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PROOF OF INSURANCE (2021 - 2022) CLOSED (2)Policy Number: uDc-47296e4 Date Entered Dz�5/2021nY Y)Y CERTIFICATE OF LIABILITY INSURANCE 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 NA E, Eugene J Solomon Solomon Insurance Agency IPNIONE' AX, -9409 10)414 4 92 37 (310m). 840 Apollo OEM, A Na E-MAILss:e ,41 gene@eugenesolomon.com ADORE Suite 306 .............�..m. INSURER(S) AFFORDING COVERAGE NAIC A El Segundo, CA 90245 Insurance Company INSURER AHiscox INSURED IM Consulting LLC INSURER B: Kristen Bergevin INSURER C„ 1142 S Holt Ave INSURERD: Unit 3 INSURER E: Los Angeles, CA 90035 INSURER F: COVERAGES CERTIFICATE NUMBER'„ REVISION NUMBER: THIS IS TO CERTIFY THA11 T 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 IIN O WVO POLICY NUMBER LY.. FF' POLICY EXP LIMITS.. MMIOD/YYYY MM/DDfYYYY A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 2,000,000 CLAIMS -MADE ® OCCUR X 'UDC-4729684 02/OS/2021 02/OS/2022 PREM. SES Ea ocpurrence. 100,0 S 00 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY 5 GEN'L AGGRErG'�A'�TE LIMIT APPLIES PER GENERAL AGGREGATE S 2,000,000 FRO- POLICY U........r PRO LOC PRODUCTS - COMPIOP AGG S 2,000,000 GSTHER:. $ AUTOMOBILE LIABILITY CC:"M'DINEID uINOILE L.�M•+Vd'T fiEn persdpnb) $ BODILY INJ;E_$ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOSHIRED BODILY INJ 5 (Per accden S NON -OWNED AUTOS ONLY AUTOS ONLY S UMBRELLA LIAR' OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS -MADE AGGREGATE S DED RETENTION S S "WORKERS COMPENSATION H- STATUTE ER AND EMPLOYERS' LIABILITY Y / N ANY PRO PRIETO RIPARTN ERIEXEC UTIVE p""""""'p E.L EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? Inl NIA �— II.. (Mandstoryin NH) E,L, DISEASE - EA EMPLOYEE S If yes, describe under DESCRIPTION OF OPERATIONS below E..L.. DISEASE POLICY LIMIT S A Professional Liability X UDC-4729684 02/05/2021 02/05/2022 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Public Relations Consulting Certificate Holder is also listed as Additional Insured CERTIFICATE HOLDER CANCELLATION City of El Segundo 350 Main Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo Ca 90245 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 f Iffs HISCOX Policy Number: Named Insured: Endorsement Number: Endorsement Effective: U DC-4729684-CGL-21 KNB Consulting LLC 1 February 5, 2021 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED, - AUTOMATIC STATU'S This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any per- son(s) or organization(s) for whom you are performing operations or leasing a premises when you and such person(s) or organiza- tion(s) have agreed in writing in a contract or agreement that such person(s) or organiza- tion(s) be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to lia- bility 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: 1. In the performance of your ongoing opera- tions; or 2. In connection with your premises owned by or rented to you. A person's or organization's status as an addi- tional insured under this endorsement ends when your operations or lease agreement for that additional insured are completed. r;. CGL E5421 CW (02/14) Includes copyrighted material of Insurance Services Office, Inc., with its Page 1 of 1 permission. For Roadside Assistance: 800-531 -8555 Report a claim, get coverage and deductible information, request a tow from the accident scene, schedule an appraisal or reserve a rental car using: usaa.com, USAA's Mobile App, or By calling 210-531-USAA (8722), our mobile phone shortcut number #8722 or 800-531-USAA. California Evidence of Financial Responsibility This ID card is evidence of liability insurance for your vehicle. The card is valid only as long as liability insurance remains in force. Keep a copy of the ID card in your vehicle at all times. You may be required to produce your identification card at vehicle registration or inspection, when applying for a driver's license, following an accident, or upon a law enforcement officer's request. FCA1 Rem. 6-13 50781-0513_...02 -- ------------------------------------------------------------------- —------------------ _-.------------------------__-_--_----------_-__-- b a c k CALIFORNIA EVIDENCE OF FINANCIAL RESPONSIBILITY Name and Address of Insured NAIC 25968 California Evidence of Financial Responsibility KRISTEN BERGEVIN Keep this card. 1142 S HOLT AVE APT 3 LOS ANGELES CA 90035-2423 IMPORTANT: The California Financial Responsibility Act (Section 16020) of the Vehicle Code requires every owner or operator of a vehicle subject to the requirements of the Financial Responsibility Act to carry evidence of financial responsibility in the vehicle at all times. Under vehicle code (Section 16028) every driver f involved in an accident must provide evidence of o financial responsibility at the scene. Failure to comply is I an infraction and shall be punishable by fines, d impoundment or license suspension. KRISTEN BERGEVIN Insurance Company USAA CASUALTY INSURANCE COMPANY Policy Number Effective Date Expiration Date 00748 27 03C 7101 1 06/01 /21 12/01 /21 Vehicle Make/Vehicle Identification Number Year LEXUS 2009 This policy provides at least the minimum amounts of liability insurance required by the CA VEH CODE SECTION 16056 for the specified vehicle and named insureds and may provide coverage for other persons and other vehicles as provided by the insurance policy. Additional copies available at usaa.com CONTACT US: 210-531-USAA(8722) OR 800-531-USAA 9800 Fredericksburg Road, San Antonio, Texas 78288 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: (U 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 # (.X_) 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 theworkers;' compensation provisions of Labor Code § 3700 1 must immediately comply with those proves o or e Eg eennentu automatically become void.. Signature of Applicant Date 2i8i2021 Print Name Kristen Bergevin Agreement for: Dated: __--• "� . Reviewed by: