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PROOF OF INSURANCE (2022 - 2022) CLOSEDACC CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 7/30/2021 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 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 endorsement(s). PRODUCER Baldwin Krystyn Sherman 4211 W. Boy Scout Blvd. Suite 800 Tampa FL 33607 INSURED Burnham Benefits Insurance Services, LLC 4211 W. Boy Scout Blvd., Suite 800 Tampa FL 33607 William Halght WR5. 813-387-6839 nners„corn AFFORDING COVERAGE A: Great Northern Insurance B : Federal Insurance COrnD'c COVERAGES CERTIFICATE NUMBER: 1284197819 REVISION NUMBER: 813-574-6167 20303 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. iNSRRj----- ....TYPE OF INSURANCE....... -----�AQDL.,.SUH#iT�-...,...... POLICY NUMBER,...F ..v; mfoor E� F IPgLI!•CY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY Y 36069302 3/1/2021 3/1I2022 EACH OCCCURRENCE $ 1 000 0 CLAIMS -MADE OCCUR bA IJIAC� "9` AtN`t"Lb PR MI E Ea o C s ( �curran a � $ 1100 000 000 ,�' MED EXP (Any one person $ 15 000 ( PERSONAL 8. ADV INJURY $ 1,,000,OOD GATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2.000.000 PRO- POLICY JEGT X �'. LOC ....... PRODUCTS -COMP/OPAGG -_. $Included OTHER $ A AUTOMOBILE LIABILITY 73620127 3/1/2021 3/1/2022 COMBINED SINGLE LIMIT I$1000,000 X I... ANY AUTO BODILY INJURY (Per person) $ AUTOS ONLY AUTOS OH WNED SCHEDULED AUTOS BODILY INJURY (Per accident) ($ ,.,,. ,..� NON -OWNED ROPERTYDAMAGE I$ AUTOS ONLY AUTOS ONLY - i$ UMBRELLA X OCCUR 78188562 3/112021 3/1/2022 EACH OCCURRENCE EXCESS ABAB E MAD,,,,,,,,,, $25000,000 AGG,,........ SOD. ... . _ I,CLAIMS .. DED X RETENTION$ ___. -------- ......... ... ...... Is WORKERS COMPENSATION PER 1 STATUTE ER t AND EMPLOYERS' LIABILITY YNIA ,, , .........— i ANYPROPRIETOR/PARTNER/EXECUTIVE E,L. EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? (andatoin NH) E,L, DISEASE - EA EMPLYEI M SCRIPTION OF OPERATIONS below D EL, DISEASE - POLICY LIOMITE.$ ...... ...._. ..----- DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of El Segundo a its officials, and employees are included as Additional Insured With respect to General Liability if required by written contract and subject to terms, conditions, and exclusions of the policy. Coverage its provided on a Primary & Non -Contributory basis on the General Liability if required by written contract and subject to terms, conditions, and exclusions of the policy. CERTIFICATE HOLDER CANCELLATION 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD C H U B B• Liability Insurance Endorsement Policy Period MARCH 1, 2021 TO MARCH 1, 2022 Effective Date MARCH 1, 2021 Policy Number 3606-93-02 BHM Insured BRP GROUP, INC. Name of Company GREAT NORTHERN INSURANCE COMPANY Date Issued MARCH 11, 2021 This Endorsement applies to the following forms: GENERAL L14,Bl 1TY Under Who Is An Insured, the following provision is added Who Is An Insured Add"iillonal Insured - Persons or organizations shown in the Schedule are insureds; but they are iisureds only if you are Scheduled Person obligated pursuant to a contract or agreement to provide them with such insurance as is afforded by Or Orgsnr"zfon this policy. However, the person or organization is an insured only: • if and then only to the extent the person or organization is described in the Schedule; • to the extent such contract or agreement requires the person or organization to be afforded status as an insured; • for activities that did not occur, in whole or in part, before the execution of the contract or agreement; and • with respect to damages, loss, cost or expense for injury or damage to which this insurance applies. No person or organization is an insured under this provision: • that is more specifically identified under any other provision of the Who Is An Insured section (regardless of any limitation applicable thereto). • with respect to any assumption of liability (of another person or organization) by them in a contract or agreement This limitation does not apply to the liability for damages, loss, cost or expense for injury or damage, to which this insurance applies, that the person or organization would have in the absence of such contract or agreement. Liability Insurance Add&wW Insured - SdWuled Pa" Ogwww. bon conftied Form 80ML2367(Rev. 5-M Endorsemont Page 1 CHUBBe Liability Endorsement (continued) Under Conditions, the following provision is added to the condition titled Other Insurance. Conditions' Other Insurance — If you are obligated, pursuant to a contract or agreement, to provide the person or organization Primary, Noncontributory shown in the Schedule with primary insurance such as is afforded by this policy, then in such case Insurance — Scheduled this insurance is primary and we will not seek contribution from insurance available to such person Person Or Organization or organization. Schedule Persons or organizations that you are obligated, pursuant to a contract or dement, to provide with such insurance as is afforded by this policy. All other terms and conditions remain unchanged. Authodked Representative Liability Ineuranoe !neared - led Person Or Organization lest Form 804ZM67 (Rev. 5-07) Ehdbrawwt Page 2 DATE (MM/DD/YYYY) .4C"R" CERTIFICATE OF LIABILITY INSURANCE 7/30/2021 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 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 endorsement(s). PRODUCER CONTACT NAME .,. William H3tlght Baldwin Krystyn Sherman PHONE 813 I i nX 4211 W. Boy Scout Blvd. (A!� M,a�u $Mt) 387 6839 c No) 813 574 6167 r MAIL whIgNnRbks artners �Orn _ Suite 800 �tlrptESS p Tampa FL 33607 p........ ........ ...............................1.Nsg.RERlsh.^FFoRDLIN9..cpvERnGE.......................................". ._ ,__,_......NAIC# ---- INS ________ -... _ INSURER A Arch Specialty Insurance Comp "" 21199 - a INSURED INSURER B : Burnham Benefits Insurance Services, LLC .. " 4211 W. Boy Scout Blvd., Suite 800 INSURERC Tampa FL 33607 INSURERD: COVERAGES CERTIFICATE NUMBER: 1928711174 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 ° DU Rg POLICY' EFF Pt'S LICYEXP TYPE OF INSURANCE.... LTR ',. NSD I POLICY NUMBER LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE l $ `MAC�EiiixT ---' CLAIMS -MADE .....I OCCUR PREMISES.-(Eaoccurrprice) $ ... ........... MED EXP (Any one person) !.-$-- ...... ..................... ---- ............ .... '.. PERSONAL & ADV INJURY $ ..,„_....... GEN'L ------ ---- .......... ..... .......... AGGREGATE LIMIT APPLIES PER - ------ --..... .....,,., GENERAL AGGREGATE POLIY � LOC PRODUCTS- COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY SINGLELOdWiBINEDI % �4 q) MIT '� $ ANY AUTO BODILY INJURY (Per person) $ OWNED INJURYPer accident) AUTOS ...E $AUTOSONLY .,.SCHEDULED HIR AUTAUTOS ONLY ff TIdCRY �OP ......... ....... $ V UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ ..., EXCESS LIAB CLAIMS -MADE •DED... ........., ....___"_,- AGGREGATE ... ............... _...,, $ ------- . RETE... NTION $ $ WORKERS COMPENSATION PER OTH- STATUTE ER AND EMPLOYERS' LIABILITY YIN ___ ................ ANYPROPRIETOR/PARTNER/EXECUTIVE EL EACHACCIDENT $ OFFICER/MEMBEREXCLUDED? NIA ""-"'"'"'"'"' ""---""'"'""' - ---- (Mandatoryin NH) E L DISEASE EA EMPLOYEES $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT ,, $ A Errors & Omissions SPL004221110 3/1/2021 3/1/2022 Each claim Ilnmit $5,000,000 Aggregatetimlt $5,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION 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 XAUO"1401�11PREE El Segundo CA 90245 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD BURNBEN-01 DLIVINGSTON �►co�ro,,, CERTIFICATE OF LIABILITY INSURANCE `.�•-- DATE(MM/DD/YYYY) 8/5/2021 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 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 endorsement(s). PRODUCER License # OM75874 CONTACT NAME: PHONE FAX (A/C, No, Ext): (310) 370-5000 , No):(310) 370-5454 Burnham Risk and Insurance Solutions, LLC 15901 Hawthorne Blvd. Suite 200 Lawndale, CA 90260 E-MAILreceptionist@burnhamrisk.com INSURERS AFFORDING COVERAGE NAIC # INSURERA:Massachusetts Bay Insurance Company INSURED INSURER B : INSURER 7 Burnham Benefits Insurance Services INSURER D : 2200 Michelson Dr. Ste 1200 Irvine, CA 92612 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. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MMIDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑ OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP (Any oneperson) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICYEl JJECT LOC OTHER: GENERAL AGGREGATE $ PRODUCTS - COMP/OPAGG $ $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY Perperson) $ BODILY INJURY Per accident $ PROPERTY DAMAGE Per accident $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A X WDFA32762510 6/8/2021 6/8/2022 X PER OTH- STATUTE ER E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE- EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Waiver of Subrogation applies in favor of City of El Segundo subject to the terms of the attached endorsement form. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo ty g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Hanover Insurance Group.. WHFA327625 1001741 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 due on such remuneration. Person or Organization CITY OF EL SEGUNDO 350 MAIN STREET EL SEGUNDO, CA 90245 % of the California workers' compensation premium otherwise Schedule Job Description 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 Insured Policy No. WHF-A327625-10 Endorsement No. Insurance CompanyTHE HANOVER INSURANCE COMPANY Countersigned By WC 04 03 06 (Ed 04-84)