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PROOF OF INSURANCE (2022) CLOSED4C CERTIFICATE OF LIABILITY INSURANCE °AT4/06/2°/Y1 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 endorsement(s). PRODUCER CONTACT NAME, Janet Ramirez Merriwether & Williams Insurance Services PHONE (213) 258-3096 FAX A/C. Nd , (213) 336-3012 License No.: 0001378 A6IDRESS: jramirez@imwis.com 550 Montgomery St., Suite 550 INSURER(S) AFFORDING COVERAGE NAIC # San Francisco CA 94111 INSURERA: Hiscox Insurance Company Inc. 10200 INSURED INSURER B Jeff Cason INSURER C : 531 Main Street #412 INSURER D : INSURER E t El Segundo CA 90245 1 INSURER F rnVFRAr:FC CFRTIFICATF NIIMIRFR^ CL214616956 RFVI-Rlnm N1IMRFR• 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. LTR TYPEOFINSURANCE INSO WVO POLICY NUMBER ANM/00 MMIDD= LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE � OCCUR PREMISES Ea occu�urrence . $ 100,000 MED EXP (Any one person) $ 5,000 X Primary&Non-contributory PERSONAL & ADV INJURY $ 1,000,000 A Y Y UDC-4795016-CGL-21 04/06/2021 04/06/2022 GEN'LAGGREGATE LIMIT APPLIES PER: ,. POLICY 0PROW JEC�.T LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMP/OPAGG S/T Gen A $ 99' $ OTHER! AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Me acdder tlT $ 1,000,000 , ANY AUTO BODILY INJURY (Per person) $ A OWNED SCHEDULED AUTOS ONLY AUTOS Y UDC-4795016-CGL-21 04/06/2021 04/06/2022 BODILY INJURY (Per accident) $ -. PROP DAMAGE Par aoadenp $ HIRED ,,,,,,« NON -OWNED AUTOS ONLY X'.... AUTOS ONLY $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR El CLAIMS -MADE DED I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- .STATUTE ER E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? ❑ N I A E,.L, DISEASE - EA EMPLOYEE $ .(Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT $ A Professional Liability UDC-4793843-EO-21 04/06l2021 04/06/2022 Each Claim $1,000,000 Aggregate $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) The Certificate Holder isdded as Additional Insured with respects to our Insured's operations only. This insurance is primary and non-contributory as ulred b written contract. q y Joseph IIIIoI Finance Director SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Stret AUTHORIZED REPRESENTATIVE El Segundo CA 90245 JM ' ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 04/05/2021 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 endorsement(s). PRODUCER Hiscox Inc. d/b/a/ Hiscox Insurance Agency in CA 520 Madison Avenue 32nd Floor New York, NY 10022 INSURED Jeff Cason 531 Main Street, #412 El Segundo CA 90245 COVERAGES CERTIFICATE NUMBER: I �r �tl..___(88 ..202-3007.. ............. ... .....�.-+ C�.N E-MAIL contact h scox corm INSURER(S) AFFORDING COVERAGE _NAIC # INSURER A: Hiscox Insurance Company Inc 10200 INSURER B INSURER C INsuRER D INSURER E : INSURER F : 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, EXCLUSION S SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. S AND CONDITIONS OF SUCH POLICIES. LIMITS u _- ................ INSR TYPE OF INSURANCE INsn Wvn SUER POLICY NUMBER. LTR �......_. EXP hA!&DI0fY IY POLDI p m LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ E] CLAIMS -MADE OCCUR PRf�paRtlSESIT(bW�a��cunrrt�nr,�,) $ _.........., PERSONAL & ADV INJURY $ N'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATEPOLICY FGE"I PRO- LOC JEOT ......... PRODUCTS - COMP/OP AGG $. OTHER: $ AUTOMOBILE LIABILITY COMINNE0 SWGLE LWIT Ja acce_n?5..,........_,., $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED ._.............__----.mm.-.-. BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON -OWNED PROPERTYOAMAGE $ AUTOS ONLY AUTOS ONLY (PA? gGgB__...- . ........... .. UMBRELLA LIAR pCCUR EACH OCCURRENCE _. $ w EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION PER OTH J AND EMPLOYERS' LIABILITY YIN$,TIJTE ••, •• -,„-• , ANYPROPRIETOR/PARTNERIEXECUTIVE '���""jJ L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA _E m mmmmmmmmmmmm (Mandatory In NH) EL. DISEASE - EA EMPLOYEE _w................... $ _-................ If YysS , describe under DESCRIPTION. OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A Professional Liability UDC-4793843-EO-21 04/06/2021 04/06/2022 Each Claim:. $ 1,000,000 Aggregate: $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) -7 7 Joseph Lillio, Finance Director TE HOLDER 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 V ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 440 IJCOX. Policy Number: Named Insured: Endorsement Number: Endorsement Effective: UDC-4795016-CGL-21 Jeff Cason 1 April 6, 2021 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - AUTOMATIC ATIC STATUS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any per- son(s) or organization(s) for whom you are performing operations or leasing a premises when you and such person(s) or organiza- tion(s) have agreed in writing in a contract or agreement that such person(s) or organiza- tion(s) be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to lia- bility for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing opera- tions; or 2. In connection with your premises owned by or rented to you. A person's or organization's status as an addi- tional insured under this endorsement ends when your operations or lease agreement for that additional insured are completed. CGL E5421 CW (02/14) Includes copyrighted material of Insurance Services Office, Inc., with its Page 1 of 1 permission. 4o HISC X Policy Number: UDC-4795016-CGL-21 Named Insured: Jeff Cason Endorsement Number: 2 Endorsement Effective:April 6, 2021 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. �. t ' This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy, pro- vided: 1. you have agreed in a written contract or agreement to add such additional insured to a policy providing the type of coverage af- forded by this policy; and 2. you have agreed in a written contract or agreement with such additional insured that this insurance would be primary and would not seek contribution from any other insur- ance available to the additional insured. CGL E5581 CW (03/16) Includes copyrighted material of Page 1 of 1 Insurance Services Office, Inc., with its permission 140 HISCOX . Policy Number: Named Insured: Endorsement Number: Endorsement Effective: UDC-4795016-CGL-21 Jeff Cason 16 April 6, 2021 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. MODIFIED WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS S TO CIS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: You may waive your rights against another party so long as you do so in writing prior to: (i) an offense arising out of your business that caused a "personal and advertising injury'; or (ii) an "occurrence" that caused "bodily injury' or "property damage". CGL E5402 CW (03/10) Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1 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: L_) 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 Policy Number Expiration Date Name of Agent 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 beco a su " ct the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those r i n o the agreement will automatically become void„ Signature of Applicant Date 5-6-21 Print Name Agreement Dated: b4 bi., yi Reviewed by; ��