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PROOF OF INSURANCE (2021) CLOSEDAC OP ID: DR oRa® CERTIFICATE OF LIABILITY INSURANCE DATE(MMMD/YYYY) 12/09/2020 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 endorsements , PRODUCER CONTA T Alliance Mgt. & Insurance Sery NAME: Michelle A Nowell PHONE - .. mP—. 355 Via Vera Cruz #7 (AIC Nc. E;rl) 760-471-7116 lac, Nod: 760-471-9378 CA A ent/Broker Lic# 0737966 E-MAIL — ADDRESS mnowell amiscor .com San arcos, CA 92078 PRo�uC'�tf � � ,,.. Michelle A. Nowell CUSTnm EFRR In e•JLGRO-1 mQUKMNa)!9rrVKUINU UUVERAGE NAIC # INSURED JL Group LLC INSURER A: Acceptance Casualty InS COm 10349 1831 Bent Twig Lane Tustin, CA 92780 INSURER B INSURER C : W A E: lJVtKAG1=5 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. _ TYPE OF INSURANCE GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY X CLAIMS -MADE Fx] OCCUR Errors & Omission "PENTL IT APPLIES PER: N X _PO LICYAGGREGATEPRO-i LOC AUTOMOBILE LIABILITY A ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS X HIRED AUTOS _,- X NON-OWNEDAUTOS UMBRELLA LIAB X OCCUR X,.. EXCESS LIAR A CLAIMS MADE' DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below A ICyber 1 LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) El Segundo is named as additional insured with respect to the work ned by the named insured. CA -- E L. EACH ACCIDENT $ E L DISEASE EA EMPLOYEE $ .., E.L. DISEASE - POLICY LIMIT I $ 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. Liana Osborne 350 Main Street AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 ^ tx.(.L - ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: CP00962747 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Section II - Who Is An Insured is amended to in- clude as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability 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: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 202607 04 0 ISO Properties, Inc., 2004 Page 1 of 1 0 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: (_) 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 # 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 workers' compensation provisions of Labor Code § 3700 1 must immediately comply with thos rr `si s o the agreement will automatically become void. Signature of Aprlicant Date Print Name Agreement for: Agreemnet No. 6062 Dated 5/3/21 Reviewed by: JL