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PROOF OF INSURANCE (2022 - 2022) CLOSED�® GERTIFICAT ..... E %jr LIABILITY INSURANCE DATE(MAIpDTYYYY) THIS CERTIFICATE 15 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 CERTIFICATI HOLDER. IMPORTANT: If the certificate hoidar is an ADDITIONAL IN3URi=p, the policy(les) must have ADDITIONAL INSURED prgYisions or be endorsed. If SUBROGATION do IS of confer subject to the terms and conditions of the Policy, certain policies may require an endorsement. A statement on this certificate does not confer rf hts to the certificate holder in lies, of such endorsement(s). PRgAUCER N a r EROL hiASSAN a e EROL HASSAN NAME — ... A PHONE 310 545 6579 -- FAX 3540 HIGHLAND AVE (el�' N� �'� --- ---. � 4tc No : 320 545-6821 E-MAIL oj: -- - 1 MAN1 IA"r7AN BEACH, CA 90266 ,kQPf SS_�. . —--- - _ �. CLIFFORD, SUSAN SAYE DR A PROFESSIONAL CORPORATION 16530 VENTURA BLVD STE 603 --..-_..-,_._ INSURER(S AFFOROINGCOVERAGE _ _ NAIC# State Farm General Insurance Company 25151 INSURER A _ INSURi R8: State Faros Fire and CSSLial Com an —_ - - ..- tY P Y 25143 - _._. ERC..__ CERTIFICATE NUMBER: This IS TO CERTIFY THAT THE POLICIES Oi INSURANCE REVISLISTED BELOW HAVE BEEN ISSUED TO THE iNSUREU NAMIEED ABOON VE FOR THE —POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHE CERTIFICATE MAY BIS E SUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE R DOCUMENT WITH RESPOLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,PECT TO WHICH THIS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPSOF WSURANGE POLICYEFF - POLICY EXP POLICY NUMBER I JDD �MfD � LIMITS --- -� II COMMERCIAL GENERAL LIABILITY ° II . rscH OCCURRENCE $ 1,000,000 ,--+—� CLAIMS -MADE � OCCUR-D"A"I✓iAG�"1"C)R. 1L.`l". "'---....--------- A -- - _ Y I N 1 92-92-2579-2 OATE LIMIT POLICY E] P90- APPLIES D LOG i AUTOMOBILE LIABILITY tANY AUTO I� OIANEO (....... I SCHEDULED }_ AUTOS ONLY ;AUTOS + I HIRED NON -OWNED I AUT06 ONLY AUTOS ONLY UMBRELLA LIAR I _ OCCUR i EXCESS LIAR CLAIMS -MADE DIED RETENTION$ WORKERS COMPENSATION I AND EMPLOY€R& LIABILITY i ANY PROPRIETORlPARTNERfEXECUTiVE YIN B OFRCERIMEMi FREXCLUDED? NIAi Y [ 92-GM-BO77-9 (Mandatory In NH) If yes, describe under EN -❑ - _— PREMLSt S.IE a xurrgp�e)._. 5 300,000 04118/2021 04/18/2022 MED FXP (Any vn�eisvi},,, ti 5,000 ............ PEj. RSONAL & ADV INJURY $ GENERALAGGREGATE $ 2,000000 PRODUCTS - COMPIOP AGG $ 2,000 000 {S CflfU,81NF0 51NGLE I IMIT ' _[Ea_a_ccitleni}- i � a001LY INJURY (Per parson) S BODr1,Y INJURY (Per accident)— PROPERTYpAMAGE F EACH OCCURRENCE g I AGGREGATE 07101/2021 07/01/2022 E-L.EACHACCIDENT 1,000,000 E.L,DISEASE -EAEMPLOYEq $ 1,000,000 E.L. DISEASE - POLICY LIMIT i $ 1,000,000 DESCRIPTION OF OPERATIONS ) LOCATIONS I VEHICLES (ACORO 101. AAdltionel Remarks 9chedide, ropy be attached If more space Is required) I PSYCOLOGICAL SERVICES Additional insured: THE CITY OF EL SEQUNDQ, ITS OFFICERS, OFFICIALS, EMPLOYEES AGENTS AND VOLUNTEERS CA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN IEI Segundo Police Department ACCORDANCE WITH THE POLICY PROVISIONS. 348 Main Street EI Segundo, CA 90245 AUTHORIZED REPRgSpNTAT It ACORD 25 (2016103) The ACORD name and lo©1988-2015 ACORD CORPORATION. All rights reserved. go are registered marks of ACORD 1001486 132849,12 03-10-2016 SS Policy No. 929225792 1308—FA75 CMP-4786.1 Page 1 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CMP-4786,1 ADDITIONAL INSURED — OWNERS, LESSEES, OR CONTRACTORS (Scheduled) This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 929225792 Named Insured: CLIFFORD, SUSAN SAXE DR A PROFESSIONAL CORPORATION 16530 VENTURA BIND STE 603 ENCINO CA 91436-5017 Name And Address Of Additional Insured Person Or Organization: THE CITY OF EL SEQUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES AGENTS AND VOLUNTEERS 348 MAIN ST EL SEGUNDO CA 90245 3813 SECTION ll — WHO IS AN INSURED of b. If coverage provided to the additional in - SECTION II — LIABILITY is amended to in- sured is required by a contract or agree- clude, as an additional insured, any person or ment, the insurance provided to the organization shown in the Schedule, but only additional insured will not be broader than with respect to liability for bodily injury", "property damage", or "personal and advertis- that which you are required by the contract ing injury" caused, in whole or in part, by: or agreement to provide for such addition - a. Ongoing Operations al insured; and c. If the contract or agreement between you (1) Your acts or omissions; or and the additional insured is governed by (2) The acts or omissions of those acting California Civil Code Section 2782 or on your behalf; 2782.05, the insurance provided to the in the performance of your ongoing opera- additional insured is the lesser of that tions for that additional insured; or which: b. Products — Completed Operations "Your work" performed for that additional insured and included in the "products - completed operations hazard". However, Paragraph 1. above is subject to the following: a. The insurance afforded to the additional insured only applies to the extent permit- ted by law; (1) Is allowed for the satisfaction of a de- fense or indemnity obligation by Cali- fornia Civil Code Section 2782 or 2782.05 for your sole liability; or (2) You are required by contract or agreement to provide for such addi- tional insured. We have no duty to defend or indemnify the additional insured under this endorsement un- til a claim or "suit' is tendered to us. O, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services office, Inc., with its permission. CONTINUED CMP-4786.1 2- Any insurance provided to the additional in- sured shall only apply with respect to a claim Page 2 of 2 (3) The nature and location of an y injury made or a "suit" brought for damages for which you are provided coverage. g damage arising out of the "occur - re rence" or offense; 3. With respect to the insurance afforded to the b. an t"suhe detonse indemnitoinsur additional insured, the following is added to claim orender us and to all otherand ers who may have insurance SECTION II — LIMITS OF INSURANCE: potentially available to the additional insured; and If coverage provided to the additional insured is required by contract or agreement, the most c. Agree to make available any other insur- we will pay on behalf of the additional insured ance the additional insured has for de - fense will be the lesser of the amount of insurance: or damages for which we would a. Required by the contract or agreement; or provide coverage under SECTION II — LIABILITY. b. Available under the applicable Limits Of $• With respect to the insurance afforded the ad - Insurance shown in the Declarations, ditional insured, the following replaces SEC- This endorsement shall not increase the a p- TION II —LIABILITY of Paragraph 7. Other Limits Of Insurance shown in the Insurance of SECTION I AND SECTION II — ecle Decla Declarations. COMMON POLICY CONDITIONS: 4. With respect to the insurance afforded to the a• This insurance is primary to and will not additional insured, the following is added to seek contribution from any other insurance available to the additional insured Paragraph 3. Duties In The Event Of Occur- that the additional insured is a nad mednd- rence, Offense, Claim Or Suit of SECTION sured under such other insurance. 11— GENERAL CONDITIONS: The additional insured must: b. Regardless of any agreement between you and the additional insured, this insur- a. See to it that we are notified as soon as ance is excess over any other insurance practicable of an "occurrence por an of- fense which may result in whether primary, excess, contingent or an any other basis for which the additional in- a claim. To the extent possible, notice should include: sured has been added as an additional in - (1) How, when and where the "occur- sured on other policies. rence" or offense took place; There will be no refund of premium in the event (2) The names and addresses of any in- this endorsement is cancelled. jured persons and witnesses; and All other policy provisions apply. CMP-4786.1 O, Copyright, State Farm Mutual Automobile Insurance Company, 2C13 1007033 148011 08-21-2014 Includes copyrighted material of Insurance Services office, Inc., with its permission. PRODUCER PREMIER ENS O44006 06 MERCURY RCCU 00 5b08 CHESEBRO ROAD STE 200 RY AGOURA HILLS CA .91307 J� INSURANCE AUTOMOBILE POLICY DECLARATIONS TELEPHONE {818) 223-8383 IMPORTANT COVERAGE EXCLUSION_, FQLiCY {Ut11iAf1Ett - PL}LtGY PEBiC0 _ ._- Ate'£ ► ABLE TO ALL OAYi RAGES fNCLUF31ii{�i f3tl iVCST LlMI7 p 7 tl 411 gILiTY 420 rRorA04102/202112.OIAM T004102/202212 D1AnaI c. - - ) ANO UN�SUtiCII IV Q7 FRIfiTS I...... EC3 @10GtF Oq U}7ER Ft. s agrs8d thstii1L+ Fns}tra�Tns a!£orrl i by tbi. PF11SL7i1L57N5UREf} goficY aoz accrus: to the beneYif:'Df any InSLred or eny tfiild party alatrnat}I vittarl env molar v'0411te.ls.hsirig or: DRIVERS --— -- -- .used operated 6y a isarsori ;lisiecl;tiefaW regardfess:'uf i�t -- - -. arsart rsstd'es or whether file person t$i{+CenseBad drlue SAXE-CLIFPORD j ADDRESS -- _- >CAi1 . YEAit i - ::-bf,Fj1lE t}RlPT14111 1 2015 FORD MUSTANG GT CPE — -- ensr,pRVALos ; ItlEWV/IIs>Uj PURCIR DATE yP/c}o.. 2 '2016 FORD EXPLORER PLATiNU UTL 4DR J IU I N L3 :2020 TESLA MODEL 3 SED 4DR N CAR RP Al ii4 LOSS PfAIEE$;Lpt AtL#TtONA11d7ElfSiS iA14.LOSS pAXEES ArfDAi]WitONAL1NIERfSfS 2tA GAftA6drG ROtNiE53ES tCA;}.itMn Rfg57E1tEQ UyyNE45 tROt IISlR TRAPt5£US7ED ftliiiVF 2 GA- 3 LA ;TESLA TEMECULA CA 92591 I PORTLAND OR 97208 Coverage applies only if premium charge is listed below. Coverageli.irmts are subject to all policy terms GOztEfiAcS - _ 11Nl1TS: Git C1A:BMfTir - - — P-- REltlI1[FNiS -. — Fi4CFORY,.EQUIPMENT BODILY INJURY LIABILITY $254,000 EACH PERSGW $ 500,000 EACH ACCIDENT CARt �- cAR2 - cnas ITEMS INSURED AND AMOUNTS OF - -- - PROPERTY DAMAGE LIABILITY 00 EACH ACCIDENT _..... "-- --- _ 390 — .. 268 .. - — 426 - - INSURANCE FOR EACH ITEM ARE STATED "UNINSUA�"ry�OTpAiST� -- ---� — -. � — __ ..._.. .. i . ___ ._ _.._�_ 358 .. - - .- 45$ 522 HEREIN, ITEMS INSURED ARE SUBJECT TO ; $ � BODILY INJURY LIABILITY � 50,00❑ EACH PERSON $ 500,000 EACH ACCIDENT I--- 1 7$ - 140 .--_.._270 THEL'}EDUCTIBLE. UNINSURED MOTORISTS ; PROPERTY DAMAGE LIABILITY$ MAXIMUM cittta tTEtt9; Vx.uftED:_ �!tilT _.� COWSION DEDUCTIBLE WAIVER — _ - — F - - - - --.— MEDICAL EXPENSE $5,000 - � -�-'-- `— 28-:i 22 T— _ 14 30 LEASEILOAN GAP COVERAGE CAR CAR CAR; i REPAIR OR REPLACEMENT COST COVERAGE .CAR CAR CAR ... - --- - -- _ -- -- COMPREHENSFVE DEDUCTI9K CAR? 0500 CAR2 $500 __- --. _—_ CAR3 $500 ---- 50 30 - - - _ 40 eAL» — —. — COLLISION— jDEDUCMECAR1 $1,000 CAR2 $500 '. — . — CAR3$2,000616 ORNw AssEsaxExcTs . OADS16.-- �ROADSIpEASSISTANCEEac+T-`---..�.......---------- --- - 388 938 CA FRAUD FEE lFOR TOWING SE-RY10E5}"OCCURRENCE CARt $75 CAR2 $75 CAR3 $75 8 8 ----`-""-- --- ' CIGA RENTAL CAR BENEFIT . S i 00 PER DAY 30 DAYS I 748 148 i 8 148 FEE INTERVENOR FEE -- - - £t1tDORS£ME►}FTSJL7TACi3Et? f0 TFi PQLiCY - . - ._ ..... IJ_1 n 1 9/9n-I 5z 1784 1 1464 TOTAL PREMIUM IMPORTANT INFORMATION *For Non -Towing Service,rA , emit of LYabil-ty is $75 per Occurrence. Maximum 5 Occurrences in tote Towing and Non -Towing services per policy period. 649.28 i 1 for EFFECTIVE 04/021/2021 12:Ol-P14 This revised declarations page reflects the changes you requested for the policy jperiod indicated above, 'The enclosed Auto Insurance Renewal Bill and the U251 IMPORTANT NOTICE are part of this policy, These :specify the amount of your premium, your payment options, any applicable fees, and the due date. Your automobile insurance expires and coverage ceases at 12:OlAM on 04/02J2021. Coverage under (this policy will .become effective provided you pay the premium and any applicable fees as indicated ,on the Auto Insurance Renewal Bill. If you have any questions, please contact your agent or broker at the phone number provided above. iMAILED TO: U-176 6712019- INSURED COPY PE]IiCY-;l i{1M -E rm 20 M. AUJNG:DATE:;: 03/19/2021 Account Number: CA SUSA 1650 Date: 3/10/21 Initials: iA CERTIFICATEC, OF INSURANCE ALLIED WORLD INSURANCE COMPANY C/O: American Professional Agency, Inc. 95 Broadway, Amityville, NY 11701 800-421-6694 This is to certify that the insurance policies specified below have been issued by the company indicated above to the insured named herein and that subject to their provisions and cond- ^ the coverages indicated insofar as such coverages apply to the Occupation or bus Itions, such Policies afford as stated. iness of the Named Insured(s) THIS CERTIFICATE OF INSURANCE NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS EXTENDS OR ALTERS THE COVERAGE(S) AFFORDED BY THE POLICY(IES) LISTED ON THIS CERTIFICATE Name and Address of Named Insured- SUSAN SAXE-CLIFFORD, PH.D. A PROFESSIONAL CORP. 16530 VENTURA BLVD STE 603 ENCINO CA 91436 Type Of Work Covered: PROFESSIONAL PSYCHOLOGIST Location of Operations: N/A (If different than address listed above) Claim History: t�roactive Coverages PROFESSIONAL/ LIARTT.TTV to is 03 01 20 Policy _e is 5011-0137 Effectiv--e Date 3/01/21 Additional Named Insureds: SUSAN SAXE-CLIFFORD, PHD CATHY GOODMAN, PHD WILLIAM SMITH, PSY.D. MEREDITH RIMMER, PH.D. Expiration Date 3/01/22 Limits of Liability 2,000,000 4,000,000 NOTICE OF CANCELLATION WILL ONLY BE GIVEN TO THE FIRST NAMED INSURED, WHO SHALL ACT ON BEHALF OF ALL INSUREDS WITH RESPECT TO GIVING OR RECEIVING NOTICE OF CANCELLATION. Comments: THE DEFENSE REIMBURSEMENT LIMIT FOR PROCEEDING ON THIS POLICY IS $150,000. ADDITIONAL INSUREDS: SEE ATTACHED This Certificate Issued to: Name: SUSAN SAXE-CLIFFORD, PH.D. A PROFESSIONAL CORP. Address: 16530 VENTURA 13LVD STE 603 ENCINO CA 91436 APA 00138 00 (06/2014) Au------- - '�horized Representative WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT . CALIFORNIA 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 California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization THE CITY OF EL SEGUNDO ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS AND VOLUNTEERS 350 MAIN ST EL SEGUNDO, CA 90245 .lob Description CONTRACT: $5,100 CODE: 8810 01 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 07/20/21 Policy No.92 G8x323 0 Endorsement No. Insured SUSAN SAXE-CLIFFORD PHD Insurance Company State Farm Fire and Casualty Company A PROFESSIONAL CORPORATION Countersigned By WC 04 03 06 (Ed. 4-84) 1007722 124282.2 01-25-2019