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PROOF OF INSURANCE (2021 - 2022) CLOSEDrr� aa............................................................._. DATE (MMIDD/VYYY) ► CERTIFICATE LIABILITY INSURANCE1 ............................. ............. .....m............._o?/a8,2az1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERT IFICATE 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 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 endorsement(s). PRODUCER ................................................ CONTACT' AUTO CLUB INSURANCE AGENCY LLC/PHS9!f....................................................................................................... 72253682 PHONE (866) 467-8730 FAX (888) 443-6112 (AIC, No, Ext): (A/C, No): The Hartford Business Service Center 3600 Wiseman Blvd E-MAIL San Antonio, TX 78251 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# '.. INSURED INSURERA : Sentinel Insurance Company Ltd. 11000 David Ebeling INSURER B 3456 LOTUS ST INSURER : IRVINE CA 92606-2117 ................. 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. '.. INSIR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP POLICY NUMBER LIMITS LTR. INSR WVD .. O .. '. COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $2,000,000 CLAIMS -MADE OCCUR DAMAGE TO RENTED $1,000,000 PREMISES (Ea occurrence) X ...General Liability '... MED EXP (Any one person) $10,000 ...... ................._. _................. A X 72 SBM BC9401 11/07/2020 11/07/2021 PERSONAL $ADV INJURY $2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER : _._.... ..... ..................... ..... GENERAL AGGREGATE 1 $4,000,000 POLICY PRO LOG „„ JECT PRODUCTS - COMP/OP AGG $4,000 000 OTHER. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT fEa accident) ........ ANY AUTO BODILY INJURY (Per person) ALL OWNED SCHEDULED BODILY INJURY (Per accident) AUTOS AUTOS HIRED NON -OWNED ._..._..............._._......_........................_............................................ PROPERTY DAMAGE AUTOS AUTOS '... (Per accident) LIABOCCUR EACH OCCURRENCE ESS LIAB CLAIMS- AGGREGATE JRELLA MADE RETENTION $ WORKERS COMPENSATION W. ..WWWW......W ......... ..... ....... ...... ..... WW_.,. _ ..........�... PER OTH AND EMPLOYERS' LIABILITY STATUTE ANY Y/Ni E.L EACH ACCIDENT PROPRIETOR/PARTNER/EXECUTIVE „„.„„„„„„„„„„„„„„„ „„ ---„„„„„„„„„„„„„„„„„ •---• NIA OFFICER/MEMBER EXCLUDED? C EmL.mmDISEASE EA EMPLOYEE (Mandatory in NH) ...... If yes, describe under E.L. DISEASE -POLICY LIMIT DES RIPTION OF OPERATIONS below ............................. ............... . .. ..... ..... ........ _.... DESCRIPTION OFOPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the Insured's Operations. The City of El Segundo its officers, officials, employees and volunteers is additional insured per the Business Liability Coverage Form SS0008 attached to this policy. Coverage is primary and noncontributory per the Business Liability Coverage Form SS0008, attached to this policy. CERTIFICATE HOLDER CANCELLATION THE 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 WITH THE POLICY PROVISIONS. REPRESENTATIVE �AUTHORIZED ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD THE HARTFORD BUSINESS SERVICE CENTER THE 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 THE CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO CA 90245-3813 Account Information: ..... [PHolder Details David Ebeling ....... .... . ... ... �l�Ic: July 8, 2021 %Q Contact Us Business Service Center Business Hours: Monday - Friday (7AM - 7PM Central Standard Time) Phone: (866) 467-8730 Fax: (888) 443-6112 Email: agency.services@thehartford.com Website: Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team WLTRO05 POLICY NUMBER: 72 SBM BC9401 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - VENDOR CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO CA 90245 Form IH 12 00 11 85 T SEQ. NO. 001 Printed in U.S.A. Page 001 Process Date: 08/21/20 Expiration Date: 11/07/21 PROOF OF INSURANCE Interinsurance Exchange of the Automobile Club NAIC #: 15598 �aM1iJ Named Insured Policy Number: CAA 071832643 EBELING, KATHLEEN & DAVID a u. Effective Date: 07-28-21 Expiration Date: 07-28-22 This policy provides at least the minimum amounts of liability insurance required by the CA VEH CODE SECTION 16056 for the specified vehicles and named insureds. Coverage subject to policy terms and limits. VEHICLES ON POLICY YEAR MAKE VE;H W Rd 2013 SUBA 2013 HOND 2013 VLKS DRIVERS ON POLICY EBELING, KATHLEEN A EBELING, DAVID EBELING, KAILA EBELING, HANNAH DATE(MM/DDIYYYY) ACC CERTIFICATE OF LIABILITY INSURANCE ' 11/18/2020 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 INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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). ONT CT PRODUCER NAM. Bonnie Ayersman w......... SPIB Insurance Agency, Inc PHONE (g49)582-5220 FAX (vae)ssz 3aiz AI o East'...(A/C, No); License Number 0719264 E-MAIL bonnie@spib.com ADDRESSa 26441 Crown Valley Parkway#200 INSURERS AFFORDING COVERAGE NAIC # Mission Viejo CA 92691 INSURERA:RLI Insurance Company 13056 INSURED Ebeling Communications, DBA: E-Link.com 3456 Lotus St Irvine CA 92606 1 INSURER F: COVERAGES CERTIFICATE NUMBER:MASTER 2020-2021 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 `U POLICY E,FF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER kVmmmy .YY" DIYYYY '.... LIMITS COMMERCIAL GENERAL LIABILITY ''.. EACH OCCURRENCE $ 'DAMAGETORENTED CLAIMS -MADE D OCCUR ''. PREMISES Fa occurrence $ MED EXP (Any ane person) $ PERSONAL &ADV INJURY $ GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ POLICY 0 JECT ❑ LOC .PECT PRODUCTS - COMP/OPAGG $ $ OTHER, AUTOMOBILE LIABILITY C BIC~t'..D IN LT LIMIT Ea accident $ BODILY INJURY (Per person) S ANYAUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS... NON -OWNED ROP,u:l� HIREDAUTOS I AUTOS �DAMA4GE...... $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ wawa ....... EXCESS LIAB CLAIMS -MADE AGGREGATE $ �DED RETENTION $ $ WORKERS COMPENSATION R CiTH- TAT T ER AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA ''.... (Mandatory in NH) EL DISEASE - EA EMPLOYEE $ If yes describe under DESCRIPTION OF OPERATIONS below E..L. DISEASE - POLICY LIMIT $ A PROFESSIONAL LIABILITY RTP0019342 11/7/2020 11/7/2021 1,000,000OCCURANCE DED 1,000 1,000,000 AGGREGATE DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION CITY OF EL SEGUNDO 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 REPRESENTATIVE L Hines, CPCU ARM CLU o(iry�.ly�I,�y U 1983-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) 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.. C_J 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 # 1 certify that, un 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 s,bjt to the workers' compensation provisions of Labor Code § 3700 1 must immediatelyg comply with t visions or the agreement will automatically become void. Signature A Pp nt z Date l Print Name AN(., c Agreement for: Dated: 7-22-2021 Reviewed by: Amendment #5808B Hank Lu, Risk Manager