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PROOF OF INSURANCE (2022) CLOSEDDATE (MM/DD/YYYY) Ac"R" CERTIFICATE OF LIABILITY INSURANCE 04/14I2021 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 Janet Ramirez NA Merriwether & Williams Insurance Services rN(213) 258-3096 A (213) 336-3012 License No: 0001378 amire550 Montgomery St, Suite 550 INSURERS) AFFORDING COVERAGE �702 San Francisco CA 94111 ACE Fire Underwriters Insurance Company INSURED Hiscox Insurance Company Inc, Security Design Concepts INSURER C : 17943 W. El Caminito Dr, INSURER D INSURER E : Waddell AZ 85355 1INSURER F: rrnVFRecFs CPRTIRICeTP NIIMi CL2141417002 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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, N _ POLICY EFF POLICY LIMITS LTR TYPE OF INSURANCE INSD wVD POLICY NUMBER MM/DD/YYYY MMIDD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE ❑X OCCUR AGE � TkW. _ PREMISES. Ea occurrence 100,000 $ .WWI.... MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 2,000,000 A Y Y D96051785 04/14/2021 04/14/2022 GEN'LAGGREGATE LIMITAPPLIES PER: ! GENERAL AGGREGATE $ 4,000,000 PRODUCTS-COMP/OPAGG 4,000,000 $ [::]'PRO POLICY JECT LOC $ OTHER: AUTOMOBILE LIABILITY EL1 clNGLE. tl.IM1'H" de¢til�m $ ANYAUTO INJURY (Per person) $ OWNED _ SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY INJURY (Per accident) ........ ......... .................. RTY DAMAGE LAGGREGATE $ $ UMBRELLA LIAR OCCUR CCURRENCE $ �EXCESS LIAR CLAIMS -MADE _.ED $ Is RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NIA _ PERSTATUTE EOETPRH_ E,L: EACH ACCIDENT $ ,(Mandatory in NH) .L. DISEASE- EA EMPLOYEE $ ,L, DISEASE - POLICY LIMIT $ '... If yes, describe under DESCRIPTION OF OPERATIONS below B Professional Liability UDC-4803330-EO-21 04/14/2021 04/14/2022 [EachClaim $1,000,000 ggregate $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The Certificate Holder is added as Additional Insured with respects to our Insured's operations only. This insurance is primary and non-contributory as required by written contract. City of El Segundo, its officers, officials, employees, agents, and 350 Main St. ElSegundo CA 90245 CANCELLATION 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD :,&11eh3rM State Farm Fire and Casualty Company M cha son, 7XX 75085-3907 Pa BOX 853907 AT1 002369 _-0001. . A-24- 1357-FABE L RAMM, ROGER & �Illllllll�l�l�ll�llll�l�llll�llllllllllllll�llrl�lllllllrl��l� 0 ,I.z coo SFPP No:1205207424 Forms and Endorsements _Personal Liability Umbrella Fuel Oil Exclusion Amendatory Endorsement F FP-7950.2 FE-5837 FE-5897 RENEWAL CERTIFICATE I" Personal Liability Urnorella Policy JUL 07 2020 to JUL 07 2021 BILLED THROUGH SFPP COVERAGES AND LIMITS L Personal Liability $2, 000, 000 Self -Insured Retention None UNDERLYING EXPOSURES Our records show the following underlying information. This information was used in determining the rate of the policy. AUTOMOBILE EXPOSURES Automobile(s) 3 Automobile Operator(s) 2 OTHER LIABILITY EXPOSURES Personal Residential Annual Premium *Notify your agent immediately if the advve listed coverages and/or Underlying Exposures are incorrect s Your Coverages and/or bill can be affected if this Information Is not correct. 0 0 The Class 50 Discount has reduced the premium on your policy by $52.00 s a Required Underlying Insurance on reverse side $464.00 " -0-ww Moving? See your State Farm agenl.. N 3266 Agent JARED FINK INSURANCE AGCY INC See reverse far important infotmation. Tolonhnno lR9Sl1 Fi R_Ol3AR RFC P--.r-H nnnv Va onW) Type of Policy Automobile Liability Recreational Motor Vehicle Liability Including Passenger Bodily Injury Personal Residential Liability Watercraft Liability NOTICE TO POLICYHOLDER: CONTINUED FROM FRONT Required Underlying Insurance (Terms in Bold in this section are defined in the policy) Minimum Underlying Limits Combined Limits (Bodily Injury and Property Damage) or $500,000 Bodilylnjury- $500,000 5100,000 $100,000 Property Damage - Bodily Injury - Property Damage- Split Limits S 2 5 0, 0 0 0 Per Person $ 5 0 0, 0 0 0 Per Accident $ 10 0 , 0 0 0 Per Accident $ 2 5 0, 0 0 0 Per Person * 5 0 0, 0 0 0 Per Accident $ 10 0 , 0 0 0 Per Accident Policy changes requested before the "Date Prepared", which appear on this notice, are effective on the Effective Date of this policy unless otherwise indicated by a separate endorsement, binder, or amended declarations. Any coverage forms attached to this notice are also effective on the Effective Date of this policy. Policy changes requested after the "Date Prepared" will be sent to you as an amended declarations or as an endorsement to your policy. Billing for any additional premium for such changes will be mailed at a later date. Please keep this with your policy. = Sip ACE Fire Underwriters Insurance Company p Y Businessowners Policy Declarations This Policy is issued by the stock insurance company listed above ("Insurer"). AT LEAST ONE OF THE ENDORSEMENTS IS A CLAIMS MADE AND REPORTED COVERAGE SECTION. EXCEPT AS OTHERWISE PROVIDED HEREIN, THIS COVERAGE SECTION COVERS ONLY CLAIMS FIRST MADE AGAINST THE INSURED AND REPORTED TO THE INSURER DURING THE POLICY PERIOD OR THE EXTENDED REPORTING PERIOD. PLEASE READ THIS COVERAGE SECTION CAREFULLY. THE LIMITS OF LIABILITY AVAILABLE TO PAY INSURED DAMAGES SHALL BE REDUCED BY AMOUNTS INCURRED FOR CLAIMS EXPENSES. FURTHER NOTE THAT AMOUNTS INCURRED FOR DAMAGES AND CLAIMS EXPENSES SHALL ALSO BE APPLIED AGAINST THE RETENTION AMOUNT. Policy Number: D96051785 Renewal of: New Named Insured & Principal Address: SECURITY DESIGN CONCEPTS 17943 W El Caminito Dr Waddell, AZ 85355 ADVANCED PREMIUM: $264.00 Admitted Status: Admitted Policy Period Auditable/Not Auditable: Yes Auditable Period: Annual From 04-14-2021 To 04-14-2022 12:01 AM* Standard Time at your mailing address shown IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE INSURANCE AS STATED IN THIS POLICY Business Description: Services Section 2. LIABILITY Described Premises: 17943 W El Caminito Dr, Waddell, AZ 85355 w.... .......... Prem. Classification Class Code Rating Basis Premium Premium No. Basis Prem/O s PR/CO 1 Consultant- NOC _ 65171 Payroll 25,000 $26 0 LIMITS Other than Products/Completed Operations Aggregate $4,000,000 Products/Completed Operations Aggregate $4,000,000 Liability and Medical Expenses $2,000,000 Per Occurrence Damage to Premises Rented to You $100,000 Any One Premises Medical Expense $5,000 Per Person Combined Total Aggregate $4,000,000 All Locations Combined BOP-43591 a (04/19) © 2017 Page 1 of 3 POLICY NUMBER: D96051785 BUSINESSOWNERS BP 04 48 07 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Name Of Additional Insured Persons Or Organization City of El Segundo Information required to com lete this Schedule, if not shown above„ will be shown in the Declarations. Section II — Liability is amended as follows: B. With respect to the insurance afforded to these A. The following is added to Paragraph C. Who Is An additional insureds, the following is added to Insured: Paragraph D. Liability And Medical Expenses Limits Of Insurance: 3. Any person(s) or organization(s) shown in the Schedule is also an additional insured, 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 in the performance of your ongoing operations or in connection with your premises owned by or rented to you. However: a. The insurance afforded to such additional insured only applies to the extent permitted by law; and b. 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. 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 Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits Of Insurance shown in the Declarations. BP 04 48 0713 0 Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: D96051785 BUSINESSOWNERS BP 04 97 01 06 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST" OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Name Of Person Or Orcianization: City of El Segundo Information required to complete this Schedule, if not shown a Paragraph K. Transfer Of Rights Of Recovery Against Others To Us in Section III — Common Policy Conditions is amended by the addition of the following: 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. will be shown in the Declarations. BP 04 97 01 06 C ISO Properties, Inc., 2004 Page 1 of 1 13 Item C. OPTIONAL COVERAGES (LIABILITY) PRIVACY LIABILITY & DATA BREACH LIMITS Privacy Liability Each Claim Limit Privacy Liability Aggregate Data Breach Fund Each Claim Data Breach Aggregate Maximum Policy Aggregate Limit of Liability Retention Retroactive Date: Item E. COVERAGE FORMS $25,000 $25,000 $10,000 $10,000 $35,000 $1,000 04-14-2021 Total Data Breach Liability Premium: $75 Total Privacy Liability Premium: $35 Total Terrorism (TRIA) Premium: $3 Total General Liability Premium: $264 Total Policy Premium: $264.00 Form Number Edition Title BOP43591e 0419 BUSINESSOWNERS POLICY DECLARATIONS CC1k11i 0218 SIGNATURES BP0003 0713 BUSINESSOWNERS COVERAGE FORM BOP43603 0814 EXCLUSION -GENETICALLY MODIFIED ORGANISMS BOP43828 0614 ASBESTOS MATERIAL EXCLUSION POLLUTION,ORGANIC PATHOGEN, SILICA, ASBESTOS AND LEAD EXCLUSION WITH HOSTILE BOP43862 0914 FIRE AND HUMAN FOOD PRODUCT EXCEPTIONS BOP45202 0215 PRIVACY LIABILITY AND DATA BREACH FUND ENDORSEMENT BOP51381 1018 OPIOIDS GOODS OR PRODUCTS EXCLUSION - TOTAL BP0448 0713 ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION BP0497 0106 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US BP0501 0702 CALCULATION OF PREMIUM BP0517 0106 EXCLUSION - SILICA OR SILICA -RELATED DUST BP0595 0514 ELECTRONIC DATA LIABILITY - LIMITED COVERAGE BP0598 0713 AMENDMENT OF INSURED CONTRACT DEFINITION BP1488 0713 PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION BOP47736 0416 AMENDMENT OF BODILY INJURY DEFINITION - INCLUDING RESULTING MENTAL ANGUISH BOP-43591e (04/19) © 2017 Page 2 of 3 BP0523 0115 CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM BOP48573 0117 LEAD EXCLUSION BOP47643 0316 EMPLOYMENT -RELATED PRACTICES EXCLUSION BOP45068 1214 PROPERTY COVERAGE PART EXCLUSION BOP48528 1016 ASBESTOS, SILICA OR SIMILAR COMPOUNDS, INCLUDING MIXED DUST EXCLUSION BOP49665 0817 COMMUNICABLE OR INFECTIOUS DISEASES EXCLUSION - TOTAL ALL20887 1006 ACE PRODUCER COMPENSATION PRACTICES AND POLICIES ILP001 0104 U.S. TREASURY DEPARTMENT'S OFFICE OF FOREIGN ASSETS CONTROL ("OFAC") ADVISORY NOTICE TO POLICYHOLDERS ALL42490B 0716 U.S. FOREIGN ACCOUNT TAX COMPLIANCE ACT ("FATCA") ALL21101 1106 TRADE OR ECONOMIC SANCTIONS ENDORSEMENT BOP50397 0518 MARIJUANA EXCLUSION BOP52270 0619 WHO IS AN INSURED - SUBSIDIARIES OTHER THAN PORTFOLIO COMPANIES BP0515 1220 DISCLOSURE PURSUANT TO TERRORISM RISK INSURANCE ACT BPO138 0120 ARIZONA CHANGES Item F. Notice under this Policy shall be given to: Chubb North America Claims P.O. Box 5122 Scranton, PA 18505-0554 Toll Free: 844-539-3801 ACECRS-CLAIMS@chubb.com Item G. Producer Name and Mailing Address MERRIWETHER & WILLIAMS INSURANCE SERVICES, INC. 550 MONTGOMERY ST.#550 SAN FRANCISCO, CA 94104-0000 Item H. Producer Code: 279141 IN WITNESS WHEREOF, the Insurer has caused this Policy to be signed by its President and Secretary, and countersigned by a duly authorized representative of the Insurer. DATE: 04-14-2021 Authorized Representative BOP-43591 a (04/19) 0 2017 Page 3 of 3 CHUBB0 SIGNATURES Named Insured Endorsement Number SECURITY DESIGN CONCEPTS CC1k11i0218 _.._._..-.......�.._ ............ _ ..-......._ _. � ........ Policy Symbol Policy Number Policy Period Effective Date of Endorsement SER D96051785 04-14-2021 to 04-14-2022 04-14-2021 Issued By (Name of Insurance Company) ACE FIRE UNDERWRITERS INSURANCE COMPANY THE ONLY COMPANY APPLICABLE TO THIS POLICY IS THE COMPANY NAMED ON THE FIRST PAGE OF THE DECLARATIONS. By signing and delivering the policy to you, we state that it is a valid contract. INDEMNITY INSURANCE COMPANY OF NORTH AMERICA (A stock company) BANKERS STANDARD INSURANCE COMPANY (A stock company) ACE AMERICAN INSURANCE COMPANY (A stock company) ACE PROPERTY AND CASUALTY INSURANCE COMPANY (A stock company) INSURANCE COMPANY OF NORTH AMERICA (A stock company) PACIFIC EMPLOYERS INSURANCE COMPANY (A stock company) ACE FIRE UNDERWRITERS INSURANCE COMPANY (A stock company) WESTCHESTER FIRE INSURANCE COMPANY (A stock company) 436 Walnut Street, P.O. Box i000, Philadelphia, Pennsylvania 191o6-3703 REBECCA L. COLLINS, Secretary 5:� JOHN J. LUPICA, President CC-iKui (02/18) BUSINESSOWNERS BP 14 88 07 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. il • • �" Me • , 1 • This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM The following is added to Paragraph H. Other 2. You have agreed in writing in a contract or Insurance of Section III — Common Policy agreement that this insurance would be Conditions and supersedes any provision to the primary and would not seek contribution from contrary: any other insurance available to the additional Primary And Noncontributory Insurance insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: 1. The additional insured is a Named Insured under such other insurance; and BP 14 88 07 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1 CERTIFICATE OF LIABILITY INSURANCE DA4/114/2021 DD21 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 Diana Spinoglio NAME: BMR Insurance Agency, Inc. PHONEmt. (714) 838-1911 Na c7l i838 also P.O. Box 1025 &"nnrjrMAI. A dianas@bmrins.com Tustin CA 92781 INSURED Security Design Concepts, Inc 17943 W E1 Caminito Dr IG COVERAGE NAIC # Ins. Co.. 24074 Waddell AZ 85355 INSURERF; COVERAGES CERTIFICATE NUMBER:21-22 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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,. I> JZR TYPE OF INSURANCE D 'SU R POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP ',. MM/DD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ._ AWA'ffE._TUN CLAIMS -MADE OCCUR P'REMISf"S. Ea aacuaararrec�e';I MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERALAGGREGATE $ GEN L AGGREGATE LIMIT APPLIES PER: $ r E POLICY JLOC PRODUCTS - COMP/OPAGG I$ OTH'EW AUTOMOBILE LIABILITY COMBINED SHN 6.E lipir JEa araMdaml I $ BODILY INJURY (Per person) $ ,W ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS ROPERUd $ NON -OWNED HIREDAUTOS AUTOS �IDAMAGE....... : $ UMBRELLA LIAB [ICCRU EACH OCCURRENCE $ AGGREGATE $ EXCESS LIABRETELAIMS-MADE DED NTION $ $ WORKERS COMPENSATION R OTH- TATT ER. AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? (Mandatory in NH) � NIA y XWO60828126 1/17/2021 1/17/2022 EL. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE POLICY LIMIT J $ 1,000,000 If yes, descbbe under DESCRHPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) 30 days written notice of cancellation except SO days notice for non-payment of premium. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE Gary Arch/DIANA 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B (Ed. 7-01) POLICY INFORMATION PAGE ENDORSEMENT The following item(s) ❑ Insured's Name(WC 89 06 01) ❑ Item 3.13. Limits(WC 89 06 12) ❑ Policy Number(WC 89 06 02) ❑ Item 3.C. States(WC 89 06 13) ❑ Effective Date(WC 89 06 03) ❑ Item 3.D. Endorsement Numbers(WC 89 06 14) ❑ Expiration Date(WC 89 06 04) ❑ Item 4.' Class, Rate, Other(WC 89 04 15) ❑ Insured's Mailing Address(WC 89 06 05) ❑ Interim Adjustment of Premium(WC 89 04 16) ❑ Experience Modification(WC 89 04 06) ❑ Carrier Servicing Office(WC 89 06 17) ❑ Producer's Name(WC 89 06 07) ❑ Interstate/Intrastate Risk ID Number(WC 89 06 18) ❑ Change in Workplace of Insured(WC 89 06 08) ❑ Carrier Number(WC 89 06 19) ❑ Insured's Legal Status(WC 89 06 10) ❑ Issuing Agency/Producer Office Address(WC 89 06 25) ❑ Item 3.A. States(WC 89 06 11) is changed to read: Waiver of subrogation has been added in favor of City of El Segundo. See Extension of Information Page and any other document. * Item 4. Change To: Classifications Code Premium Basis Total Rate Per Estimated No. Estimated Annual $100 of Annual Remuneration Remuneration Premium " See Extension of Information Page Total Estimated Annual Premium $564.00 Total Estimated Cost $564.00 Minimum Premium: $178. oo AZ Deposit Premium: All other terms and conditions of this policy remain unchanged. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation " of the policy.) Endorsement Effective 01/17/2021 Endorsement No. 0001 Policy Effective 01/17/2021 Premium $250.00 State Policy No. XWO (22) 60 82 81 26 Insured SECURITY DESIGN CONCEPTS, INC Insurance Company The Ohio Casualty Insurance Company 11363 Countersigned by: WC 89 06 00 B (Ed. 7-01) 02001 National Council on Compensation Insurance, Inc.