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PROOF OF INSURANCE (2022 - 2022) CLOSEDEFFIC-1 OP ID: KN ,4coRo,, CERTIFICATE OF LIABILITY INSURANCE `.�•-' PDATE(MM/DD/YYYY) 05/26/2021 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). PRODUCER 209-526-2697 Nicholson Insurance, Inc. License # 0498116 CONTACT Karen A. Nicholson NAME: PHONE 209-526-2697 FAX 209-526-4631 (A/C, No, Ext): (A/C, No): 4317 Northstar Way, Ste B E-MAIL karen@nicholsoninc.com ADDRESS: Modesto, CA 95356 Karen A. Nicholson INSURERS AFFORDING COVERAGE NAIC # INSURERA: Homeland Ins Co of New York 34452 INSURED Efficient X-Ray Inc. dba Efficient Environmental Services 9650 Topanga Can on Place Chatsworth, CA 91311 INSURER B: Atlantic Specialty Ins Co 27154 State Compensation Ins Fund INSURERC: p 35076 INSURER D INSURER E : INSURER F : 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 DDL INSD UBR WVD POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE j OCCUR 793-01-08-70-0000 02/20/2021 02/20/2022 EACH OCCURRENCE $ 2,000,000 FIR I ESES S( Ea occurrence RENTED FIR $ 50,000 MED EXP (Any oneperson) $ 5,000 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X JECT El LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OPAGG $ 2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY 793-01-08-71-0000 02/20/2021 02/20/2022 COMBINED SINGLE LIMIT Ea accident 1,000,000 $ X BODILY INJURY Perperson) $ BODILY INJURY Per accident $ X PROPERTY DAMAGE Per accident $ A UMBRELLA LIAB EXCESS LAB X OCCUR CLAIMS -MADE 793-01-08-72-0000 02/20/2021 02/20/2022 EACH OCCURRENCE $ 1,000,000 X AGGREGATE $ DED X RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N /A X 9054402 05/01 /2021 05/01 /2022 X PER OTH- STATUTE ER E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE- EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of El Segundo is listed as Additional Insured with Waiver of Subrogation to apply to Worker's Compensation. CERTIFICATE HOLDER CANCELLATION CITYOEL 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. 350 Main St AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Policy Number: 793-01-08-70-0000 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS -- SCHEDULED PERSON OR ORGANIZATION - FORM III This endorsement modifies coverage provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS ENVIRONMENTAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations Any person or organization that the Any location where required by the "Named Insured" agreed to add as an written contract or written agreement additional insured in a written in which the "Named Insured" agreed to contract or written agreement that was add the person or organization fully executed by the "Named insured" qualifying as an additional insured prior to the performance of the "Named under this endorsement. Znsured's" work that is the subject of such written contract or written agreement. Coverage afforded to such person or organization will not be broader than the scope of .insurance agreed to by the "Named Insured" in such written contract or written agreement. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. SECTION II - WHO IS AN INSURED is amended to include 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, environmental damage or personal and advertising injury caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the iocation(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contractor 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. S. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to bodily injury, property damage or environmental damage occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or OSENV GE 346 (01 19) Contains copyrighted material of Insurance Services Office, Inc. with its permission. Page 1 of 2 Copyright 2019, OneBeacon Insurance Group LLC E-INSURED Policy Number: 793-01-08-70-0000 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST This endorsement only modifies coverage provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS ENVIRONMENTAL LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Any person or organization that the "Named Insured" agreed to waive its rights of recovery against in a written contract or written agreement that was fully executed by the "Named Insured" prior to the performance of the "Named Insureds" work that is the subject of such written contract or written agreement. Such waiver will not be broader than the scope of the waiver agreed to by the "Named Insured" in such written contract or written agreement. SECTION IV - CONDITIONS, 13. Transfer of Rights of Recovery Against Others To Us is deleted and replaced with the following: 13. Transfer of Rights of Recovery Against Others To Us If the insured has rights to recover all or part of any payment we have made under this policy, those rights are transferred to us. The insured must do nothing to impair them. At our request, the insured will bring suit or transfer those rights to us and help us enforce them. Any recovery will be paid first to us until all amounts we have spent on a claim or suit have been reimbursed. The insured expressly waives the right to be made whole by any such recovery. 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. All other terms and conditions remain the same. OBENV GE 320 (0411) Includes copyrighted material of Insurance Services Office, Inc. 'I of 1 Copyright 2011, OneBeacon Insurance Group LLC E-iNSURED THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies coverage provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS ENVIRONMENTAL LIABILITY COVERAGE PART SECTION IV - CONDITIONS, 8. Other Insurance, is amended by adding the following paragraph: This insurance will be considered primary to, and non-contributory with any other insurance issued directly to a person or organization added as an additional insured under this policy, only if you specifically agree, in a written contract or agreement, that this insurance must be primary to, and non-contributory with, such other insurance. All other terms and conditions remain the same. OBENV GB 319 (0211) includes copyrighted material of Insurance Services Office, Inc. 1 of 1 Copyright 2011, OneBeacon Insurance Group LLC E-INSURED Policy Number: 793-01-08-70-0000 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION O' This endorsement only modifies coverage provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS ENVIRONMENTAL LIABILITY COVERAGE PART SCHEDULE came or Person or urganization: Any person or organization that the "Named Insured" agreed to add as an additional insured in a written contract or written agreement that was fully executed by the "Named Insured" prior to the performance of the "Named Insureds" work that is the subject of such written contract or written agreement. Coverage afforded to such person or organization will not be broader than the scope of insurance agreed to by the "Named Insured" in such written contract or written agreement. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. SECTION II - WHO IS AN INSURED is amended to include as an insured the person or organization shown in the SCHEDULE above, but only with respect to liability arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to bodily injury, property damage or environmental damage occurring after: (a) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (b) That portion of your work out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. All other terms and conditions remain the same. OBENV GE 301 (02 11) Includes copyrighted material of Insurance Services Office, Inc. 1 of 1 Copyright 2011, OneEeacon Insurance Group LLC E-INSURED ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS HOME OFFICE SAN FRANCISCO EFFECTIVE MAY 1, 2021 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING MAY 1, 2022 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME EFFICIENT X-RAY INC 9650 TOPANGA CANYON PL STE F CHATSWORTH, CA 91311 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 POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER JOB DESCRIPTION BLANKET WAIVER OF SUBROGATION REP 05 9054402-21 RENEWAL NA 2-17-73-22 PAGE 1 OF NOTHING 1N THIS ENDORSEMENT SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS ABOVE STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS IN THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 2572 AUTHORIZED REPRESENT IVE SCIF FORM 10217 (REV.4-2018) APRIL 30, 2021 PRESIDENT AND CEO 1 OLD DP 277