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PROOF OF INSURANCE (2021 - 2021) CLOSED
ACCOR " CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 5/13/2020 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 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: COMPLETE EQUITY MARKETS INC a/Co"ro Ext: 847 541-0900 a/c No: 847 541-0444 A DRIESS: 1190 Flex Court INSURER(S) AFFORDING COVERAGE NAIC# Lake Zurich, IL 60047 INSURERA : Underwriters at Lloyd's, London dba Complete Equity Markets Insurance Agency Inc. INSURED INSURER B MAK Fire Protection Engineering INSURER C INSURER D7 & Consulting, Inc. INSURER E 7 12130 Rahn Avenue INSURERF: Granada Hills CA 91344 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. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE � OCCUR TO RENTE DAMAGE SES (E. occurrDence)$ PREM 50,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 2,000,000 A X 1701127 3/16/2020 3/16/2021 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY ❑PRO ❑ LOC JECT PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/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 X 94785 6/1/2020 6/1/2021 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) Subject to all policy terms, conditions, exclusions and endorsements of each respective policy. City of El Segundo, its officers, officials, employees, agents and volunteers is an additional insured with Primary/Non-Contributory with 30-Day Notice of Cancellation but only per the terms & conditions of the endorsement generated for each respective policy and subject to all policy terms, conditions, exclusions and endorsements. Please see pages 2 and 3 for additional information CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo, its officers, officials, employees, agents and volunteers THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Carol Lynn Urner AUTHORIZED REPRESENTATIVE 314 Main Street El Segundo, CA 90245 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD IMPORTANT NOTICE: 1. The insurance policy that you have purchased is being issued by an insurer that is not licensed by the State of California. These companies are called "nonadmitted" or "surplus line" insurers. 2. The insurer is not subject to the financial solvency regulation and enforcement that apply to California licensed insurers. 3. The insurer does not participate in any of the insurance guarantee funds created by California law. Therefore, these funds will not pay your claims or protect your assets if the insurer becomes insolvent and is unable to make payments as promised. 4. The insurer should be licensed either as a foreign insurer in another state in the United States or as a non -United. States (alien) insurer. You should ask questions of your insurance agent, broker, or "surplus line" broker or contact the California Department of Insurance at the toll -free number 1-800-927-4357 or internet website www.insurance.ca.gov. Ask whether or not the insurer is licensed as a foreign or non -United States (alien) insurer and for additional information about the insurer. You may also visit the NAICs internet website at www.naic.org. The NAIC - the National Association of Insurance Commissioners - is the regulatory support organization created and governed by the chief insurance regulators in the United States. 5. Foreign insurers should be licensed by a state in the United States and you may contact that states department of insurance to obtain more information about that insurer. You can find a link to each state from this NAIC internet website: https://naic.org/state—web—map.htm. 6. For non -United States (alien) insurers, the insurer should be licensed by a country outside of the United States and should be on the NAICs International Insurers Department (IID) listing of approved nonadmitted non -United States insurers. Ask your agent, broker, or "surplus line" broker to obtain more information about that insurer. 7. California maintains a "List of Approved Surplus Line Insurers (LASLI)." Ask your agent or broker if the insurer is on that list, or view that list at the internet website of the California Department of Insurance: www.insurance.ca.gov/01-consumers/120-company/07-lasli/lasli.cf m. . If you, as the applicant, required that the insurance policy you have purchased be effective immediately, either because existing coverage was ping to lapse within two business days or because you were .required to have coverage within two business days, and ou did not recei ve this disclosure form and a request for your signature until alter coverage became effective, you have the right to cancel this policy within five days of receiving this disclosure. If you cancel coverage, the pre nium will be prorated and any brokers fee charged for this insurance will be returned to you. D-2 (Effective January 1, 2020) AMENDATORY ENDORSEMENT NO.: 1701127 INSURED: A4AK FIRE PROTECTION ENGINEERING & ADDITIONAL PREMIUM: Included CONSULTING, INC. RETURN PREMIUM: N/A EFFECTIVE: March 16, 2020 to March 16, 2021 +IhNOR 'I �, . IR F 14 50210,01'sm 3,016, 1 In consideration of the additional premium paid as shown above, it is hereby understood and agreed that Underwriters shall provide a 30-day written notice of cancellation regarding this policy of insurance to: Ms. Carol Lynn Urner City of El Segundo City of El Segundo 314 Main Street El Segundo CA 90245 For correctional purposes only. This endorsement replaces Endorsement #13 attached to Endorsement 1701127 issued March 16, 2020 All other terms, conditions, limits and exclusions remain unchanged. Attached to and forming part of Cover Note/Certificate/Policy No.: NI 9023 Dated: March 26, 2020 AUTHORIZATION NO.: (UMR) B0429BA2001027 AIF 23911 (06/99) (UMR) B0429BA2001027 P14**34 Endorsement #35 UNDERWRITERS AT LLOYD'S, LONDON Complete E Ldty Markets, Inc. dba Umplete P�l �Um ity Mar�ets Iunce q raAgwi, bic, ,CASL-,, OD44077) �—d By , 4�' � ?-T A4y' Lawrence T.P. Molloy AMENDATORY ENDORSEMENT NO.: 94785 ADDITIONAL PREMIUM: Included ASSURED: MAK FIRE PROTECTION ENGINEERING & CONSULTING, INC. EFFECTIVE: June 1, 2020 to June 1, 2021 In consideration of the additional premium paid as shown above, it is hereby understood and agreed that if Underwriters cancel this insurance for any reason other than non-payment of premium, Underwriters shall provide a 30-day written notice of cancellation to the following: Ms. Carol Lynn Urner City of El Segundo 314 Main Street El Segundo CA 90245 All other terms, conditions, limits and exclusions remain unchanged. Attached to and forming part of Certificate No.: CEM 58 - 20 Dated: June 9, 2020 UNDERWRITERS AT LLOYD'S, LONDON AIF 2119 (09/08) Complete Equity Markets, Inc. dba Complete Equity Markets Insurau�cre A�e��cr�P Irt (CASL#OD44077) (UMR) B0429BA2001026 Lib"23 revised 7/04 8/04 9/08 By Lawrence T.P. Molloy Endorsement #15 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 # 4 l 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 bec�e�"beoj*!orkers'jcompensation provisions of labor Code 370 I must Signature of Applicant greement will automatically become voids immediately comply with tho isloDate 2r Agreement for: I j12Pl1'I i'I,l + (Oft I•il n Dated: AV - .... Reviewed by: