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PROOF OF INSURANCE (2021) CLOSEDTIFFHOM-01 KPOUBLEY CERTIFICATE OF LIABILITY INSURANCE DATE712/202 YYY' rzrzoza 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 endorsements. PRODUCER License # 07577776 CO ACT Karen Gourley HUB International Insurance Services Inc. PHONE FAX 3390 University Avenue (AIC, No Ex�(909) 912-6438 {vc Nod Suite 300 5 55 Kp!j�R' CagU,1"1eyghubinternational Com Riverside, CA 92501 - _..... 9N 4YR ii(SI FufifiDRIYpNG,�CO E,RA,E..... ...... .... ,...r . - .-N.AIC# I suRERA,underwriters at C-I�yd"s L��c� n 615792 INSURED � INSURER B . I Tiffany Home Care InrsusaR um ._........ .... .. _ .... ._..... .. _. DBA: Always Right Home Care...... . W.•-�e . ....._. __..... .... _pNSURR .... 9700 Reseda Blvd., Ste 105 D . ... ,,,, ,,,... .. _.....___ Northridge, CA 91324-5516 1 IN'SURERE: INSURER F : OVERAGES 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. NNSR,,.___...- ,,,..... .TYPE OF INSURANCE ...�..-.... �ADC7L�,SUBR� .......... ....POLICY NUMBER.. � POLICY EFF I POLICY EXr+���..... - ...'. .....____ ._ ....,.-.,,,�.. LIMITS. A X COMMERCIAL GENERAL i I i µ ���� � 1,�00,0010; X = CLAIMS -MADE OCCUR 'W2B8EF20010 6/15/2020 6/15/2021RENTED0 X Retr O Date 6/15/03 MEIN lXu&rlymLkPgpxnp, 5,000 „ PpvDYwIIaIRr..._.. Included X N POLICY! LIMIT APPLIES PER: I b ,GENERAL AGGREGATE 3,000,000 _ IPET Loc Pl��rrrlsC�s coollaraAI .- 1,000000 OTHER. J_ _ �.....— A AUTOMOBILE LIABILITY COMBINED SINGLE LIMN" 1 ANY AUTO jW2B8EF20010 6/15/2020 i 611512021 ......... O1'",r+1'NED ; SCHEDULED r BODILY INJURY LPgrpvstrn '. AUTas ONLY Auros rDiLYYN wa (Ercc!�si.._. _ RR�� OW I� ... _........ ! AU Fi ONLY X ALOI CYa Cs1�1 Y !. I. prl ctt m.S� At�flA SE...,. ...:._: mm. Sublimit s 1,000,000 UMBRELLA LIAB I OCCUR ACkGkEhTE �. EACH O CURREiJ .0 , EXCESS LU1B CLAIMS -MADE DED RETENTION $ Y p N E LC OTH I AND EMPLOYERS' LIABILITY STdT_Lp'fE EMI .,... ..,.; WORKERS COMPENSATION PER W IETORIPXCLUDEIF�f.ECUTIVE ACq. DE 4T ANY PROPR F9n a1;MEMBEREXCLUDED' NIA andatcry n NH) -w I1 e�1, drrsc«Iha unr,Iear o. W Df SEA.E EAoE rf.. e._ D SCRiPTtlON P O E,RATQh'S' bolow a.L.IDISEASE POLICY LIMIT A Prof Liab RD 6P15103 IW288EF20010 611512020 i 6115/2021 1,000,600 q Prof Liab RD 6/15/03 W268EF20010 6/15/2020 6/15/2021 3,000,000 i E OESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) SeXuaUPhysical Misconduct (Sublimit) 1M/3M Employee theft: each occurrence limit 25k Certificate Holder is included as Additional Insured as respects to the General Liability when required by written contract per policy terms and conditions as respects Senior In Home Care Project for the City 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 ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DAT/ Y) 020 03/30/30/2020 PRODUCER THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Douglas J Carlson HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1820 S. Elena Avenue, Suite H ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Redondo Beach, CA 90277 INSURERS AFFORDING COVERAGE NAIC # ......... INSURED --------- INSURER A: Cypress Insurance Company __ Tiffany Homecare Inc. .... ..... ....... .w .... ......... INSURER B dba Always Right Home Care I INSURER C 9700 Reseda Blvd. Ste 105 ...-..... _ ["INSURER INsuRER D Northridge, CA 91324 R ........................................................... INSURER E. COVERAGES 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, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ........ ......,---.....-.- ---- ......_ .,FINSURAN ..... ILTR 1 lwNSRIrI TYPE O - ... ... CE POLICY NUMBER .......... OATEYM.... ..................._._ ._._. ......._ ......... ....... MIDDIYYEµ, _ � PpgTE MM/Dp YIYON LIMITS GENERAL LIABILITY EACH OCCURRENCE $ - �$ t GENERAL LIABILITY �. .,COMMERCIAL J� CLAIMS MADE 1 j OCCUR ........ MED EXP (Any one person) __ - _ $ ........... PERSONAL & ADV INJURY .__ _ _ __, $ _.............. ----..... _ ..................... .._......._ GENERAL AGGREGATE ..PRODUCTS $ ....... ,.. LIMIT GEN'L AGGREGATE IT APPLIES PER: COMP/OP AGG $ PROIT .I POLICY a PRO IEG ',T j LOC -, . I $ 1 — AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY i $ D AUTOS NON OWNE..�m (Per accident) .. ........... ......__,,........... �PROPERTY DAMAGE l 1 A (Per accident) i GARAGE LIABILITY I AUTO ONLY EA ACCIDENT ANY AUTO OTHER THAN .. . EA ACC $ OTHER AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITYO RRENCE $ OCCUR CLAIMS MADE AGGREGA E $.,. ...._._ DEDUCTIBLE $ RETENTION $ , $ WORKERS COMPENSATION AND A TIWC120214 WC 6 QIN TORAU 03/01/2020 03/01/2021 .TOR- LIMITS _ I ER. EMPLOYERS' LIABILITY f- E L ACCIDENT $ 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED?E --- I,4 L. DISEASE EA EMPLOYEE; $ 1,000,000 yes, � E1. DISEASE --POLICY LIMIT I $ 1,000,000 SPECif SPECIAL PROVISIONS below IAL. ISJO OTHER DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS City of El Segundo 350 Main Street El Segundo, CA 90245 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of El Segundo DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN 350 Main Street El Segundo, CA 90245 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 20 (12001108) ORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statment on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 26 (2001/08) Important Information Insured Tiffany HomeCare, Inc. 9700 Reseda Blvd Ste 105 Northridge, CA 91324-5516 I"- M E TATr, COMPAuNIES Agency R-T SPECIALTY INSURANCE SERVICES, LLC 500 S. Grand Avenue Suite 2100 Los Angeles, CA 90071 Changes to Your Workers' Compensation Policy with Cypress Insurance Company Policy Number TIWC120214 .......................... .. ........... Policy Period From March 1, 2020 to March 1, 2021, 12:01 AM, standard time at the insured's mailing address. Type of Endorsement Added CA CIGA Adjustment - 0% on 2019 Premium Transactions effective 03/01/2020 State: CA; New: 0.0000 Added Forms effective 03/01/2020 WC990402C - CA Waiver Of Right To Recover - Specific Added Waiver of Subrogation effective 03/01/2020 Name: City of El Segundo; Job Description: Per written contract Added Waiver of Subrogation Class Code effective 03/01/2020 State: CA; Code: 8827 Home Care Services Premium change: $ 318.00 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 See Above Insured Tiffany HomeCare, Inc. Insurance Company Cypress Insurance Company WC 99 00 13 (Ed. 11-14) Policy No, TIWC120214 Endorsement No, 1 Premium Countersigned by WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA WC990402C (Ed. 9-14) 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.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 5% of the applicable manual premium otherwise due on such remuneration subject to a policy maximum charge for all such waivers of 5% of total manual premium. The minimum premium for this endorsement is $350. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule Schedule Specific Waiver Person/Organization: City of El Segundo Job Description: Per written contract Waiver Premium: 350.00 Payroll Subject Class State to Waiver 8827 CA 9,144.00 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: 03/01/2020 Policy No.: TIWC120214 Endorsement No.: Insured: Insurance Company: Cypress Insurance Company WC 99 04 02C (Ed. 9-14) Countersigned by Premium $