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PROOF OF INSURANCE (2022 - 2022) CLOSED
CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 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 ri hts to the certificate holder in lieu of such endorsements . PRODUCER raa mr. O, COMPLETE EQUITY MARKETS INC 1190 Flex Court Lake Zurich, IL 60047 INSURED MAK Fire Protection Engineering 8r Consulting, Inc. 12130 Rahn Avenue INSURER D : INSURER E AFFORDING London COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: -0444 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, .N-... ....... TYPE OF INSURANCE.......... ...I�. --- ,.... ..... ............„... .,. .. ...�......... INSR AODL �Si.16k ������� � POLICY EFF POLICY EXP TR .�__ ��� _ POLICY NUMBER MMJDDfYYYY MM/DDIYYYY .._ ....---- LIMITS ..........� _.... .. I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ QQQ 000 A .. CLAIMS-MADE.C. _� � OCCUR i� _ .a... �! Md61 a urcaeeucel. MED EXP (Ark one person) ., I5 QQQ ------- — — — '.., A X 1701294 3/16/2021 3/16/2022 PERSONAL & ADV I NJURY $ z,.000,Q00 N AGGREGATE APPLIES PE : .... AGGREGATE gt9Q0 f XPOLICYJzeT�OC PRODUCT $ ._2 00Q,000 OTHER i $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ - ANY AUTO BODILY INJURY (Per person) $„ OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY --- AUTOS —.._._ .. ...... _ IHIRED NON -OWN I PROPERTY� AUTOS ONLY .,.,..... . AUTOS ONEDY C 5�4tf m))DAMAGE _ ..$UMBRELLA . AB,.,....,..�.. OCCUR EO I1EXCESS LIABLAIMS MAD AGGREGATE— $ . .. ,..,�.. ---' . I DED RETENTION $ $ WORKERS COMPENSATION PER OTH STVjI AND EMPLOYERS' LIABILITY YIN "i . ..-)nTR,_.mmm,,, ANY PROPRIETOR/PARTNER/EXECUTIVE EEACH OFFICE ///MEn BE EXCLUDED? N/A (Mandatory . NH ) E L D SEASECIDA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E L. DISEASE - POLICY LIMIT $ A Professional Liability 7XT94891 6/1I2021 6/1/2022 Each Claim $1,000,000 Aggregate $1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Subject to all policy terms, conditions, exclusions and endorsements of each respective policy. City of El Segundo, its officers, officials, employees, agents and volunteers is an additional insured with a PrimarylNon-Contributory and a Waiver of subrogationon the professional liability policy but only per the terms & conditions of the endorsement generated for each respective policy and subject to all policy terms, conditions, exclusions and endorsements. PrimarylNon-Contributory applies to the General Liabiity, Policy. 30-Day Notice of Cancellation applies to the General and Professional Liability Policy. ''. Please see pages 2 and 3 for additional information. CERTIFICATE H City of El Segundo, its officers, officials, employees, agents and volunteers Attn: Carol Lynn Urner 314 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 zr,�e/�ry ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AMENDATORY ENDORSEMENT NO.: 94891 ASSURED: MAK FIRE PROTECTION ENGINEERING & ADDITIONAL PREMIUM: CONSULTING, INC. EFFECTIVE: June 1, 2021 to June 1, 2022 EXIE SiO .E" 00YER GE _1� C QUS_LJ B1T.Y' (Primary and Waiver) It is hereby agreed and understood that Underwriters will pay es and Claimon behalf of the entity/entities listed below f'or its/their vicarious or imputed lia "lity which arises from Claims caused by the negligent errors or omissions of the Named Assureds identified in the Declarations in the performance of their Professional Services for the below identified Additional Assureds: The City of El Segundo, its officers, officials, employees, agents and volunteers It is further understood and agreed that such coverage stated above shall apply only to the listed entity/entities and its/their employees. This extension of coverage toes not increase the Limits of Insurance nor amend any other provision in the Certificate which shall remain the same. It is further agreed that the coverage provided hereunder to the above -named Additional Assured(s) shall be primary anti non-contributory to any insurance or self-insurance maintained by the Additional Assured(s). It is further agreed that Underwriters waive all rights of subrogation against the Additional Assured(s) with respect to claims or damages arising out of Professional Services provided by the Named Assured. (Included) All other terms, conditions, limits and exclusions remain unchanged. Attached to and forming part of Certificate No.: CEM 58 - 20 Dated: May 19, 2021 UNDERWRITERS AT LLOYD'S, LONDON LII 197-2 (08/15) Complete E uity Markets, Inc.. (UMR) B0429BA2001026 dba omplete i uity Markets iSL#OD44077) Lib"505 By Lawrence T.P. Molloy Endorsement #14 AMENDATORY ENDORSEMENT NO.: 94891 ADDITIONAL PREMIUM: Included ASSURED: MAK FIRE PROTECTION ENGINEERING & CONSULTING, INC. EFFECTIVE: June 1, 2021 to June 1, 2022 In consideration of the additional premium paid as shown above, it is hereby understood and agreed that if Underwriters cancel this insurance for any reason other than, non-payment of premium, Underwriters shall provide a 30-day written notice of cancel]ation to the following: Ms. Carol Lynn Urner City of El Segundo 314 Main Street El Segundo CA 90245 Ms. Alice Atkins, CMC The City of Monrovia, its officers, officials, employees and volunteers 415 S Ivy Avenue Monrovia CA 91016 All other terms, conditions, limits and exclusions remain unchanged. Attached to and forming part of Certificate No.: CEM 58 - 20 Dated: May 19, 2021 UNDERWRITERS AT LLOYD'S, LONDON AIF 2119 (09/08) Complete E uity Markets, Inc. dba Complete b guity Markets Insumnce, Agency, I . ( A" L OD44077) (UMR) B0429BA2001026 a Lib"23 revised 7/04 8/04 9/08 By Lawrence T.P. Molloy Endorsement #15 NOTICE: 1. THE INSURANCE POLICY THAT YOU HAVE PURCHASED IS BEING ISSUED BY AN INSURER THAT IS NOT LICENSED BY THE STATE OF CALIFORNIA. THESE COMPANIES ARE CALLED "NONADMITD" OR "SURPLUS LINE" INSURERS. 2. THE INSURER IS NOT SUBJECT TO THE FINANCIAL SOLVENCY REGULATION AND ENFORCEMENT THAT APPLY TO CALIFORNIA LICENSED INSURERS. 3. THE INSURER DOES NOT PARTICIPATE IN ANY OF THE INSURANCE GUARANTEE FUNDS CREATED BY CALIFORNIA LAW. THEREFORE, 'T14ESE FUNDS WILL NOT PAY YOUR CLAIMS OR PROTECT YOUR ASSETS IF THE INSURER BECOMES INSOLVENT AND IS UNABLE TO MAKE PAYMENTS AS PROMISED. 4. THE INSURER SHOULD BE LICENSED EITHER AS A FOREIGN INSURER IN ANOTHER STATE IN THE UNITED STATES OR AS A NON -UNITED STATES (ALIEN) INSURER. YOU SHOULD ASK QUESTIONS OF YOUR INSURANCE AGENT, BROKER, OR "SURPLUS LINE" BROKER OR CONTACT THE CALIFORNIA DEPARTMENT OF INSURANCE AT THE FOLLOWING TOLL -FREE TELEPHONE NUMBER: 1-800-927-4357. ASK WHETHER OR NOT THE INSURER IS LICENSED AS A FOREIGN OR NON -UNITED STATES (ALIEN) INSURER AND FOR ADDITIONAL INFORMATION ABOUT THE INSURER. YOU MAY ALSO CONTACT THE NAIC'S INTERNET WEB SITE AT WWW.NAIC.ORG. 5. FOILEIGN INSURERS SHOULD BE LICENSED BY A STATE IN THE UNITED STATES AND YOU MAY CONTACT THAT STATE'S DEPARTMENT OF INSURANCE TO OBTAIN MORE INFORMATION ABOUT THAT INSURER. 6. FOR NON -UNITED STATES (ALIEN) INSURERS, THE INSURER SHOULD BE LICENSED BY A COUNTRY OUTSIDE OF THE UNITED STATES AND SHOULD BE ON THE NAIC'S INTERNATIONAL INSURERS DEPARTMENT (' ) LISTING OF APPROVED NONADMIT' ED NON -UNITED STATES INSURERS. ASK YOUR AGENT, BROKER, OR "SURPLUS LINE" BROKER TO OBTAIN MORE INFORMATION ABOUT THAT INSURER. 7. CALIFORNIA MAINTAINS A LIST OF APPROVED SURPLUS LINE INSURERS. ASK YOUR AGENT OR BROKER IF THE INSURER IS ON THAT LIST, OR VIEW THAT LIST AT THE INTERNET WEB SITE OF TIME CALIFORNIA DEPARTMENT OF INSURANCE: WWW.INSURANCE.CA.GOV. 8. IF YOU, AS THE APPLICANT, REQUIRED THAT THE INSURANCE POLICY YOU HAVE PURCHASED BE BOUND IMMEDIATELY, EITHER BECAUSE EXISTING COVERAGE WAS GOING TO LAPSE WITHIN TWO BUSINESS DAYS OR BECAUSE YOU WERE REQUIRED TO HAVE COVERAGE WITHIN TWO BUSINESS DAYS, AND YOU DID NOT RECEIVE THIS DISCLOSURE FORM AND A REQUEST FOR YOUR SIGNATURE UNTIL AFTER COVERAGE BECAME EFFECTIVE, YOU HAVE THE RIGHT TO CANCEL THIS POLICY WITHIN FIVE DAYS OF RECEIVING THIS DISCLOSURE. IF YOU CANCEL COVERAGE, THE PREMIUM WILL BE PRORATED AND ANY BROKER'S FEE CHARGED FOR THIS INSURANCE WILL BE RETURNED TO YOU. D-2 (Effective July 21, 2011) 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 tabor 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 tabor Code § 3700 for the performance of the work for which the agreement with the City of El Segundo is executed. My workers' oompensation insurance carrier and policy number are: Carrier Name of Agent Policy Number Expiration Date Phone # 41 certify that, in the performance of the work set forth in the agreement with the City of Et 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 u'bject to t' workers' compensation provisions of Labor Code § 370P 1 must immediately comply with th isions agreement w111 automatically become void. Signature of Applicant Date '54r11Y w Agreement for: " �'�' I^� ' !�"� j1Q,PiYI i'>,j �-�) n (. Dated: (�. Reviewed b: