PROOF OF INSURANCE (2022) CLOSEDOP ID: MN
DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
07/21 /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 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 Michelle A Nowell
Alliance 35 A is era Cruz
#7 0737966 LNc No k4l 760-h71-7116 N �;w,760�71-9378
9 FAX
CA
ESS: mnowell al�amiscor com
San Marcos CA 92078 P OLDvi dER
Michelle A. Nowell 415�IqMg (n u. WYATT-2
INSURED �� Inv gative Services INSURER � INSURERS) AFFORDING COVERAGEpNAIL #
�.18
INSURER s Insurance Coma m—
Ga on Wyatt 7521 RER A Peleu n 34
Riverside, CA 92513 URER C : INS .! . EF ,!.. INSURER D
r+1L.,ATar1^A=A1IIAe^ IC . RI=tPICNn?d NI IMRFR•
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.
.. __ ..,. ...............,,,.• ...... -�-m,.__..—
-NNSR ...--..._. -� — irL C(EY� ... POLICY EFF� P�'Y tTiO
.. ___...... TYPE LIMITS
OF INSURANCE POLICY NUMBER.
LTR� MWDDPMY MM/DDIYYYY
GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,00
A
X COMMERCIAL GENERAL LIABILITY
X
PKV0000776
07/31/2021
07/31/2022
pMM §,ES ( aoccurrence)
$ 100,000
OCCUR
MED EX _ one person)
$mmmmm 5,000
X Errors 8i Omission
PERSONAL & ADV INJURY
$ 1,000,00,m
GENERAL AGGREGATE
�___ . .,,_....
$ 5,000,00
00
—....................................�....'000,00
_....,,,,,. P IES PER:
GEN'L AGGREGATE LIMIT APL �
PRODUCTS- COM P/OP AGG
$ 1
—.,�...
X POLICY PRO LOC
$
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
$ 1,000,00
A
ANY AUTO
PKV0000776
07/31/2021
07/31/2022
'BODILYdenINJURY (Per person)
-
ALL OWNED AUTOS
BODILY INJURY (Per accident)
$
SCHEDULED AUTOS
PROPERTYDAMAGE
$
X
HIRED AUTOS
PER
) .........................w,m,......
�.
�X
NON -OWNED AUTOS
UMBRELLA LIAB
CLAIMS
EACH OCCURRENCE
.... .......
$
OCCUR
EXCESS LIAB -MADE
AGGREGATE
$
DEDUCTIBLE
$
RETENTION $
O
$
WORKERS COMPENSATION
WC STATU- OTH-'
T AI TD
AND EMPLOYERS' LIABILITY YY
-T��
ANY ECUTIVE
E L. EACH ACCIDENT
E
$ _ _......
OFFICERIMEMBER/EXCLUDED?
(Mandatory in NH)
N / A
DO
DISEASE A M,m.
E EMPLOYEE
$
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L DISEASE -POLICY LIMIT
$
DESCRIPTION OF OPERATK)NS I LOCATIONS I VEHICLES (Attach ACORD 101 AddltlorW Roma rfts Schedule, if more space is required)
City of El Se undo, their off'Icialls,officers,agents and ern loyees are named
by the
as addltiona insured with respect, to the work performed named
insured.
Investi ations, CA --
f A. WNCI II A"rIR' kl
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of El Segundo
350 Main Street
El Segundo, CA 90245
AUTHORIZED REPRESENTATIVE
a foww
-
V "1V56-LUUU Ak UKU 9,UKrUKA I IUIY. Akil nynta UtMVI VCU.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: PKV0000776 COMMERCIAL GENERAL LIABILITY
CG 20 26 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT
CAREFULLY.
ADDITIONAL INSURED - DESIGNATED
PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Section II - Who Is An Insured is amended to in-
clude as an additional insured the person(s)
or organization(s) shown in the Schedule, but only
with respect to liability 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:
A. In the performance of your ongoing
operations; or
B. In connection with your premises owned by
or rented to you.
CG 202607 04 0 ISO Properties, Inc., 2004 Page 1 of 1 ❑
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-_) 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 #
KI certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not
oy 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' compensation provisions of Labor Code § 3700 1 must
immediately g ppP Y P g � Y void.
Amply with thus rovisiora or t e a reement will automatically become v Date y
licant
Agreement for:
Garon Wyatt - Agreement
Dated: 4/17/2020
Joseph Lillio�
tiwdd WUMMYh`Iw�w YMgb lrr'NY^+^'� JtllrneMe
Reviewed by:
CM4w PtldlYgW pT fS.,%f fA AFI'q�