PROOF OF INSURANCE (2021) CLOSED' CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDD/YYYY)
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 .
CONTACT
PRODUCER 221 Main Street, on PHONE ill 562 193-39
SKS Insurance Agency, Inc r e kat( IiaesWel...... ance,com FAx
562�93�900 ...... Arc
License #: OH52941 ADDRESS INSURER(S)AFFORDING„COVERAGE ) m
£ MAItt
Seal Beach, CA 90740 r
NAIC #
INSURED Monlaras & Wlsmeyer Group Inc. INSURERB: m.�eiiUQlaIn. iur �,nC,e...,c',,,.011l„pani
DBA Return to Work Partners msuRER,c US,L „______
2201 E Willow St Ste D189 INSURERp
Signal Hill, CA 90755-2148 JNSURER E: _
INSURER F
COVERAGES CERTIFICATE NUMBER: 00009453-1337459 REVISION NUMBER: 80
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.
iM .......„.. ---.......... . . . ..-....'AI' $f ; lBtd6 POLICY „„„„.,.... _..-V?OLICY EF ................. __. .........
TYPE OF INSURANCE...__.
POLICY XP LIMITS
NUMBER D YY MMN!'ODIYYYY'Y.
A
A- COMMERCIALELIABILITY
Y
Y
ACP7814144291
08/29/2020
08/29/2021
EACH OCCURRENCE
$ 2 000 000
300000
� XOCCUR
PRMISES ,(Fa. ocurrencq�
$ ,.......,..
-
i
one person)
$ 5�.....000
...._
PERSONAL & ADV INJURY
,000
$ 2 OOO mm ...
�
AGGREGATE LIMIT APPLIES PER:
.......„„.
GENERALAGGREGATE
. ...
$
GEN'L
POUCYOTHER. ......� LOW"
p�
PRODUCTS.. IOI.. PAG,G
$ „.m_, 4, 000,000
A
AUTOMOBILE LIABILITY
ACP7814144291
08/29/2020
08/29/2021
C O EI Na5SINGLE DWI
$
ANY AUTO
BODILY INJURY (Per person)
$
.....
..,.,.,,. OWNED ...... SCHEDULED
. ... .t.
BODILY INJURY (Per acciden)
..m_
$
AUTOS ONLY ____. AUTOS
HIRED NON -OWNED
1'ROF'ER7Y DAMAGE
$
AUTOS ONLY X AUTOS ONLY
4.'+P:"rr_radant ..,.,.,...,.
—..____ .....
$
UMBRELLA OCCUR
OCCURRENCE
—ENCE
$ _
.. ..
�LBAB
....
EDECOE S L _ CLAIMS -MADE
AGG REGATE
$
RETENTION $
$
B
WORKERS COMPENSATION
QWC1116'.359
08/29/2020
08/29/2021
X�{( PER OTN
€R
AND EMPLOYERS' LIABILITYANYP OO PRIE R/P RTTNER/EXECUTIVE Y/N
E.L. EACH ACCIDENT CI. ENT
$ 1,000,000
FCER/MEMBER EXCLUDED?
OFI❑
Mandato m NH
( ry )
NIA A
PLO
E.L. DISEASE- EMPLOYE
$ 1 ,
. .„,000,000
If yes, describe under
1,000,000
DESCRIPTION OF OPERATIONS below
E.L. DISEASE -POLICY LIMIT
$
C
Errors & Omissions
I
SP1018321 K
1112912020
01/29/2021
Occurence
1,000,000
Retention
$5,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
City of El Segundo its officials, and employees are listed as Additional Insureds as per written contract.
..................... — 0
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS.
EI Segundo, CA.....AUTMORIZEDREPRESENTATIVE -,
1"-19) 1988"-2015ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
Printed by KLT on March 10, 2021 at 04:10PM
BUSINESSOWNERS
PB 60 72 07 11
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
AMENDMENT TO OTHER INSURANCE CLAUSE FOR
ADDITIONAL INSUREDS - PRIMARY AND NON-
CONTRIBUTORY WHEN REQUIRED IN A WRITTEN
AGREEMENT OR CONTRACT WITH, YOU
This endorsement modifies insurance provided under the following: IL
PREMIER BUSINESSOWNERS COMMON POLICY CONDITIONS
Only with respect to any additional insured, in the COMMON POLICY CONDITIONS, form PB 00 09, under
condition H. OTHER INSURANCE, paragraph 2.a. is replaced by the following:
H. OTHER INSURANCE
2. Under any liability coverage provided by this policy,
a. If for injury or loss we cover, there is other valid and collectible insurance available to any additional
insured under another policy, our obligations are limited as follows:
(1) Issued by another insurer, or if there is self insurance or similar risk retention that applies to a
loss covered by this policy, then this insurance provided by us shall be excess over such other
insurance, unless you have agreed in a written contract or written agreement signed prior to the
loss that this insurance shall be primary:
(a) Then this insurance is primary. If other insurance is also primary, we will share with all that
other insurance as described in d. below; and
(b) The coverage afforded by this insurance is non-contributory with the additional insured's own
insurance.
Paragraphs (a) and (b) do not apply to other insurance to which the additional insured has been
added as an additional insured to any other person or organization's policy; or
(2) Issued by us or any of our affiliate companies, that applies to a loss covered by this policy, then
only the highest applicable Limit of Insurance shall apply to such loss. This condition does not
apply to any policy issued by us that is designed to provide Excess or Umbrella liability insurance.
All terms and conditions of this policy apply unless modified by this endorsement.
PB 60 72 07 11 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1