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PROOF OF INSURANCE (2021) CLOSED,.,, n„,„; Z7-) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 09/29/2020 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 be endorsed. If SUBROGATIONIS 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 NUTMEG INS AGENCY INC/PHS 76210775 NAME: PHONE (888)925-3137 (A/C, No, Ext): FAX (888)443-6112 (A/C, No): The Hartford Business Service Center E-MAIL 3600 Wiseman Blvd San Antonio, TX 78251 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURER A: Sentinel Insurance Company Ltd. 11000 Jimmy Pete DBA Power of Choice Consultants INSURER B : 3014 N OXNARD BLVD INSURER C : OXNARD CA 93036-5343 INSURER D : 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MM/DD/Y YYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $2,000,000 CLAIMS -MADE OCCUR DAMAGE TO RENTED $1,000,000 PREMISES Ea occurrence MED EXP (Any one person) $10,000 X General Liability A 76 SBU BG8460 09/05/2020 09/05/2021 PERSONAL & ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 JECT POLICY ❑ PRO- Fx LOC PRODUCTS -COMP/OP AGG $4,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $2,000,000 BODILY INJURY (Per person) ANY AUTO A ALL OWNED SCHEDULED AUTOS AUTOS 76 SBU BG8460 09/05/2020 09/05/2021 BODILY INJURY (Per accident) X HIRED NON -OWNED AUTOS X AUTOS PROPERTY DAMAGE (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS- MADE AGGREGATE DED RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY STATUTE ER E.L. EACH ACCIDENT ANY Y/N PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L. DISEASE -EA EMPLOYEE (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 350 Main Street BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED El Segundo, CA 90245 IN ACCORDANCE WITH THE POLICY PROVISIONS. REPRESENTATIVE �AUTHORIZED ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Lillio Finance, ity nSgundoou=Director ofJoseph Lillio nanc,=dull'@isgu0orgcls Date: 10 Select Customer Insurance Center 3600 WISEMAN BLVD. SAN ANTONIO TX 78251 Policyholder, please call us at: (877) 287-1316 Agent, please call us at: (888) 925-3137 INSURANCE ENDORSEMENT ATTACHED *** PLEASE REVIEW THE CHANGE *** THE HARTFORD u71- Enclosed is an endorsement for your business insurance policy. Please review it at your convenience. If you have questions or need to make further changes: Policyholder, please call us at: (877) 287-1316 Agent, please call us at: (888) 925-3137 between 7 A.M. and 7 P.M. CST. The premium billing will be mailed to you separately. You can expect to receive it soon. Thank you for allowing us to service your business needs. NUTMEG INS AGENCY INC/PHS THE HARTFORD SELECT CUSTOMER INSURANCE CENTER The Hartford Hartford Fire Insurance Company and its Affiliates One Hartford Plaza, Hartford, Connecticut 06155 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGE MAOW jz- This endorsement changes the policy effective on the Inception Date of the policy unless another date is indicated below: Policy Number: 76SBUBG8460 DW Named Insured and Mailing Address; JIMMY PETE DBA POWER OF CHOICE CONSULTANTS 3014 N OXNARD BLVD OXNARD CA 93036 Policy Change Effective Date: 10/07/20 Effective hour is the same as stated in the Declarations Page of the Policy. Policy Change Number: 001 Agent Name: NUTMEG INS AGENCY INC/PHS Code: 210775 POLICY CHANGES: SENTINEL INSURANCE COMPANY, LIMITED ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING STATEMENT. IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BANK ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A BILL. NO PREMIUM DUE AS OF POLICY CHANGE EFFECTIVE DATE RATES AND PREMIUMS ARE CHANGED. LOCATION 001 BUILDING 001 IS REVISED PRO RATA FACTOR: 0.912 THIS ENDORSEMENT DOES NOT CHANGE THE POLICY EXCEPT AS SHOWN. Form SS 12 11 04 05 T Page ool (CONTINUED ON NEXT PAGE) Process Date: 10/07/20 Policy Effective Date: 09/05/20 Policy Expiration Date: 09/05/21 POLICY CHANGE (Continued) Policy Number: 76 SBU BG8460 Policy Change Number: 001 BUSINESS LIABILITY OPTIONAL COVERAGES ARE REVISED WAIVER OF SUBROGATION IS ADDED: FORM SS 12 15 LOCATION 001 BUILDING 001 SEE FORM IH 12 00 FORM NUMBERS OF ENDORSEMENTS ADDED AT ENDORSEMENT ISSUE: SS 12 15 03 00 IH12001185 WAIVER OF SUBROGATION Form SS 12 11 04 05 T Page 002 Process Date: 10/07/20 Policy Effective Date: 09/05/20 Policy Expiration Date: 09/05/21 POLICY NUMBER: 76 SBU BG8460 ( Aulk THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF SUBROGATION CITY OF EL SEGUNDO 350 MAIN STREET EL SEGUNDO, CA 90245 Form IH 12 00 11 85 T SEQ. NO. 001 Printed in U.S.A. Page 001 Process Date: 10/07/20 Expiration Date: 09/05/21 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: BUSINESS LIABILITY COVERAGE FORM We waive any right of recovery we may have against: 1. Any person or organization shown in the Declarations, or 2. Any person or organization with whom you have a contract that requires such waiver. Form SS 12 15 03 00 Page 1 of 1 © 2000, The Hartford 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 Name of Agent ( certify that, in the performance of the work set forth employ any person in any manner so as to becEk, spb'E agree that, if I should become subject to the 'immediately comply with those provisions orr ieerr, 6 Signature of Applicant Print Name - '� vi°l Yk I �_ Agreement for: Jimmy Pete - PSA #5953 Dated: 10-08-2020 Digitally signed by Joseph Lillio Joseph Lillio 0 Di eJoseph Lillio, o=City of El Segundo, ou=Director of Finance, Reviewed by. — email=jlillio@elsegundo.orq, c=E U IJ Date: 2020.10.0817:14:49 -0T00' Policy Number Expiration Date Phone # in the agreement with the City of El Segundo, I will not at-tp the workers' compensation laws of California, and pensation provisions of Labor Code § 3700 1 must t-1 utgmatically become void. a Date