PROOF OF INSURANCE (2021 - 2021) CLOSED (2)CERTIFICATE OF LIABILITY INSURANCE
DATE (MWDDfYYYY)
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 1400 E. Cooley Dr. Ste. 202-A NAME-
JERRY MACIAS
No Hassle Insurance Agency NAME-- JERRY FAX
y .g1n. (BBB}aa0409a Arc : (909)793»79110
Colton, CA 92324 E AIL
_"macies nohassleins.net
License #: OE74924 _ „„„„„ INSURER($) AFFORDING COVERAGE _ NAIc k
INSURED INSURER B
Christopher Heppell DBA: Precision Reef Systems ---------•-••
INSURER C :
3537 Torrance Blvd, #24 iN$uRERI?;_,,_ _,,---
Torrance, CA90503 INSURER E.,_mm
INSURER F :
COVERAGES CERTIFICATE NUMBER. 00004050-1.9094 REVISION NUMBER: 9
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 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.
'ASR SRPOLICY NUMBER PO dC MM � (+ _ LIMITS
TYPE OF INSURANCE wvn ITS
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE NJ OCCUR
Y
CL 1757885D
06111/2020
06111/2021
EACH OCCURRENCE
s 1,000000
$ 1 OO Oy OO
MEDEXP An aneFereon
$ 60O0
PERSONAL & ADV INJURY v
$ 1.000 000
GEN'LAGGREGATE LIMIT APPLIES PER:
POLICY E CT LOG
+GCNERALAGGREGATE
s 2,000 000
_
PRODUCTS -COMPIOPAGG
$ 2,000,000
Deductible
$ 0 '......
OTHERt
AUTOMOBILE LIABILITY
O )-0r NLEE u1Mt .
�: ,.�.... L
S-..,-..-.....-.._...,...,
ANY AUTO
BODILY INJURY (Per person)
$
OWNEDSCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
BODILY INJURY (Par accident)
S
PROPERTYOA11,tlAGE
P rra itienU
$
S
UMBRELLA LIAR OCCUR
W
EACH OCCURRENCE
S
AGGREGATE
$
EXCESS LIAR CLAIMS -MADE'.
DED RETENTIONS
S
WORKERS COMPENSATION
AND EMPLOYERS" LIABILITY Y f N
ANYPROPRIETORfPARTNERlEXECUTIVE F
OFFICERIMEMBER EXCLUDED?
NIA
OTH-
TA7 " 0� -
E,L EACHACCIDENT
S
--W
(Mandatory In NH)
If yea, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE • EA EMPLOYE
.....
S
--""'�""""'-
E.L. DISEASE • POLICY LWIT
$
DESCRIPTION OF OPERATIONS 1 LOCATIONS f VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H more alpaca Is required)
The City of El Segundo and its employees
350 Main Street
El Segundo, 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
vmn
01968-201 ORD CORPORATION. All rahts reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
Printed by JMA on June 10, 2020 at 03:42PM
Harada, Patricia
From: Kristina Kora-Beckman
Sent: Thursday, August 20, 2020 12:14 PM
To: Harada, Patricia
Cc: Shilling, Mona; Le May, Jessie; Lillio, Joseph
Subject: Precision Reef System - General Liability Endorsement Insurance Waiver
Importance: High
Hi Patricia,
Hope you and your family are well..
Regarding Precision Reef System's insurance, Joe Lilio has approved waiving the GL endorsement this time (please see
email below).
Please let me know if anything else is needed to process the waiver.
Thank you,
El Segundo Public Library
ill W. Mariposa
El Segundo, CA • .
a524-2772
•
From: Lillio, Joseph
Sent: Thursday, August 20, 2020 9:58 AM
To: Kristina Kora-Beckman
Cc: McCollum, Melissa
Subject: RE: Insurance Cost Relative to Service Agreement Value
The liability exposure seems very low. I am okay with waiving the endorsement this time..
The reason I asked about the technician being supervised is, there is risk of kids in the library being exposed to the
technician's equipment or chemicals and possibly being injured. I would like to have assurance that staff is taking a
proactive approach and ensuring curious children are not permitted near the tank while it is being cleaned. If the
company had the endorsement, I would not be asking this question.
I�a%raaMI
(MMT*qyyY)
CERTIFICATE OF LIABILITY INSURANCE DQW20211
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 POLMIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERIS), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDEFL
IMPORTANT: It the cartifleate holder Is an ADDITIONAL INSURED, the palleyfles) must have ADDITIONAL INSURED provisions or be endomed,
If SUBROGATION IS WAIVED, subJect to the terms and conditions of the palicy, certain Wicies may require an andorsement A statement or
this cortificatede" not confor qghtstotbeceirlifficate holderiolleaof mach andarsomooMl.
Mefissasanders PROWC" NAW,-�'
Sfiife Farf n, Went K Whitlock Insurance Agency Inc PHONE 310-82 1 -0864 FAX rs�t 310-fAI-6199
IAM� NP. W;-, -- -7--- .. .. ....... ....... ......
26441, H1r4,94, Rd Sto 503 IO
fi,-MAIL niefiss,a.sanders.1s,aki@statelarm,wnii
R O2 hng Hills Estates, CA 9074 AVREW WSWItER(S) AFIRIANO - COVEMOE 4 NAIJal a.
jK5,jjA6A A Slaw Fami Mutual Aulamoble insurano pa J 5178
— ------ . .....
Chnstapher Heippell
77'12 Goddard Ave
Los Angeles,, CA 90045
COVERA GE$ CERTIFICATE NUMBER.
REVISION NUMBER:
THIS M TO CIERTIFY THAT T14E POCICES OF INSURANCE LISITO BELOW HAVE BEEN ISSUED, TO THE INSURED NAMED ABOVE FOR THE POLICY PEROD
INDMA"M,D, NOTWTHS7ANOWD, ANY REQUIREMENT, 'II I*A OR CON01110N OFANY CIONTRAC3
OR OTHER fY)CUMIENT VATH RESPECT TO MICH PUS
CEIRTIFKATE MAY BE ISSUED OR MAY PERTAIN, 1HE INSURANCE, AFFORDED BY THE POUOES
()ESCROIED HEREIN IS SUBJECT TO ALL THE TERMS
EXCAVSIONS AND CONOMONS OFSUCH POLICIES, LIMITS SHOVAII MAY HAVE BEEN REDUCED BY PAID CLAIMS,
.......... . . . ................. .. . 60,
rYPf OIF INSURANCE !A9MIwR, ..........
*ki6t4s; . . ... ........ . . ......... . ..
LAW'S
001MMEACIAL GERfKAt LIAMLITY
0CCVRF0MTVZ s
'EACH
...... .....
PrrASONAt & �CV INJURY 5
1 fI UWr AF11U*S PEIR
G , W4AY, A1,w3K GA7 f,',
I txc
AUTOIN(MME, UANIUrf 012 9574,-C14-75 010,1412021
OW1412021
POP, Au'ro
BODILY aNARY,,Tlipw PVWXNl 3,
A "I K
"41 Per *,tT0Jw1rP I I 1001010(to
AVrOS
... ... HRED
— ...... .. .. -
PIN10Pr fl: TY UWAGE S BwNE Ili
AUTUS UNLY A1.140S f,
................................. ... . . ........
wuwt" UAQ OCCUP
F:1 Ack"I r4cluaR F"N"r t
OLD m-, �cjf� s
..........
WORKER1 COMPEN,64100N
J
AND V1 OPLOYEAS'UASU"� YIN
AINY ] wA
10,4+KLKMfi,Vf%A CXCU)Dr
IMOM&Wry In YMIN
on%nNne
1,1`114;1,R,1W r, W04 Or oPrOA10T4 Wow
t: L INSEAgE r
bVIS IIOMN OF OPMAn0"S 4 L OCA VIOK$ r VEIAWL" IACOAD I at, A44#11a,us R~%e 54badjAe, wney he mnached V moft *pace 4 s*qWMdj
CERTIFICATE HOLDER CANCELLATION
. .. . ..................................... . ......
SHOULD ANYOF THE ABOVE DESCRIBED POLICIES 06 CANCELLED BEFORE
THE EXPIRATION 0AT9 THEREOF, NOTICE WILL BE DELIVERED IN
The City of EI Segundo a0 its emptoyetis ACCORDANCE MTH TH11POLICY PROVI(TIN &
350 Main Street AUTHOWFU Ri"AF
ri Segundo. CA 90245
V,198S-2D15 ACORD CORPORATION',, All rights raserve&
IBC 26 (201643) The A CORD name and logo are registared roarks, of ACO,RD
POW486 1444912 V3-164016
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:
(_) 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 #
(XI 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 workers' coal ensation provisions of Labor Code § 3700 1 must
'ill automatically become void.
Signature of Applicant ' reemen
immediate) complywith thos rc�v�s�ons or the Date
Print Name k
Agreement for: ,
Dated:
Reviewed by: