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PROOF OF INSURANCE (2022 - 2022) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 12/18/2020 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 INSURERS , 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 endorsements). PRODUCER CONTACTNAME: PRESIDIO FIN AND INS SOLUTIONS 72256527 PHONE (805) 499-7300 FAIL (805) 499-7070 31365 OAK CREST DRIVE 225 (A'C, No, Ext). (AIO, No): WESTLAKE VILLAGE CA91362 &VIAILADDRESS: INSURED DROP FUSION IV 937 CYPRESS ST EL SEGUNDO CA 90245-2419 • I INSURER(S) AFFORDING COVERAGE NAIC# I INSURER A. Sentinel Insurance Company Ltd. INSURER B : INSURER C INSURER D : INSURER E : INSURER F : 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, INS TR TYPE OF INSURANCE ADDL SR SUER' POLICYNUMBER POLICY EFF POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $2,000,000 CLAIMS-„MADEI X OCCUR L General i IBbklltyP X DAMAGE TO RENTED 4 $1,000,000 MED EXP (Any one person) $10,000 A X 72SBA BD7391 02/01/2021 02/01/2022 PERSONAL & ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY PRO- JECT LOC PRODUCTS -COMPIOPAGG $4,000,000 OTHEIT: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ...... aarxid. nI BODILY INJURY (Per person) '.. ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) HIRED NON -OWNED PROPERTY DAMAGE AUTOS AUTOS (Per accident) UMSRELLA. LIAR OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS - MADE AGGREGATE ED RETENTION $ I WORKERS COMPENSATION PER 0T H- AND EMPLOYERS' LIABILITY STAT TE R E.L. EACH ACCIDENT E.L.DISEASE-EA EMPLOYEE' ANY YIN PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBEREXCLUDED? NIA (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT D SCR PTION OF OEERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schadule, 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. HOLDER ° EL 111111 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 90245-3813 IN ACCORDANCE WRH THE POLICY PROVISIONS. AUTNOR17ED REPRESENTATIVE ©1988 2015 ACORD CORPORATIO All ightS res ed, ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT POLICY. w This endorsement changes the policy effective on the Inception Date of the policy unless another date is indicated below: Policy SBABD7391 SC Named Insured and Mailing Address; DROPFUSION IV 937 CYPRESS ST EL SEGUNDO CA 90245 Policy Change Effective Date: 02/01/21 Effective hour is the sane as stated in the Declarations Page of the Policy. Agent PRESIDIO FIN AND INS SOLUTIONS Code: 256527 POLICY CHANGES: SENTINEL INSURANCE COMPANY, LIMITED ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING STATEMENT. IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BANK ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A BILL. PREMIUMNO `.... AS POLICY 1 LIABILITY f MEDICAL ARE REVISED LIABILITY ` $1,000,000 EACH OCCURRENCE TO $2,000,000 EACH OCCURRENCE PERSONAL AND ADVERTISING INJURY LIMIT IS CHANGED FROM $1,000,000 TO $2,000,000 ENDORSEMENTTAIS O rm SS 12 11 04 05 T Page001 (_ PAGE) Date:Process 12/18/20 ry I.- - - (CONTINUED ON NEXT . , M", THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement changes the policy effective on the Inception Date of the policy unless another date is indicated below: Policy Number: 72 SBA BD7391 SC Named Insured and Mailing Address; DROPFUSION IV 937 CYPRESS ST EL SEGUNDO CA 90245 Policy Change Effective Date: 02/01/21 Effective hour is the same as stated in the Declarations Page of the Policy. gPRESIDIOFIN i INS SOLUTIONS Cod e: 256527 POLICY CHANGES: INSURANCE COMPANY, LIMITED ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING STATEMENT.IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BANK ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A BILL. POLICYNO PREMIUM DUE AS OF DAA BUSINESS LIABILITY OPTIONAL COVERAGES ARE REVISED ADDITIONAL INSURED(S) ARE ADDED THE FOLLOWING ARE ADDITIONAL INSURED FOR BUSINESS LIABILITY COVERAGE IN THIS POLICY. LOCATION 001 BUILDING 001 PERSON/ORGANIZATION: SEE FORM IH 12 00 FORM NUMBERS OF ENDORSEMENTS ADDED AT ENDORSEMENT ISSUE: PRO RATA FACTOR: 1.000 THIS ENDORSEMENT DOES NOT CHANGE THE POLICY EXCEPT AS SHOWN. Form SS 12 11 04 05 T Page001 (CONTINUED ON NEXT PAGE) Date:Process 12/18/20 Policy Effective: 02/01/21 Policyit i : 02/01/22 POLICY C (Continued) Policy Number: 72 SBA BD7391 Policy Change Number: 001 AGGREGATE LIMITS: PRODUCTS -COMPLETED OPERATIONS AGGREGATE LIMIT IS CHANGED FROM $2,000,000 TO $4,000,000 GENERAL AGGREGATE LIMIT IS CHANGED FROM $2,000,000 TO $4,000,000 Form SS 12 1104 05 T Page 002 Process Date: 12 / 18 / 2 0 Policy Effective Date: 0 2 / 01 / 21 Policy Expiration Date: 02/01/22 POLICY NUMBER: 72 SBA BD7391 THIS ENDORSEMENT CHANGESPOLICY. ADDITIONAL INSURED - PERSON -ORGANIZATION LOC 001 BLDG 001 CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO, CA 90245-3813 Form IH 12 00 11 85 T SEQ. NO. 001 Printed in U.S.A. Page 001 Process Date: 12 / 18 / 2 0 Expiration Date: 0 2 / 01 / 2 2 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDr✓YYI) 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 terns 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 CT Carla Ramirez ElSegundo CA 90245 INSURERF: 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 CLAIMS. (PAID ..._.................................. ,_, ..., ...,... .. .... ... h 0U CEFF 1.,,OLEXP POLI INTR TYPE OF INSURANCE A I7 R1 MMIDD INSD vivoPOLICXNUMBER M2Y ......... LIMITS CO L LIABILITY ... CLAIMS-MADEE ... . ................. "a .,, ... OCCUR �rri nce $ E MED EXP (Any one ers.�o.n.,).. . ..is .... 1 _J_—.. �....... .. ...... .............. w;�ErJI9.AG�GR'ECwATIjIR'LIMITAPPLIESPER: .............. �.GEINERAILAGGREGA$,,,,,, ....TE POLICY PRO LOC JEC I' wwwww wwwww PRODUCTS - COMP/OP AGG $ OTHERS ......m , AUTOMOBILE LIABILITY COMOWED VNOLE LIMIT is 1,000,000 00 AA8fd�%1�4En�o,...........,..� ANY AUTO BODILY INJURY (Per person) L..... $ A CSCHEDULED OWNEDSONLY NXTGFT4R1R-00-CA 06/23/2021 06/23/2022 BODILY INJURY (Per accident) $ A UTO AUTOS HIRED ..w NON -OWNED II'�fif7PERT'YDAMAk"aE 11 $ AUTOS ONLY "�„ AUTOS ONLY ,(G'or�rcYonrul,) ......... ..... f„, ....._. __._,__ ------------- ELLALIAB OCCUR EACH OCCURRENCE $ EXCESSLIAB � CLAIMS -MADE — -... AGGREGATE [$,_„ DED RETENTION $ $ WORKERS COMPENSATION �; (( PER LOTH 1 I AND EMPLOYERS' LIABILITY ...... 1 STATUTE IER .......... .... ANYPROPRIETOR/PARTNERIEXECUTIVE X / N E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) N/A --' - ---- If . DESCRIPTION PTION OF OPERATIONS below .E.L.DISEASEEAEMPLOYEEI.$ E.L. DISEASE - POLICY LIMIT I $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) The certificate holder is also named as additional insured with respect to liability arising out of the operations of the named insured. 6:CKIIrlt;AIt MULUIr:K City of El Segundo, its officers, officials, employees agents and volunteers 350 Main St. ElSegundo CA 90245 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD MARKRCO-01 JULIERA 144cORO` DATE (MMIDD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE 6/8/2021 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. NFP Prope & Casualty Services, Inc. 8201 Northlayden Road Scottsdale, AZ'862 8 515-0123 5s(&,nf,D.com 928) 775-3429 INSURED INSURER B :. ... ... ....f .... .. ... Marc R. Cohen, MD INSURER c 346 Manhattan Ave INSURER D Hermosa Beach, CA 90254 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, MAY HAVE BEEN REDUCED BY PAID CLAIMS. EXCLUSIONS AND CONDITIONS F SUCH POLICIES, NUMBER ---... __......_ ..._.___ —... LTR TYPE OF INSURANCE Y, POLICY INSR ,ADDL '5UBR4 POLICY EFF POLICY EXP .................................._.... �.I�� 1 LIMITS COMMERCIAL GENERAL LIABILITY _ ..------ .EACH OCCURRENCE CLAIMS -MADE OCCUR DAMAGE TO RENTED _ -PR LM1.3 ..LFa.o�ur[�n�a $ _ MED EXP (Any one Person) � S __ PERSONAL & ADV INJURY S _BN"L AtGGRIEGATE. LIMIT APPLIES PER: � GENERAL AGGREGATE POLICYJECT 1:1 LOC PRODUCTS COMP/OP OTHERCOMONED 5.... r$ AUTOMOBILE OVJNED LIABILITY SCHEDULED � �INGLLtCMi'T $ ANY AUTO BODDI,Ly,lNJ�URYteer,oerson) , AUTOS ONLY AUTOS BODILY INJURY (Per accident,) S,,,m, E� NI� ��O [�� P4C)PERTY...DAMAGE .� ............ AUTOS ONLY ..� ARO"CTCia�t",Y ( i,Per,aceA(fenf) ......... mmg. S UMBREL LA LIAB OCCUR pp EXCESS LIAB CLAIMS MADE j AGGREGATE- . ..........r. DIED RETENTION $ PER OT11 WORKERS COMPENSATION I STFTUTE Ir R --------------------- --- ANY PROPRIETOR/PARTNER/EXECUTIVE N /A 1.A ACCIDENT Is AND EMPLOYERS' LIABILITY ory in EA DESCRIPTION OF OPERATIONS below �. ................ .. .......... ......... _...._ E1, DISEASE, POLICPIO IT ,$„.-- If es, describe under w t LIMIT $ A 'Professional Liab X E0000045366-04 611/2021 1I 6/1/2022 Each Claim 1,000,000 A Professional Liab X E0000045365-04 6/1/2021 I 6/1/2022 JAggregate 3,000,000 DESCRIPTION OF OPERATIONS I (LOCATIONS I VEHICLES (ACORD 101 Additional Remarks Schedule, may be attached If more space Is required) The certificate holder is named additional insured with respects to professional liability per endorsement EO 09 54 08 20. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Milan A. Collins dba: Dro fusionlV THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P ACCORDANCE WITH THE POLICY PROVISIONS. 937 Cypress St. El Segundo, CA 90245-2419 ••••••• ......••• AUTHORIZED REPRESENTATIVE ............. _...... ........... ,....._..._._ ..... . .................... ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CITY OF EL SEGUNDO i 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 # (_V) 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 . s% egmpensation provisions of Labor Code § 3700 1 must immediately comply with those provisions "" men t will 'utomatically become void. Signature of Applicant Date r ' Agreement for: Drop Fusion - Agreement No. 5993 Dated: `ol? Reviewed by Z,_�