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PROOF OF INSURANCE (2021 - 2022) CLOSEDDATE (MM/DDIYYYY) LIABILITY INSURANCE 03/12/2021IT ........ .�.... .......... ........ ....... _ THIS CERTIFICATE Is ISSUED CER $"AGATE FMATTER 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 BIN INSURANCE HOLDINGS LLC/PHS NAM •................. ., PH. No. ExtIT (866) 467�730 ....._. _.. /C (888) 443$112 C 46505301 (A/c. No): The Hartford Business Service Center 3600 Wiseman Blvd E-MAIL San Antonio, TX 78251 ADDRESS: _. INSURE S AFFORDING COVERAGE R() COVERAGE NAIC# INSURED INSURERA: Sentinel Insurance Company L td 11000 PROGRESSIVE SOLUTIONS INSURERB : .................. __ ...... ... ... PO BOX 783 INSURER C : BREA CA 92822-0783 __....... ................. . — ......... INSURER D INSURERE: L..J..........�...,... ®..,—. _ ..... ER". REVISION l'IeF.PA.# ......................... INSU COVERAGES n NUMBER THIS IS OECERTIFY THAT THE POLICIES OF INSURANCE MLISS �................._..._._ �____D � ..... .....HE _ R LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWI THSTANDING 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._ ADDL SUER POLI POLICY EFF CY EXP LTR, TYPEOFINSURANCE ._. ... D POLICY NUMBER LIMITS ......T. .. LMMIOD/YYYY.. Ml'(lY,,,,„YYY ,.,_,„„,,,,„IT„ ,........ R j COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $2,000,000 DAMAGETO�RENTED cLnllw�s -MADE X OCCUR$1,000.000 '',PREMISES (Ea occurrenr�) X General Liability MED EXP (Any one person) $10,000 A X 46 SBA RI9399 04/10/2021 04/1012022 PERSONAL a ADV INJURY $2.000,000 GENLAGGREGATE LIMIT APPLIESPER GENERAL AGGREGATE $4,000,000',.. JECT $4,000.000 (POLICY LOC PRODUCTS -COMPlOPAGG O`T H M ll ..............�.-,............�......_._ _.. _............. .. ......... _. ...._....__....._..._ AUTOMOBILE LIABILITY COMBINEDSINGLELIMIT $2.000,000 ..._.. _....._................ ANY AUTO BODILY INJURY (Per person) ALLOWNED SCHEDULED A Auros AUTOS 46 SBA RI9399 04/10/2021 O4/10/2022 LBODILY INJURY (Per accident) _.._ ....�...., HIRED NON -OWNED ERTY DAMAGE X AUTOS X AUTOS ccident) ...... ........_ ........ ......_� _ ........ _.. _. ....UMBRELLA LIAB OCCUR OCCURRENCE _...._ ........._. ....a........... EXCESS LIAR I� CLAIMS- AGGREGATE MADE .............._. .....�. RETENTION $ ......_.... ..... _._....,..... ............. .,� .... ....... ...... ....... a. ._..,...: WORKERS COMPENSATION PER �OTH AND EMPLOYERS' LIABILITY _ST_ATUTE ANY YIN E.L. EACH ACCIDENT PROPRIETORIPARTNERIEXECUTIVE _..... " OFFICER/MEMBER EXCLUDED? NIA E.L. DISEASE -EA EMPLOYEE (Mandatory in NH) If yes, describe under E.L DISEASE -POLICY LIMIT ,.,rRi,PTIQN„F PPERATION..1'PIrnN ...I ................. ..�,............_................�.............._._._. ....,_ .. .............. ..._ DESCRIPTIONOFOPERATIONS /LOCATIONS/VEHICLES ACORD101, ......... mmmmmmmmifmmmmo ,_,_,_ ....._..._ ...� ... ( Additional Remarks Schedule, may be attached if more space is required) Those usual to Insured's operations. Certificate holder is named as Additional Insured. CERTIFICATE HOLDER CANCELLATION �. _...._ m,_w_ Office of The City Clerk SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Patti Adlen BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 350 Main Street IN ACCORDANCE WITH THE POLICY PROVISIONS_ _._.�..... ._. __.._ El Segundo CA 90245-3895 AUTHORIZED REPRESENTATIVE C�ueGtn o� ��za7iiru�� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD N N o- 0 6124 Progressive Solutions Inc Certificate Of Insurance 9/2/2020 6:33:21 PM C""�...,1w]e DATE (MM/DDIYYYY) L,�R,.��'!1. CERTIFICATE OF LIABILITY INSURANCE 9/2/2020 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 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 endorsementlsl. PRODUCER 000 o*.Techlnsurance Techlnsurance 30 N. LaSalle, 25th Floor, Chicago, IL 60602 INSURED Progressive Solutions Inc Po Box 783, Brea, CA, 92822 C.T*ITl4. CT 'f CERTIFICATE NUMBER- 668-7020 R(S) AFFORDING COVERAGE INSURER A : Sentinel Insurance Compppy,orr it INSURER B Phlladelph(p !9de Tlplty INSURER C : PhllBdelphla IndE!.rT1f1lnsUr2;[1Cc, INSURER D :.. INSURER E INSURER F : RFVISICN NIIMRFR- 877-826-9067 NAIC p 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. ...----. .......... ...�_ IN�Ff ................. I�S'�YIL'�'N')I'I�T�,' .........�..... .. POLhCY E�FF� P6IaCY EXP LTR TYPE OF INSURANCE POLICY NUMBER '.. MM/DD/YYYY MM/DDM/YY LIMITS COMMERCIAL GENERAL LIABILITY `�` EACH OCCURRENCE $ 2,000,000 CLAIMS �— ✓ OCCUR �--� I I A'E t FNTtr 1,000,000 -MADE --- 6�FMl�F�.(Fa —. MED EXP.(Ar one person) $ 10,000 ......_.... A Yes 46SBARI9399 4/10/2020 4/10/2021 2000000 PERSONAL & .___DV. INJURY � $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4000000 ✓ POLICY LOC .... ........ ........ .........., 4,000000 _ JEcrr PRODUCTS COMP/OPAGG $ OTHER° $ AUTOMOBILE LIABILITY IOMBINL:INULEIU ,,.$... Ea a cdderu .. 2,000.000 ... .---------- ANY AUTO BODILY INJURY Per arson ( P ) $ ALL OWNED i SCHEDULED AUTOS Yes 46SBARI9399 4/10/2020 4/10/2021 BODILY INJURY (Per accident ) $„__ A ✓ NON -OWNED ✓ �......., PROPERTY' DAMAGE �. m H RTEDSAUTOS AUTOS �...6Per,p��crd�ru)1... ... $ ... ... UMBRELLA LIAB OCCUR EACH OCCURRENCE I $ EXCESS LIAB CLAIMS -MADE... AGGREGATE $ ..... DED..��........,..RETENTION$........; I .......... L. $............................ .. ........... WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN . I P TM - ,,.,, I $TAT.IT......1_ ER . ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMSER EXCLUDED? LJ NIA E L EACH ACCIDENT $ - ----- IMandatery In NH) E L DISEASE EA EMPLOYES $ If es, deseribe under D SCRIPTION OF OPERATIONS below ...... . ... ..... .......— — E L DISEASE -POLICY LIMIT I $ B Professional Liability (Errors and Omissions) PHSD1557775 7/7/2020 7r7/2021 Occurrence/Aggregate $1,000.000I $1,000,000 ''.. C Cyber Liability PHSD1558292 7/7/2020 7/7/2021 Each Occurrence $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is named as Additional Insured as their interests may appear in regards to general liability City of El Segundo/Office of The City Clerk Attn: Tracy Weaver 350 Main Street El Segundo, CA 90245 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 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD BUSINESS LIABILITY COVERAGE FORM 2. Applicable To Medical Expenses Coverage We will not pay expenses for "bodily injury": a. Any Insured To any insured, except "volunteer workers". b. Hired Person To a person hired to do work for or on behalf of any insured or a tenant of any insured. c. Injury On Normally Occupied Premises To a person injured on that part of premises you own or rent that the person normally occupies. d. Workers' Compensation And Similar Laws To a person, whether or not an "employee" of any insured, if benefits for the "bodily injury" are payable or must be provided under a workers' compensation or disability benefits law or a similar law. e. Athletics Activities To a person injured while practicing, instructing or participating in any physical exercises or games, sports or athletic contests. If. Products -Completed Operations Hazard Included with the "products -completed operations hazard". g. Business Liability Exclusions Excluded under Business Liability Coverage. C. WHO IS AN INSURED 1. If you are designated in the Declarations as: a. An individual, you and your spouse are insureds, but only with respect to the conduct of a business of which you are the sole owner. b. A partnership or joint venture, you are an insured. Your members, your partners, and their spouses are also insureds, but only with respect to the conduct of your business. c. A limited liability company, you are an insured. Your members are also insureds, but only with respect to the conduct of your business. Your managers are insureds, but only with respect to their duties as your managers. d. An organization other than a partnership, joint venture or limited liability company, you are an insured. Your "executive officers" and directors are insureds, but only with respect to their duties as your officers or directors. Your stockholders are also insureds, but only with respect to their liability as stockholders. e. A trust, you are an insured. Your trustees are also insureds, but only with respect to their duties as trustees. 2. Each of the following is also an insured: a. Employees And Volunteer Workers Your "volunteer workers" only while performing duties related to the conduct of your business, or your "employees", other than either your "executive officers" (if you are an organization other than a partnership, joint venture or limited liability company) or your managers (if you are a limited liability company), but only for acts within the scope of their employment by you or while performing duties related to the conduct of your business. However, none of these "employees" or "volunteer workers" are insureds for: (1) "Bodily injury" or "personal and advertising injury": (a) To you, to your partners or members (if you are a partnership or joint venture), to your members (if you are a limited liability company), or to a co -"employee" while in the course of his or her employment or performing duties related to the conduct of your business, or to your other "volunteer workers" while performing duties related to the conduct of your business; (b) To the spouse, child, parent, brother or sister of that co - "employee" or that "volunteer worker" as a consequence of Paragraph (1)(a) above; (c) For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in Paragraphs (1)(a) or (b) above; or (d) Arising out of his or her providing or failing to provide professional health care services. If you are not in the business of providing professional health care services, Paragraph (d) does not apply to any nurse, emergency medical technician or paramedic employed by you to provide such services. (2) "Property damage" to property: (a) Owned, occupied or used by, Page 10 of 24 Form SS 00 08 04 05 BUSINESS LIABILITY COVERAGE FORM (b) Rented to, in the care, custody or control of, or over which physical control is being exercised for any purpose by you, any of your "employees", "volunteer workers", any partner or member (if you are a partnership or joint venture), or any member (if you are a limited liability company). b. Real Estate Manager Any person (other than your "employee" or "volunteer worker"), or any organization while acting as your real estate manager. c. Temporary Custodians Of Your Property Any person or organization having proper temporary custody of your property if you die, but only: (1) With respect to liability arising out of the maintenance or use of that property; and (2) Until your legal representative has been appointed. d. Legal Representative If You Die Your legal representative if you die, but only with respect to duties as such. That representative will have all your rights and duties under this insurance. e. Unnamed Subsidiary Any subsidiary and subsidiary thereof, of yours which is a legally incorporated entity of which you own a financial interest of more than 50% of the voting stock on the effective date of this Coverage Part. The insurance afforded herein for any subsidiary not shown in the Declarations as a named insured does not apply to injury or damage with respect to which an insured under this insurance is also an insured under another policy or would be an insured under such policy but for its termination or upon the exhaustion of its limits of insurance. 3. Newly Acquired Or Formed Organization Any organization you newly acquire or form, other than a partnership, joint venture or limited liability company, and over which you maintain financial interest of more than 50% of the voting stock, will qualify as a Named Insured if there is no other similar insurance available to that organization. However: a. Coverage under this provision is afforded only until the 180th day after you acquire or form the organization or the end of the policy period, whichever is earlier; and b. Coverage under this provision does not apply to: (1) "Bodily injury" or "property damage" that occurred; or (2) "Personal and advertising injury" arising out of an offense committed before you acquired or formed the organization. 4. Operator Of Mobile Equipment With respect to "mobile equipment" registered in your name under any motor vehicle registration law, any person is an insured while driving such equipment along a public highway with your permission. Any other person or organization responsible for the conduct of such person is also an insured, but only with respect to liability arising out of the operation of the equipment, and only if no other insurance of any kind is available to that person or organization for this liability. However, no person or organization is an insured with respect to: a. "Bodily injury" to a co -"employee" of the person driving the equipment; or b. "Property damage" to property owned by, rented to, in the charge of or occupied by you or the employer of any person who is an insured under this provision. 5. Operator of Nonowned Watercraft With respect to watercraft you do not own that is less than 51 feet long and is not being used to carry persons for a charge, any person is an insured while operating such watercraft with your permission. Any other person or organization responsible for the conduct of such person is also an insured, but only with respect to liability arising out of the operation of the watercraft, and only if no other insurance of any kind is available to that person or organization for this liability. However, no person or organization is an insured with respect to: a. "Bodily injury" to a co -"employee" of the person operating the watercraft; or b. "Property damage" to property owned by, rented to, in the charge of or occupied by you or the employer of any person who is an insured under this provision. 6. Additional Insureds When Required By Written Contract, Written Agreement Or Permit The person(s) or organization(s) identified in Paragraphs a. through f. below are additional insureds when you have agreed, in a written Form SS 00 08 04 05 Page 11 of 24 BUSINESS LIABILITY COVERAGE FORM contract, written agreement or because of a (e) Any failure to make such permit issued by a state or political inspections, adjustments, tests or subdivision, that such person or organization servicing as the vendor has be added as an additional insured on your agreed to make or normally policy, provided the injury or damage occurs undertakes to make in the usual subsequent to the execution of the contract or course of business, in connection agreement, or the issuance of the permit_ with the distribution or sale of the A person or organization is an additional products; insured under this provision only for that (f) Demonstration, installation, period of time required by the contract, servicing or repair operations, agreement or permit. except such operations performed However, no such person or organization is an at the vendor's premises in connection with the sale of the additional insured under this provision if such product; person or organization is included as an additional insured by an endorsement issued (g) Products which, after distribution by us and made a part of this Coverage Part, or sale by you, have been labeled including all persons or organizations added or relabeled or used as a as additional insureds under the specific container, part or ingredient of any additional insured coverage grants in Section other thing or substance by or for F. — Optional Additional Insured Coverages. the vendor; or a. Vendors (h) "Bodily injury" or "property damage" arising out of the sole Any person(s) or organization(s) (referred to negligence of the vendor for its below as vendor), but only with respect to own acts or omissions or those of "bodily injury" or "property damage" arising its employees or anyone else out of "your products" which are distributed acting on its behalf. However, this or sold in the regular course of the vendor's exclusion does not apply to: business and only if this Coverage Part provides coverage for "bodily injury" or (i) The exceptions contained in "property damage" included within the Subparagraphs (d) or (f); or "products -completed operations hazard". (ii) Such inspections, adjustments, (1) The insurance afforded to the vendor tests or servicing as the vendor is subject to the following additional has agreed to make or normally exclusions: undertakes to make in the usual This insurance does not apply to: course of business, in connection with the distribution (a) "Bodily injury" or "property or sale of the products. damage" for which the vendor is (2) This insurance does not apply to any obligated to pay damages by insured person or organization from reason of the assumption of whom you have acquired such products, liability in a contract or agreement. or any ingredient, part or container, This exclusion does not apply to entering into, accompanying or liability for damages that the containing such products. vendor would have in the absence of the contract or agreement; b. Lessors Of Equipment (b) Any express warranty (1) Any person or organization from unauthorized by you; whom you lease equipment; but only with respect to their liability for "bodily (c) Any physical or chemical change injury", "property damage" or in the product made intentionally and advertising injury" by the vendor; by caused, in whole or in part, by your (d) Repackaging, except when maintenance, operation or use of unpacked solely for the purpose of equipment leased to you by such inspection, demonstration, testing, person or organization. or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container; Page 12 of 24 Form SS 00 08 04 05 BUSINESS LIABILITY COVERAGE FORM (2) With respect to the insurance afforded e. Permits Issued By State Or Political to these additional insureds, this Subdivisions insurance does not apply to any (1) Any state or political subdivision, but "occurrence" which takes place after only with respect to operations you cease to lease that equipment. performed by you or an your behalf for c. Lessors Of Land Or Premises which the state or political subdivision (1) Any person or organization from has issued a permit. whom you lease land or premises, but (2) With respect to the insurance afforded only with respect to liability arising out to these additional insureds, this of the ownership, maintenance or use insurance does not apply to: of that part of the land or premises (a) "Bodily injury", "property damage" leased to you. or "personal and advertising (2) With respect to the insurance afforded injury" arising out of operations to these additional insureds, this performed for the state or insurance does not apply to: municipality; or (a) Any 'occurrence" which takes (b) "Bodily injury" or "property damage" place after you cease to lease that included within the "products - land or be a tenant in that completed operations hazard". premises; or f. Any Other Party (b) Structural alterations, new (1) Any other person or organization who construction or demolition is not an insured under Paragraphs a. operations performed by or on through e. above, but only with behalf of such person or respect to liability for "bodily injury", organization. "property damage" or "personal and d. Architects, Engineers Or Surveyors advertising injury" caused, in whole or (1) Any architect, engineer, or surveyor, but in part, by your acts or omissions or only with respect to liability for "bodily the acts or omissions of those acting injury", "property damage" or "personal on your behalf: and advertising injury" caused, in whole (a) In the performance of your or in part, by your acts or omissions or ongoing operations; the acts or omissions of those acting on (b) In connection with your premises your behalf. owned by or rented to you; or (a) In connection with your premises; (c) In connection with "your work" and or included within the "products- (b) In the performance of your completed operations hazard", but ongoing operations performed by only if you or on your behalf. (i) The written contract or written (2) With respect to the insurance afforded agreement requires you to to these additional insureds, the provide such coverage to following additional exclusion applies: such additional insured; and This insurance does not apply to (ii) This Coverage Part provides "bodily injury", "property damage" or coverage for "bodily injury" or "personal and advertising injury" "property damage" included arising out of the rendering of or the within the "products - failure to render any professional completed operations hazard". services by or for you, including: (2) With respect to the insurance afforded (a) The preparing, approving, or to these additional insureds, this failure to prepare or approve, insurance does not apply to: maps, shop drawings, opinions, "Bodily injury", "property damage" or reports, surveys, field orders, "personal and advertising injury" change orders, designs or arising out of the rendering of, or the drawings and specifications; or failure to render, any professional (b) Supervisory, inspection, architectural, engineering or surveying architectural or engineering services, including: activities. Form SS 00 08 04 05 Page 13 of 24 CERTHOLDER COPY SP P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 12-31-2020 CITY OF EL SEGUNDO DEPT OF BUILDING & SAFETY 350 MAIN ST EL SEGUNDO CA 90245-3813 SP GROUP: POLICY NUMBER: 9033101-2020 CERTIFICATE ID: 30 CERTIFICATE EXPIRES: 12-31-2021 12-31-2020/12-31-2021 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated.. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer„ We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to A the terms, exclusions. and conditions, of such policy. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2018-12-31 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF EL SEGUNDO ENDORSEMENT #2085 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 12-31-2012 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #1651 - GLENN VODHANEL, CEO - EXCLUDED. EMPLOYER PROGRESSIVE SOLUTIONS, INC. PO BOX 783 BREA CA 92822 SP 1REV.7-20141 M0408 �l PRINTED : 11-17-2020 WAIVER OF SUBROGATION NOTICE Enclosed is your co y of a certificate of insurance on which the certificate holder required a waiver o subrogation: 1. Please be advised that a waiver of subrogation requires that a % surcharge will be applied by State Fund ONLY to the premium assessed on the payroll', of your employees earned while engaged in work for that certificate molder who requested the waiver. (Note: if you have no employee payroll on that job, there there is no charge.) apply the 3% surcharge, you must also agree segregated, payroll records for employees engaged in work on Job/s for the certificate holder + has the waiver. The payroll records. • verification Example: Payroll for job: Sample Rate: Regular Premium equals: Surcharge: Additional Waiver charge: Total premium equals $5,000.00 13.30$ $ 665.00 3.00% $ 19.95 $ 684.95 (665.00 + 19.95)