Holder is also listed as Additional Insured
CERTIFICATE HOLDER
CANCELLATION
City of El Segundo
350 Main Street
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
El Segundo Ca 90245
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
j
Policy Number:
Named Insured:
Endorsement Number:
Endorsement Effective:
U DC-4729684-CGL-21
KNB Consulting LLC
1
February 5, 2021
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.
For Roadside Assistance: 800-531 -8555
Report a claim, get coverage and deductible information, request a tow from the accident
scene, schedule an appraisal or reserve a rental car using:
usaa.com,
USAA's Mobile App, or
By calling 210-531-USAA (8722), our mobile phone shortcut number #8722 or
800-531 -USAA.
California Evidence of Financial Responsibility
This ID card is evidence of liability insurance for your vehicle. The card is valid only as long as liability
insurance remains in force. Keep a copy of the ID card in your vehicle at all times.
You may be required to produce your identification card at vehicle registration or inspection, when
applying for a driver's license, following an accident, or upon a law enforcement officer's request.
FCA1 Rem. 6-1 3 50781-0513,_02
------------------------------------------__-------_---.------_,..___r--------------.-----....-------b-a--- c--- k ----__--....--------.______
b
CALIFORNIA EVIDENCE OF FINANCIAL RESPONSIBILITY
Name and Address of Insured NAIC 25968
KRISTEN BERGEVIN
1142 S HOLT AVE APT 3
LOS ANGELES CA 90035-2423
KRISTEN BERGEVIN
Insurance Company
USAA CASUALTY INSURANCE COMPANY
Policy Number Effective Date Expiration Date
00748 27 03C 7101 1 12/01/20 06I01/21
Vehicle Make/VehiCte Identification Number Year
LEXUS 2009
This policy provides at least the minimum amounts of liability insurance
required by the CA VEH CODE SECTION 16056 for the specified vehicle and
named insureds and may provide coverage for other persons and other
vehicles as provided by the insurance policy.
California Evidence of Financial Responsibility
Keep this card.
IMPORTANT: The California Financial Responsibility
Act (Section 16020) of the Vehicle Code requires every
owner or operator of a vehicle subject to the
requirements of the Financial Responsibility Act to carry
evidence of financial responsibility in the vehicle at all
times. Under vehicle code (Section 16028) every driver
f involved in an accident must provide evidence of
o financial responsibility at the scene. Failure to comply is
I an infraction and shall be punishable by fines,
d impoundment or license suspension.
Additional copies available at usaa.com
CONTACT US: 210-531-USAA(8722)
OR 800-531-USAA
9800 Fredericksburg Road, San Antonio, Texas 78288
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:
(U 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
Name of Agent
Policy Number Expiration Date
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 theworkers' compensation provisions of Labor Code § 3700 1 must
immediately comply with those proves o or a reement automatically become void.
Signature of Applicant Date 2i8i2021
Kristen Bergevin
Print Name
Agreement for:
Dated:
?01-7
Reviewed by:
Y