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'