Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
PROOF OF INSURANCE (2021 - 2021) CLOSEDJOEMPOL-01 TCHAMP
CERTIFICATE OF LIABILITY INSURANCE DAa/1612020 ,
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), AUTHORII:'ED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the
if SUBROGATION IS WAIVED, subject to the terms and conditions of
PRODUCER
Pay naWeetirsurance-TAG
14900 SW Barrows Rd, Site 202
Beaverton, OR 97007,
INSURED
Joemar Polygraph i investigative Services Inc
12930 BBnyon
Rancho Cucamonga, CA 91739
CERTIFICATE NUMBER!
must have ADDITIONAL INSURED provisions or be endorsed.
certain policies may require an endorsement A statement on
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.
POLICY _ IOLICY XP
IN TYPE 0P INSURANCE AWL $tIOR POLICY NUMBER LIMna
A
X CONNERCIALOENSRALLIABILITY
H R
1,000,000'
CLAIMS -MADE [. ] OCCUR
X
x
RBS0033901
7/2912020
7/2912021
DA O RENTED
100,000
5,000
A
l RY
$ 1a000,000
'L AOT,RG AT LIMIT APPLIES PER:
R A
5 2,000,000
T�.
)C POLICY L1 JE8{ ❑ Loc
ITS. :MPP
2,000,000
THER
AUTOMOBILE UABILITY
CQMaINEiP S4NDI E LYAA'IT
ANY AUTO
3
ALU TOp�LEDD
UONLY
Y NI P
I
A81%ONLY A
I
OPE Y
UMBRELLA UAB
OCCUR
RR NL
$
EXCESSLIAe
CLAIMS
aI A
DED RETENTIONS
C
0YOEtV
•RANY
YIN
PR
IEWEXEC
Rhw RT&AJDECI? .NEVVE
m
N/A
AJS A
IP P RArI
-P LP 1M r
A
Errors A OMISSIOnB
X
x
RBS0033901�
712912020
7r2912021
each Claim
1,000,000
A
Errors its Omiesions
X
x
RBS0033801
7/29/2020
712912021
aggregate
2,000,000
0E RWaTIN OP OP T1ON8 +LOCATION$ t VEHICLES IA0040101 Addl lo" Satwdulk r=y IBM! ctraaclaaad n mom spocar Is nagdrwrll
Ca Za'to holder is a NA"1Orlsl insured per attached 01.11487
Digitally signed by Joseph Lillio
Joseph Lillio Segundo, v= Llllla o ncia �I
Segcando, ncl.=CI�8elrinanclal Officer,
email- IIIIInoelsegundoorg„ c=US
Date: 2021.04.1310:25:19-07'00'
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of El Segundo ACCORHE DANCE WI ITH THE POLICY P�ISION�S E WILL BE DELIVERED IN
348 Main St
El Segundo, CA 90245
AUTHORIZED REPRESENTATIVE
ACORD 25 (2016103) 01980.2015 ACORD CORPORATION. All rights reserved.
The ACORD name end logo are registered marks of ACORD
,7L
A SCOTTSDALE INSURANCE COMPANY°
ENDORSEMENT
NO.
ATTACHED TO AND
FORNN©APART OF
ENDORSEMENT EFFECTIVE DATE
NAMmIN3Ur�
AOENrgO
POUCY NUMBER
i12R1A.MaTArDAR071ME)
RBS-0033801
7/29/2020
Joemar Polygraph & Investigative Services Inc
46722
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED-OWNERSLESSEES OR CONTRACTORS -
AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT
WITH YOU INCLUDING PRIMARY OR PRIMARY AND NON-CONTRIBUTORY
AND LIMITED WAIVER OF SUBROGATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
ERRORS AND OMISSIONS COVERAGE PART
A. SECTION II —WHO IS AN INSURED is amended to include as an additional insured any person or
organization for whom you are performing operations and you and such person or organization have
executed a written contract or agreement prior to the time of an "occurrence" giving rise to a claim that
such person or organization be added as an additional insured on your policy. Such person or organi-
zation is an additional insured only with respect to liability for "bodily injury," "property damage," "error
or omission" or "personal and advertising injury" caused, in whole or in part, by:
1. Your negligent acts or omissions; or
2. The negligent acts or omissions of those acting on your behalf;
in the performance of your ongoing operations for the additional insured.
B. With respect to the insurance afforded to these additional insureds, the following additional exclusions
apply:
This insurance does not apply to:
1. "Bodily injury," "property damage,' "error or omission" or 'personal and advertising injury" arising
out of the rendering of, or the failure to render, any professional architectural, engineering or sur-
veying services, including:
a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions,
reports, surveys, field orders, change orders or drawings and specifications; and
b. Supervisory, inspection, architectural or engineering activities.
2. "Bodily injury" or "property damage" occurring after:
GLS-487 (6-15)
a. All work, including materials, parts or equipment furnished in connection with such work, on the
project (other than service, maintenance or repairs) to be performed by or on behalf of the
additional insured(s) at the site of the covered operations has been completed; or
b. That portion of 'your work" out of which the injury or damage arises has been put to its intended
use by any person or organization other then another contractor or subcontractor engaged in
performing operations for a principal as a part of the same project.
Includes copyrighted material of 180 Properties, Inc„ with Its permission.
Copyright, ISO Properties, Inc., 2004
Page 1 of 2
C. With respect to the insurance afforded to these additional insureds, the following is added to SEC-
TION III —LIMITS OF INSURANCE:
The most we will pay on behalf of the additional insured is the amount of Insurance:
1. Required by the contractor agreement you have entered into with the additional insured; or
2. Available under the applicable Limits of Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.
D. Under SECTION IV --COMMERCIAL GENERAL LIABILITY CONDITIONS; subparagraphs a. Pri-
mary Insurance and b. Excess Insurance of paragraph 4.Other Insurance are amended as follows:
If you have agreed in a written contract and executed such a contract or agreement prior to the time of
an "occurrence" giving rise to a claim, that this policy will be afforded on a primary or primary and non-
contributory basis and without right of contribution from any insurance in force for the liability in the
performance of your ongoing operations for the additional insured(s), then this insurance will be af-
forded on a primary or primary and non-contributory basis„ and we will not seek contribution from any
other such insurance.
E. Under SECTION IV --COMMERCIAL GENERAL LIABILITY CONDITIONS, the following is added to
paragraph S. Transfer Of Rights Of Recovery Against Others To Us:
We waive any right of recovery we may have against an additional insured if you have agreed in a
written contract, and executed such a contract or agreement prior to the time of an 'occurrence" giving
rise to a claim but only with respect to liability for "bodily injury," "property damage," "error or omission"
or "personal and advertising injury" caused by:
1. The named insured's negligent acts or omissions; or
2. The negligent acts or omissions of those acting on the named insured's behalf;
in the performance of the named insured's ongoing operations for the additional Insured.
All other Terms and Conditions of this Policy remain unchanged.
AUTHORIZED REPRESENTATIVE DATE
Includes copyrighted material of ISO Proporties, Inc., vdth its permission.
Copy(Ight, ISO Propsrtles, Ino., 2004
QLS-497 (6-15) Page 2 of 2
Renewal auto policy declarations (DoAllstate,
Your policy effective date is February 11, 2021 You're in good hands,
Page I of 6
Information as of Decernber18, 2020
Total Amount Due for the Policy Period
Please review your insured vehicles and verify their VINs are correct. Summary
Vehicles covered tion Number Pretnivm Named Insured(s)
1997 Chevy Trk Blazer $575,65 Joe & Ona Delia
2010 Mercedes-B E350 875,153 Mailing address
2016 Ram Trucks 1500 2wd 851.54
California Fra'ud'Assessment Fe 2.64 AMM&��Mli
Total* $2,30 Policy number
LQ�01 �607
*Your bill will be mailed separately. Before making a payment, please refer to your Your policy provided by
latest bill, which Includes payment options and installment fee information. If you do Allstate Northbrook Indemnity
not pay in full, you will be charged an installment fee(s). Company
See the Important payment and coverage information section for details about Policy period
installment fees. Beginning February 11, 2021 through
August 11, 2021 at 12:01 a.m. standard
time
Discounts (included in your total premium) Your Allstate agency is
Good Driver (20%) $557.98 Distinguished $499.13 YI
Driver
Anti -theft $9.97
Total discounts$1,067.081
Some or all of the information on your
Discounts per vehicle
Policy Declarations Is used in the rating
of your policy or it could affect your
eligibility for certain coverages, Please
Good Driver (2011/) $126,19 Distinguished $111-96
notify us Immediately if you believe that
Driver
any information on your Policy
2010 iMqrcedes-i 650
$416.,87
Declarations is incorrect. We will make
Anti -theft $4.82
corrections once you have notified us,
Distinguished $19314
and any resulting rate adjustments, will
Driver
be made only for the current policy
016 Ram, Trucks 1500 2wd
�12-06
period or for future policy periods.
-'2.88
Please also notify us immediately if you
Anti -theft $5.15 Go-oa-D—river (2697.��21
believe any coverages are not listed or
Distinguished $194.03
are Inaccurately listed.
Driver
Listed drivers onyour policy
6r—Delia .. . . ..... .
Joe Delta
Excluded drivers from your policy
None
X
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 ATTORNEYS FEES.
I affirm under penalty of perjury under the laws of California one of the following declarations:
L—) I have and will maintain a certificate of consent ofself-insure for workers' compensation, issued by the Director
of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work sat 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 the )INorIrs' compensation provisions of Labor Code § 3700 1 must
immediately comply with those 6 isions o,� �a ment."automatically become void.
Date
Signature of Applicant - 4
Agreement for:
Dated: 04-13-2021
Digitally signed by Joseph Lillie
DN: cn=Joseph Ullio, O=CitY of El Segundo,
ou=Chief Financial officer,
Reviewed by: Jose h Lillioemail=jlillio@elsegundo.org, c=US
P 5:58 -07'00'