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PROOF OF INSURANCE (2021 - 2022) CLOSED (2)OO KRAUACT-01 LORALEEBARLOWBOYES
A� Q^ DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 3181202"1
......_._........ _ ............
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.
_.. _ ........._........ ..._......mm. ........ .......
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
NFP Property & Casualty Services, Inc.
1551 North Tustin Avenue
Suite 500
Santa Ana, CA 92705
14)505-5550
975.8966
INSURED I INSURERS ff19U.F#QL.r 1.r„Vnl�lal,l l en ulr,,,rrca� .n.... .... , +e.....
Krause ACT, Inc. DBA Air Cleaning Technology WumRES a . _--- _ ....... —
411 Rowland Ave wMsuR Da _
Santa Ana, CA 92707
INSURER F ;
_... - _. __....._
CO�`ERAS- L .......CERTIFICATE fJtJMER':...... 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,
PAID CLAIMS.
INSARX X U COMMERCIAD F INSU�OC BO n UCH _11,ADDL�SUBR LIMITS SHOWN MAY HAV a POLICY EFF PO4.4CY X ,L� OCC LIMITS �.
E BEEN REDUCED
PE
tTR
ENERAL
POLICY NUMBER
_ EACH OCCURRENCE Vim... 1 000 000
CLAIMS -MADE
..—. ._ occuR PACE4245133R2 3/7/2021 3/7I2022 DAMAGE A RENTED
p300
F/$ES4ExsvPr D A_
M� EXPIoneons $50,000gny... -- 1,000,000
POLICY G ELIMITAPPLIESL PERSQNA , ADVINJ, „m
9901AGGRE, ,�, PER: GENERAI�A(_PREGATE ,000,000
PRO- I j 000,000
JECT OC .PRODUCT$ - GOMP/OP, AGG .
COMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY (,{)mBor„Ipl) $.
ANY AUTO .,OLIILYbI`,�JI,I,RY,O?erpersan ..... ..____.�
OWNED SCHEDULED
AUTOS ONLY AUTOSN-� ROPERTY cadent $
HIRED . NOOWNED 'peracc�dant,� DAMAGE $
AUTOS ONLY AUTOS ONLY •----�----- °° •---
_ -- ...� ...........
X EXCESS LIAB CLAIMS -MADE EXC424513R1 3/7/2021 3/7/2022 ACH oCCURRFNCE ;�
A _� UMBRELLA LIAR X OCCUR 4,000,00
EGdCF%EGPtiTE4,Ii00,00._
B PER
AND KERS COMPENSATION...... ppyy"" y ...._,. .._..
AN MP Y $ YIN _....... 1/1/2021 1/1/2022 .._^ 5TATMTF- _�.-.ETB.
...... 1 000000
ANY PROPRIETOR/PARTNER/EXECUTIVE X 'M1VSD5O5860800 _E L EAQH•mAC,CIDENT „ _ I _ ' ' _
OFFICER/MEMBER EXCLUDED? N / A 0 QOQ
(Mandatory in NH) E L, DISEASE EA EM„P,LOYEE._
10
A Pollution P''L_
If yes, describe under 0,000
DESCRIPTION „OF OPERATIONS below r E.L.. DISEASE.- POLICY LIMIT
rof Liab PACE 31712021 3/7/2022 imit 1,00 0,000'
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
RE: El Segundo Fire Department, 314 Main Street, El Segundo, CA 90245.
The City of El Segundo is included as Additional Insured with regard to General Liability per attached forms EPACE100-0814 & EPACE101-0814. Waiver of
Subrogation applies to Workers' Compensation per attached form WC990634„
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 Street
El Segundo, CA 90245---•-•--••••• ._..... __.... __
AUTHORIZED REPRESENTATIVE
I U__Av, .....�
ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER:
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the following:
EnviroPACE Insurance Policy
SCHEDULE
Name Of Additional Insured Person(s) Location And Description Of Completed
Or Organization(s)Operations
Where Required By Written Contract Where Required By Written Contract
A. Section XX. WHO IS AN INSURED, Coverage Part 1 and Part 2 is amended to include as an
additional insured the person(s) or organization(s) shown in the SCHEDULE above, but only with
respect to liability for bodily injury, property damage, environmental damage, or cleanup costs
caused, in whole or in part, by your work at the location designated and described in the SCHEDULE
of this endorsement performed for that additional insured and included in the products -completed
operations hazard.
However:
1. The insurance afforded to such additional insured only applies to the extent permitted by law; and
2. If coverage provided to the additional insured is required by a contract or agreement, the insurance
afforded to such additional insured will not be broader than that which you are required by the
contract or agreement to provide for such additional insured.
B. With respect to the insurance afforded to these additional insureds, the following is added to section
XXI. LIMITS OF LIABILITY AND DEDUCTIBLE:
If coverage provided to the additional insured is required by a contract or agreement, the most we will
pay on behalf of the additional insured is the amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits of Liability shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits of Liability shown in the Declarations.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED,
EPACE100-0814 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1
with its permission.
POLICY NUMBER:
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
■ o 16101 . * T
This endorsement modifies insurance provided under the following:
EnviroPACE Insurance Policy
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s) Locations Of Covered Operations
Where Required By Written Contract Where Required By Written Contract
A. Section XX. WHO IS AN INSURED, Coverage Part 1 and Part 2 is amended to include as an
additional insured the person(s) or organization(s) shown in the SCHEDULE above, but only with
respect to liability for bodily injury, property damage, personal and advertising injury,
environmental damage, or cleanup costs caused, in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your behalf;
in the performance of your ongoing operations for the additional insured(s) at the location(s)
designated above.
However:
1. The insurance afforded to such additional insured only applies to the extent permitted by law; and
2. If coverage provided to the additional insured is required by a contract or agreement, the insurance
afforded to such additional insured will not be broader than that which you are required by the
contract or agreement to provide for such additional insured.
B. With respect to the insurance afforded to these additional insureds, the following additional exclusions
apply:
This insurance does not apply to bodily injury or property damage occurring after:
1. 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 location of the covered operations has been completed; or
2. 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 than another contractor or subcontractor engaged in
performing operations for a principal as a part of the same project.
EPACE1 01 -0814 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 2
with its permission.
C. With respect to the insurance afforded to these additional insureds, the following is added to section
XXI. LIMITS OF LIABILITY AND DEDUCTIBLE:
If coverage provided to the additional insured is required by a contract or agreement, the most we will
pay on behalf of the additional insured is the amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits of Liability shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits of Liability shown in the Declarations.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
EPACE1 01 -0814 Includes copyrighted material of Insurance Services Office, Inc., Page 2 of 2
with its permission.
CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDD/YYYY)
03/05/2021
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 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
Dan Rickabus
Statefiarm
State Farm Insurance
30131 Town Center Drive, Suite 275
Laguna Niguel, CA 92677
INSURED
Krause A C T
DBA Air Cleaning Technology
411 Rowland Ave
Santa Ana, CA 927073445
COVERAGES
CERTIFICATE NUMBER:
WI.9��..,.,.....-_ ............ No 949.,...,,�, 36
49 363-7100 -363-18
l katherine pmerry it:h@statefarm n1.......� �. �.-. �..�... �_..�..
State Farm Mutual Automobile Insu
rance nc 25178 "m°"'
INSURERS AFFORD .. RA
A e Company 5178
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. ..
..... „ __. ........... POLIC..�........-----....WIWWOX.m. _ .... .... ..I___
INSR TYPE OF . ....... ---'�NO'D4 SUER POLICY EFFPOLICY YY
LTR.. INSURANCE POLICY NUMBER 'MMBD dY' Y MMIDDIYYYY LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$
---
i4ff0 ref RE"N1Eb-
..... CLAIMS -MADE E....�� OCCUR
.MED EXP (And one pe.
....... rson)
$ .....
PERSONAL & ADV INJURY
$
..w. .........
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
------.......
$ ,.. ..
-._._
P'RO-
POLICY � ,pEOT (�1 h.0-C
PRODUCTS -COMP/OP AGO
$ _r„r„
$
OTHER:
A
AUTOMOBILE LIABILITY
Y
545 8874-001-75
03/01/2021
09/01/2021
COMBINED SINGLE Llnnu
$ 1,000,000 _..
X , '.. ANY AUTO
Per person)
BODILY INJURY e ,
( p )
_ $
ALL OWNED p SCHEDULED
X
( accident)
BODILY INJURY Per c
$
AUTOS AUTOS
5451763-001-75
03/01/2021
09/01/2021
-
NON -OWNED
X
PROPEI'7"Yf�A'VdAGE
HIRED AUTOS AUTOS
497 1093-001-75
03/01/2021
09/01/2021-(?�aca�9tt
UMBRELLA LIAB�OCCUR
EACHOCCURRENCEI_
$
EXCESS LIAB DE
AGGREGATE
: $
DED RETENTION $
$
WORKERS COMPENSATION
PER OTH-
TF�
AND EMPLOYERS' LIABILITY YIN
---
ANY ECUTIVE
E.L. EACHACCIDENT,mmR
CLUI
OFFICER/MEMBER EXRTNERI ?
NSA
(Mandatory in NH)
DISEASE EA EMPLOYEE
---
$
If yes, describe underEL-
DESCRIPTION OF OPERATIONS below
E.L. DISEASE -POLICY LIMIT
$
A
ENOL Y
507 2152-001-75
J.
03111/2021
09/01/2021
1,000.000 L
$250 Physical Damage deductible
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD101, Additional Remarks Schedule, may be attached if more space is required)
City of El Segundo, its officials and employees are named additional insured
Location: El Segundo Fire Department
Ell Segundo Fire Department
350 Main St
Ell 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 ll�,,��
42.2!5 �%%ili
©1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 1001486 132849.9 02-04-2014
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 34
(Ed. 8-00)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - BLANKET
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not
enforce our right against the person or organization nand in the Schedule. (This agreement applies only to the
extent that you perform work under a written contract that requires you to obtain this agreement from us).
The additional premium for this endorsement shall be 2% of the total California Workers' Compensation premium
otherwise due.
Schedule
Person or Onganiggtion J�ob Description
ANY PERSON / ORG ALL CA OPERATIONS
WHEN REQUIRED BY
WRITTEN CONTRACT
Policy Number: WSD 5058608 00 Insured: Krause ACT, Inc.
Endorsement Effective: 01/01/2021 Coverage Provided by: Insurance Co of the West
Issue Date: Countersigned by:
WC 99 06 34
(Ed. 8-00)