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PROOF OF INSURANCE (2022 - 2022) CLOSED
-- DATE (MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 04/12/2021 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 SUBROGATIONIS 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 USAA INSURANCE AGENCY INC/PHS PHONE (88) 242-1430 :::=FAX8'88) 443 6112 65812846 (A/C, No, Ext): A/C, No): The Hartford Business Service Center 3600 Wiseman Blvd E-MAIL ADDRESS: San Antonio, TX 78251 INSURERS) AFFORDING COVERAGE NAIC# INSURED INSURER A : Sentinel Insurance Company Ltd. 11000 REDDOOR CREATIVE, LLC. INSURERB; 208 E FRANKLIN AVE INSURER C ; EL SEGUNDO CA 90245-3823 INSURER D INSURER E : INSURER F .......------ ALIS weAMOM, 0ICt.ItQ1r%h1 IY9111MRFR• 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, INSIR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS .� COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 CLAIM&MAOE OCCUR DAMAGE TO RENTED PEEMISES (Ea rr $1,000,000 GeneralLiability MED EXP (Any one person) $10,000 X A X 65SBA TA6820 05/02/2021 05/02/2022 PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY E] PRO- El LOC I PRODUCTS - COMP/OP AGG $2,000,000 JECT OTHER: _ COMBINED SINGLE LIMIT` AUTOMOBILE LIABILITY . ANY AUTO BODILY INJURY (Per person) ALL OWNED SCHEDULED BODILY INJURY (Per accident) AUTOS AUTOS PROPERTY DAMAGE HIRED NON -OWNED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE AGGREGATE EXCESS LIAB CLAIMS- MADE ED I RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY STATUTE I E..L.. EACH ACCIDENT '.. ANY YIN PROPRIETOR/PARTNER/EXECUTIVE NIA OFFICER/MEMBER EXCLUDED? EL DISEASE -EA EMPLOYEE (Mandatory in NH) If yes, describe under E,L. DISEASE -POLICY LIMIT DE RIPTI N OFQPERATON5 h2tt__ A DATABREACH - DEFENSE & 65 SBA TA6820 05/02/2021 05/02/2022 Limit $50,000 DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the Insured's Operations. Certificate holder is an additional insured per the Business Liability Coverage Form SS0008 attached to this policy. City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 350 MAIN ST BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED EL SEGUNDO CA 90245 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 65 SBA TA6820 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PERSON -ORGANIZATION CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO, CA 90245 Form IH 12 00 11 85 T SEQ. NO. 002 Printed in U.S.A. Page 001 Process Date: 02/11/21 Expiration Date: 05/02/22 20 This Spectrum Policy consists of the Declarations, Coverage Forms, Common Policy Conditions and any 68 other Forms and Endorsements issued to be a part of the Policy. This insurance is provided by the stock TA insurance company of The Hartford Insurance Group shown below. SBA INSURER: SENTINEL INSURANCE COMPANY, LIMITED ONE HARTFORD PLAZA, HARTFORD, CT 06155 COMPANY CODE: A THE it Policy Number: 65 SBA TA6820 DX HARTFORD SPECTRUM POLICY DECLARATIONS Named Insured and Mailing Address: REDDOOR CREATIVE, LLC. (No., Street, Town, State, Zip Code) 208 E FRANKLIN AVE EL SEGUNDO CA 90245 USAA #: 116808751 Policy Period: From 05/02/21 To 05/02/22 1 YEAR 12:01 a.m., Standard time at your mailing address shown above. Exception: 12 noon in New Hampshire. Name of Agent/Broker: USAA INSURANCE AGENCY INC/PHS Code: 812846 Previous Policy Number: 65 SBA TA6820 Named Insured iS: LIMITED LIAB CORP Audit Period: NON-AUDITABLE Type of Property Coverage: SPECIAL Insurance Provided: In return for the payment of the premium and subject to all of the terms of this policy, we agree with you to provide insurance as stated in this policy. TOTAL ANNUAL PREMIUM IS: Countersigned by $751 Authorized Representative 02/11/21 Date Form SS 00 02 12 06 Page 001 (CONTINUED ON NEXT PAGE) Process Date: 02/11/21 Policy Expiration Date: 05/02/22 SPECTRUM POLICY DECLARATIONS (Continued) POLICY NUMBER: 65 SBA TA6820 BUSINESS LIABILITY LIABILITY AND MEDICAL EXPENSES MEDICAL EXPENSES -ANY ONE PERSON PERSONAL AND ADVERTISING INJURY DAMAGES TO PREMISES RENTED TO YOU ANY ONE PREMISES AGGREGATE LIMITS PRODUCTS -COMPLETED OPERATIONS GENERAL AGGREGATE BUSINESS LIABILITY OPTIONAL COVERAGES CYBERFLEX COVERAGE FORM SS 40 26 UNMANNED AIRCRAFT LIABILITY IS EXCLUDED SEE FORM: SS 42 06 Form SS 00 02 12 06 Process Date: 02/11/21 LIMITS OF INSURANCE $1,000,000 $ 10,000 $1,000,000 $1,000,000 $2,000,000 $2,000,000 Page005 (CONTINUED ON NEXT PAGE) Policy Expiration Date: 05/02/22 Insurer: SENTINEL INSURANCE COMPANY, LIMITED ONE HARTFORD PLAZA, HARTFORD, CT 06155 F1 This Declarations Page, with Common Policy Conditions, Data Breach Coverage Form and Endorsements, if any, issued to form a part thereof, shall together constitute this Data Breach Coverage Part, which in turn forms a part of the Policy Number shown below. The Common Policy Conditions and Nuclear Energy Liability Exclusion of the policy to which this Coverage Part is attached also apply to this Coverage Part. But if there is any conflict between the policy and this Coverage Part, then this Coverage Part will govern. "Coverage part" means this Declarations page and all Data Breach forms listed herein and attached hereto. POLICY NUMBER: 65 SSA TA6820 DATA BREACH COVERAGE DECLARATIONS PLEASE READ YOUR POLICY. IF YOU HAVE PURCHASED DATA BREACH - DEFENSE AND LIABILITY, NOTE THAT CLAIM EXPENSES ARE PAYABLE WITHIN THE LIMITS OF LIABILITY. Named Insured and Mailing Address: REDDOOR CREATIVE, LLC. 208 E FRANKLIN AVE EL SEGUNDO CA 90245 Policy Period Effective Date: 05/02/21 Expiration Date: 05/02/22 12:01 A.M., Standard time at the address of the named insured as stated herein. Premium: Minimum Premium: Data Breach - Response Expenses Limit Of Insurance: Retroactive Date: If no date is entered, the Retroactive Date is the same as the effective date of this Coverage Part. Business Income And Extra Expense Sub -limit: Extortion Threats Sub -limit: Data Breach - Defense and Liability (THIS IS CLAIMS FIRST MADE AND REPORTED IN WRITING INSURANCE) Limit Of Insurance: Retroactive Date: If no date is entered, the Retroactive Date is the same as the effective date of this Coverage Part. $103 NONE Data Breach - Response Expenses 10,000 Deductible: 1,000 05/02/15 Business Income And Extra Expense NOT INCLD Waiting Period Deductible: NA Hours NOT INCLD Data Breach - Response Expenses deductible shown above also applies to Extortion Threats coverage. 50,000 Data Breach - Defense and Liability Deductible: 0 05/02/15 Fines and Penalties Sub -limit: NOT INCLD PCI Loss Sub -limit: NOT INCLD Form Numbers Of Forms and Endorsements that apply: Common Policy Conditions: Form SS 00 05, Exclusion - Nuclear Energy Liability: SS 05 47 SS00470316 SS00480316 Countersigned by �'��, a C 02/11/21 (where required by law) Authorized Representative Date Form SS 00 46 09 19 Page 1 of 1 Process Date: 02/11/21 Policy Expiration Date: 05/02/22 send to printer close window Policy No: CAA063233427 Current Term 02/16/2021-02/16/2022 Manage Your Policy Change Coverages Add/Replace Vehicle Remove Vehicles Add or Remove Driver Change Loan/Lease companies DRIVERS Name Date of Birth Driver Status Timothy Holmes Regular Driver Details Gender Male Marital Status Year First Licensed Accidents & Traffic Convictions Accidents 0 Total Traffic Convictions 0 .. ,.... ...,.,., ,.. ,M .. .. ._. .._Regular...... ...,. ..., .. Driver Details Gender MOW Marital Status 411111100 Year First Licensed Accidents & Traffic Convictions Accidents 0 Total Traffic Convictions 0 _.. Excluded Driver Details Gender Marital Status son"! Year First Licensed 40"' Accidents & Traffic Convictions Accidents 0 Total Traffic Convictions 0 VEHICLES Vehicle No, Year Make 2 2009 Chev Vehicle Details Identification NumberONW1',73 Garage Zip Code 90505 Annual Miles 5,501 - 7,500 Special Equipment None Sound Equipment None ... ......... 2018 .. __..... ........ Chev Vehicle Details Identification Number i�i15 Garage Zip Code 90505 Annual Miles 7,501 - 10,000 Special Equipment None Sound Equipment None Lienholder/other Interests Name Type lMlpr Lienholder COVERAGE LIMITS Vehicle No. Year Make Premium 2 2009 Chev $1,025 Coverage Details Coverages Limits of Liability Premium Liability Bodily Injury $1,000,000 Each Person $330 $1,000,000 Each Occurrence Property Damage $50,000 Each Occurrence $200 Physical Damage Comprehensive Deductible $500 $54 Collision Deductible $500 $226 Uninsured Motorist Uninsured & Underinsured Motorist(s) $1,000,000 Each Person $215 Bodily Injury $1,000,000 Each Occurrence Uninsured Deductible Waiver No Total Premium $1,025 3. .... .. 2018__. ,.Chev. _.. ,_... $1,468. _... .. _... Coverage Details Coverages Limits of Liability Premium Liability Bodily Injury $1,000,000 Each Person $380 $1,000,000 Each Occurrence Property Damage $50,000 Each Occurrence $230 Physical Damage Comprehensive Deductible $500 $78 Collision Deductible $500 $532 Uninsured Motorist Uninsured & Underinsured Motorist(s) $1,000,000 Each Person $248 Bodily Injury $1,000,000 Each Occurrence Uninsured Deductible Waiver No Total Premium $1,4469 Tokal Premium $2,493 ^m o You received a Policy Holder Savings Dividend last year in the amount of: $214 DISCOUNTS Policy Discounts Multi -Policy: Home Other Discounts: LoyaltyMulti , Multi Car Driver Discounts Timothy Holmes .. _. .., ..., .. ... ... _, .. ... 'Good Driver Good Driver Vehicle Discounts Vehicle 2: 2009 CHEV TAHOE LT SUV Verified Mileage Vehicle 3: 2018 CHEV SUBURBAN LT SUV ;VeriFled Mileage ENDORSEMENTSVehicle AND CERTIFICATES Number Title 2011 MEMBER'S AUTOMOBILE POLICY - POLICY NUMBER CHANGE 2052 LOSS PAYABLE - NOTICE TO LIENHOLDER 2184 EXCLUSION OF DESIGNATED PERSON 2367 AMENDATORY ENDORSEMENT 'T'he Inks onl1.i ,n rf .pl lyud art kids Wa.lr:� is k,r nf9al ry )....ml +arp.+an u+v a111y ranel n nr9G I rt'r•u :9'd to 's_VBrso.pa ya tr prisky` ("idbr'Yr ¢Kln7ra ,r ur'�m. ^rB�:,) laird dffd'f. °2lkonn!r Iha) l�rra rPl i a d ka yers Inuu.P....s r woo .,yv far, (i , a.ol a 7r, 'a nd VrMf:; & b."' ldy nnreYWn'II'I CPIs dz5:1iur. ton, nd rM6 ".;s^ III, th Iwt illy icruorll' cf, p6'IpP,v v.'Iod irtlTKU(,N-?lnsI1P;.s. y 1l's "s..... sri l is. h0jprul is,rnr.ss wady Nmd is :It a Cfn'11p1 nIhnn, Ve d&,,,i1:wn bf i,K c Dvlvaaiss, 9 Puluricunl nos, front. ."', str. 41.n5l° Crl sillo1 tha gb1,:V NrtY .n.. 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Yuy umitfsthlin deablir, oY a b.dd:s, '✓slit fr'raya '. f M.", snollo s,o rY 'fM. k.,-1:1,, psWMAI',t5, d: 1.1 eny oil,br rvYp P do ;.l6iMnC! 19rJ lcl.s, aA any dr-s „^ by 61{gJYlrip And Bilk 1 J 69 uerl Ckk"b ,k!u'yv.ie£h. and rl,n, ill'Ip it bo° AAA/Ug omyGr6ab-. U ,0. nw, of tin. A ul.sroblk C.-Wit, o0. D. 250J6, S n kA 0.nts, !-dd'.?. 799-5d:11:15, While nul: r'NgPlira:d, a re.VIxaduo f.— (o—illin.os fist y.rn o.lsb upoan r¢lquepk by Cl9nP ,bng .is c5k liawy 92,,6t•al ar yaur Ortac M u)ff e. fi,sur,—,r I!., prov, dead to quaRliltn:d A'A. (1.1, IrcruarnAlaers; sy Chw 1,,Wcinsu ansb 6.':I,don{pi^. or tote AUCamnrbilm Club ("Escys"nvje"). CA I0spt of Arcl,nnY;n+'lcc LIC MOf:1031.19 %Y'R4 '10'I6202 00 (,.pV, Ight' 0 201J Andu.onlpdde (Aub of filnu0-1I Calll'on WA. Aii Rlphcrl, mbsrve d. "I:, 1441 ref Y. IP Doll- 0 i.DAYI:YY-, CnWbobla is a oIs lbe.r dub s1'fd IaWd WI I:11u the All V.r'i'.a11 Auloorl,11 My As,nu'intlpl'u (AAAp in so -0 fedo., R1. I s110 'e I'- llleM 0 e's in.,',e foe Iuw,1f d:ra 1W., ada iu if!rules: Brtuye, 1,niol,hil, K,.rn, to, Angolr.s, Mons, I)- list, Roes. I'1:.i de, Searl Bernan. Ird -, Safi Dl.go, Sag I..u,s Ohl spot 5arna EfsM;.alp, TUlarc, si'Id V)ollurars. 1: i1[fd a fddlrerepll'. AAA clluh. 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 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 workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those provisior the agreement will automatically become void.. Signature of Applicant Agreement for: Dated: 4/28/21 Amendment #5651A Reviewed by: J L Date 03/31/2021