PROOF OF INSURANCE (2021 - 2022) CLOSEDCERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDD/YYYY)
03/11 /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 .
PRODUCERMEtC Don g
Strategic Alliance Insurance PHONE 00 830 1 12 Rp 1. License 0764210
9 L VID�t*t _Ext)..
1714 Louise Lane .._ � ..e.
P _ donkl a AFFORpINGCOVE rc .. rr
Ni omo, CA 93444 lNsuRB
INSURED
Lawles Enterprises inc
149 Eucalyptus Drive
El Segundo CA 90245
Insur
................ nce Fund
State.... erTw)�en at.�arro a____
Business Insurace Company
COVERAGES CERTIFICATE NUMBER.
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.
.. ... _ �..�....W.
OLICYEXP
— m. _. _ LIMITS
ILTR , m TYPE OF INSURANCE ADDU�S4YBDk POLICY NUMBER IMM DPI MYY �M/DDfY YY
B X COMMERCIAL GENERAL LIABILITY UDC-4234626-EO-20
8-10-2020 8-10-2021 t EACH OCCURRENCE
$ 2,000,000
b;AWifrYb' C T0D
$ 100,000
ayl CLAIMS -MADE x OCCUR
P�IsES �a R�� ��������
MED EXP (Any one person) ...
-.n.n.....
$ 0
5,00.....
x rofesslonal Ll
PaGGREGATELIMITAPPLIE�
my 2, 000
.. .
GEN PLIES PER:
GENERALAGGREGA ERY
...
$„mm
. 2,000 000 ..
—u
X POLICY PFC4 LOC
JEOT
PRODUCTS COMP/OP AGG
$m 2,000,000
OTHER;
LIABILITY UDC-4234626-EO-20
B AUTOMOBILEuaaa
COMBINED SINGLE LIMl[T
8-10-2020 8-10-2021 ...tEpslw")o�'110 ...
$
2
$ ,000,000
ANY AUTO
BODILY INJURY Per
( person)
$
SCHEDULED
OWNED IIIAUTOS
BODILY INJURY (Per
$
AUTOS ONLY �u
HIRED NON -OWNED
X
E en
PROPERTYUAMAGaccident)
$
AUTOS ONLY AUTOS ONLY
Apl" A.W0 4 m.
... _. ...........
$
MBRELLALIAB CCUR
URRENCE
-EACHOC TE
$
�.... OLAIMSMADE.........
EXCESS LI
AGGREGATE .. ._
$.
pAB
RETENTION $
$
A
DED
WORKERS COMPENSATION
9227676-21
3-9-2021
3-9-2022
x PER OTH-
_ATLIT,E ER
„ ,,
AND EMPLOYERS' LIABILITY
ANYPROPRIETOR/PARTNERIEX
OFFICER/MEMBER EXCLUDEED?ECUTIVE � J
N/AI
„S,
(Mandatory in NH)
EL.. SEASECEAEMPLOYEE.
_................ ...................
$ 1,000,000
�� .........
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE -POLICY LIMIT
$ 1,000,000
B
uADP
UDC-4234626-EO-20
8-10-2020
8-10-2021
Broad Form
20„000
DESCRIPTION OF OPERATION'S I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule„ may be attached if more space is required)
Certificate holder named as additional insured per the attached endorsement
CERTIFICATE HOLDER I AL�4rLLAIIU'rW
City of El Segundo
City Clerk Office SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
350 Main St. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
El Segundo, CA 90245
AUTHORIZED REPRESENTATIVE
U 19t;S-ZU10 AUUKU GUKI-UKA I IUN. All ngnis reserve0.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
POLICYNUMBER UDC-4234626-EO-20 COMMERCIAL GENERAL LIABILITY
CG 24 040509
WAIVER OF TRANSFER OFRIGHTS OFRECOVERY AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY
COVERAGE PART
SCHEDULE
City of El Segundo
The following is added to Paragraph 8. Transfer of Rights Of Recovery Against
Others To Us of Section IV - Conditions:
We waive any right of recovery we may have against the person or organization
shown in the Schedule above because of payments we make for injury or
damage arising out of your ongoing operations or "your work- done under a
contract with that person or organization and included in the "products -
completed operations hazard". This waiver applies only to the person or
organization shown in the Schedule above.
OG240406 Insurance Services Office, Inc., 2008
ENDORSEMENT AGREEMENT
.;
WAIVER OF SUBROGATION
BLANKET BASIS
HOME OFFICE
SAN FRANCISCO EFFECTIVE MARCH 9, 2021 AT 12.01 A.M.
ALL EFFECTIVE DATES ARE AND EXPIRING MARCH 9, 2022 AT 12.01 A.M.
AT 12:01 AM PACIFIC
STANDARD TIME OR THE
TIME INDICATED AT
PACIFIC STANDARD TIME
LAWLES ENTERPRISES INC
149 EUCALYPTUS DR
EL SEGUNDO, CA 90245
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 NAMED 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
2.00% OF THE TOTAL POLTCY PREMIUM.
SCHEDULE
PERSON OR ORGANIZATION
ANY PERSON OR ORGANIZATION
FOR WHOM THE NAMED INSURED
HAS AGREED BY WRITTEN
CONTRACT TO FURNISH THIS
WATVER
JOB DESCRIPTION
BLANKET WAIVER OF
SUBROGATION
9227676-21
RENEWAL
NA
9-07-63-69
PAGE 1 OF 1
NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE
OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS
POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE
HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR
LIMITATIONS OF THIS ENDORSEMENT.
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO:
AUTHORIZED REPRESENT IVE
SCIF FORM 10217 (REV.7-2014)
MARCH 11, 2021
PRESIDENT AND CEO
2572
OLD DP 217