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PROOF OF INSURANCE (2021 - 2022) CLOSEDCERTIFICATE OF LIABILITY INSURANCE °ATE'MMI°°"YYY) 07/01 /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 cONTA T United Direct Insurance NAME': PHONE FAX 787 /A.q, naA. (818) 996 6856 16255 Ve furs Blvrdn#1255 icesMR Nnto(u $Oddi,reclins c om Encino INSURED LA UNIFORMS & TAILORING, INC. 15625 Hawthorne Blvd # D CA 91436 N wSURFR n - THE HARTFORD INSURER D : INSURER E : Lawndale CA 90260 INSURER F rr)VFRer1=C rI RTIFlr.ATr- NIIIIVIRFR• RFVII.;Ir)N NI IMRFP- 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 ...................... .......,....,. �ADDL�UB t�t� E'OLVOY EP�—POLICY EXP ^ ....... --- TYPE OF INSURANCE TR '' POLICY NUMBER Mt Y I (MMIPR=1I LIMITS X COMMERCIAL GENERAL LIABILITY OCCURRENCE I $ 1,000,000 ff EIOCCUR _EACH °I'7_AMar, Y-OidLN°I`FD 1,000,000 1 CLAIMS-MADE PR}wP1iwSEa Yre $ MED EXP (Any one person) 1 $ 10,000 A 72SBABE0351 04/14/2021 04/14/2022 I PERSONAL $ 1,000,0000 GEN L AGGREGATEL LIMIT APPLIES PER: f GENERAL AGGREGATE $2,00 O 0000 lY � �S POLICY r F�7• LOC _ PRODUCTA COMP/OP AGG S $ 2 OOO 0000 . y ......... r OTHERS. $.., AUTOMOBILE LIABILITY CS MEINED SINGI F W.6AA, dE c t}py jl) $ ANY AUTO BODILY INJURY (Per ........... 4 OWNED SCHEDULED 11 P BODILY 11 INJURY (Per ac cdent) $... N .�.....d .. AUTOS HREDAUTOSONLY NON --OWNED F'"ROPrR DAMAGEp �,.tP�r $ AUTOS ONLY _. AUTOS ONLY �tCLie��rmav) ................ UMBRELLA LIAB OCCUR � EACH OCCURRENCE $ ....7 EXCESS LIAB .CLAIMS MADE{ ^ I I AGGREGATE $ DED^� RETENTION$ $ KERS COMPENSATION PER ORH I AND EMPLOYERS' YIN IN R J ANY PROPRIETOIETOR/PARLIABILITY EXECUTIVE E L EACH AICCI ENT11", $ '.. OFOFIRCER/M R EXCLUDED? '.. (Mandatory in NH) ❑ NIA '.. EL. DISEASE - EA EMPLOYEE: $ If yes, describe under :DESCRIPTION OF OPERATIONS below _ E.L.. DISEASE POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) RE. Contract #3957, City of El Segundo The General Liability policy included an automatic Additional insured endorsement that provides Additional Insured status to certificate holder, only when there is a written contract that required such status, and only with regard to work performed on behalf of the named insured. The General Liability and workers Compensation policies included a Waiver of Subrogation endorsement in favor of the Certificate Holder as referenced above. CERTIFICATE HOLDER CANCELLATION The City of El Segundo 348 Main St 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 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD M THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGE This endorsement changes the policy effective on the Inception Date of the policy unless another date is indicated below: Policy Number: 72 SBA BE0351 SC Named Insured and MailingAddress; LA UNIFORMS & TAILORING, INC. DBA LA UNIFORMS & TAILORING 15625 HAWTHORNE BLVD STE D LAWNDALE CA 90260 Policy Change Effective Date: 07/16/21 Effective hour is the same as stated in the Declarations Page of the Policy. Policy Change Number: 001 Agent Name: UNITED DIRECT INSURANCE SVCS INC Code: 250427 CHANGES:POLICY SENTINEL INSURANCE COMPANY, LIMITED ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING STATEMENT.IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BANK ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A BILL. ADDITIONAL INSURED(S) ARE ADDED THE FOLLOWING ARE ADDITIONAL INSURED FOR BUSINESS LIABILITY COVERAGE IN THIS POLICY. LOCATION 001 BUILDING 001 •- Oo FORM NUMBERS OF ENDORSEMENTS ADDED AT ENDORSEMENT ISSUE: PRO RATA FACTOR: 1.000 Form SS1211 04 05 T Page 001 (CONTINUED ON NEXT PAGE) Process Date: 0 7 / 16 / 21 Policy Effective Date: 0 4 / 14 / 21 Policy Expiration Date: 0 4 / 14 / 22 POLICY CHANGE (Continued) Policy Number: 72 SBA BE0351 IH12001185 ADDITIONAL INSURED - OWNER, LESSEES OR CONTRACTOR Form SS 12 11 04 05 T Page 002 Process Date: 0 7 / ]. 8 / 21 Policy Effective Date: 0 4 / 14 / 21 Policy Expiration Date: 04/14/22 POLICY NUMBER: 72 SBA BE0351 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONALOWNER,t C LOC 01 BLDG 001 EL SEGUNDO POLICE DEPARTMENT 348 MAIN STREET, EL SEGUNDO, CA 90245 NUMBER OF JOB LOCATIONS 1 *ESCRIPTION OF COMPLETED OPERATIONS ALL PROJECT OF THE NAMED INSURET Form IH 12 00 1185 T SEQ. NO. 001 Printed in U.S.A. Page 00 Process Date: 0 7 / 18 / 21 Expiration Date: 0 4 / 14 / 2 2 DocuSign Envelope ID: D7085FB9-49CA-4DF3-9CEB-A99EC2DACD99 ERCRY AFJ INSURANCE COMPANY B A S 1 C D R 1 V E R S D R I V E R I N F O AUTOMOBILE APPLICATION CALIFORNIA REWRITTEN FROM BINDER # (Producer Enter) CUSTOMER # RAZA 1 POLICY PERIOD T ...Agent CODE...... Agent NAME... �_ . � ....�............. ...(.,, .� TELL TELEPHONE 12:07 AM 09/28/2021 T O T..... 12tD1 A.M. 04C965 None United Direct Insurance Services 800 805-0787 PAYMENT PLAN: Auto Pay- Same Pay (EFT) Payment with Appl'ecat APPLICANT'S ADDRESS $ 288.76 GROUP NO. 6002 Credit Card Amount STREET # 1 $ �l STREET # 2 AIM CITY„ ST, ZIP Company Use Only EMAIL ADDRESS: UNIT HOME PHONE I BUS PHONE EXT. UrW BEST TIME TO CALL BEST TIME TO CALL Are all cars garaged at Applicant's Mailing Address? Q Y/N If no show on page 2 040106140223706 SHOW BELOW ALL PERSONS TO BE COVERED BY THIS POLICY BiR3; FIRST (1M C APPI l T iO 8 CAI Y 111h9 dP1 LAST 19d 'L STATE tIOERS FIST SE k A 86 PATE To VEH UN E1l0 1 8T®fdt R TYPE y... Mukhtar Reza..._._ CA _ w... M M 40 IIIIIIIIIIA0100 IN 1 >50 % WS N N 0 2 ShakibaRaza ._.w....�.-__ . CA �. FM ;., _ .-,.m._ Sp .._.2 _>50'/PLS, N N _ 0... �.�CA )� F S DH 1 <50 Y 11 ficensa€f clffter fftafl OaJrdearrt¢e l.g7VOfZggf of ART? fr r �lsf 3 ears" OR C�iPATiG'�J NO- , E wee 4 IP'f I N. .HL 'NAME OF`E'"MPl„OYE.R OR S`Cb 00L COMPLETE�AUORES5 �s7REET a 01`r'�°j OF E'fnMFIC.$)'iI :1� d Fk ,'". "tl�'wl. SUSIN ss Ef PL 2 owner 2 owner LA Uniforms 15625 Hawthorne Blvd _..�_�................................ Lawndale CA 9�2�0 .....................�.�.-_ .. _ I Uniforms 15625 Hawthorne Blvd Lawndale CA 90 260 3 0 d I p UNLESS GOOD DRIVER, DO NOT BIND OR SUBMIT: 1. Felony(Except 23153 or 20001) 2.Auto Theft within last 5 years 3. Two major convictions with one in the last 5 years (Definition - see questions below). HAS ANY DRIVER: HAS ANY DRIVER: YES/NO REF NO. YES/NO REF NO. — Been in an accident or sustained any loss in the last 5 1 - Been convicted for ANY alcohol related incident, hit and run, reckless years (regardless of fault )? driving, manslaughter or refusal to submit to an intoximeter test in the Iasi 10 years? " Had a motor vehicle stolen in the last 5 years? If more ® — Have a physical impairment that requires compensatory equipment? than one, do not bind. -k Ever been cited for use or possession of drugs? - Ever been convicted of a felony? IFTHE TOTAL DAMAGE WAS IN 8KCESS'OF31,000. IF REF NO. TOTAL SHEETS PRINTED 6 U-1 12/2020 CA 1M B-A99EC2DACD99 ADDITIONAL HOUSEHOLD MEMBERS 3 all persons of any age, except those listed on page 1, who reside with the applicant. Please include unmarried children away at school or in the ,id forces. WARNING: Your failure to identify all persons residing with you, regardless of age or whether they drive any vehicles, will be deemed a material misrepresentation or omission and will void the coverages you are applying for. �y�rii/�I,i iil i✓ J"`'Lw"'')A,`,Vr AOE NONE %: 4Pi SldffN, : - , REL; ,:ffN,v „°,,,TO APP. i VR1� fT �ft7 YES N'Gf < P„C .- . ........ _.............. —' — -- —.. � I _ ........... AGENT: Attach a signed original copy of the Designated Person(s) Coverage Exclusion (U-45) for all residents age 15 and older with the application. �b'h�RAd BODILY INJURY LIABILITY C�.. PROPERTY DAMAGE LIABILITY O UNINSURED MOTORIST (BODILY INJURY) •- LIMITS OF LIABILITY $ 250,000 EACH $ 500,000 PERSON .. -- ...----- - -- EACH $ 100,000 ACCIDENT EACH $30,000 PERSON $ 60,000 CAR 1 EACH ACCIDENT 296 ----..— m . ..... _�.� 343 EACH ACCIDENT 46 CAW 125 ... .......... 200 29 _----.......,, V UNINSURED MOTORIST COVERAGE Y/N CAR 1 N CAR 2 N CAR CAR PROPERTY DAMAGE E COLLISION DED. WAIVER COVERAGE YIN CAR 1 N CAR 2 N CAR CAR R MEDICAL EXPENSE EACH PERSON COMPREHENSIVE DEDUCTIBLE CAR 1 $250 CAR 2 $ 250 CAR CAR '.. 10 41I A. COLLISION DEDUCTIBLE CAR 1 $500 CAR 2 $ 500 CAR CAR 433 139 GrWWW ROADSIDE ASSISTANCE PER OCCURRENCE For Towing Services CAR 1 $75 CAR 2 $75 CAR CAR 5 4 �I E RENTAL CAR COVERAGE YIN CAR 1 Y CAR 2 Y CAR CAR 28 22 $ SO PER DAY- 30 DAYS ... .._.._ .............._......................................................................................................._, ........... ............ .. ,mm ..... SLEASE LOAN GAP COVERAGE YIN CAR 1 N CAR 2 N CAR CAR a COVERAGE REPAIR OR REPLACEMENT COVERAGE YIN CAR 1 N CAR 2 N CAR COST COVERAGE CAR d NON -FACTORY TOTAL LIMIT CAR 1 CAR 2 CAR CAR ',.. EQUIPMENT PER CAR PREMIUMS PER CAR $1161 $560 IMPORTANT: FILING AND/OR POLICY FEE $ 0.0 The policy does not cover non -factory equipment in excess of $1,000 unless it is specifically described on page 2 of the application and a premium charged CA FRAUD FEE $ 1.76 thereof. CIGA CHARGE $ For Non -Towing Services, Limits of Liability is $75 per Occurrence. Maximum 5 ESTIMATED TOTAL Occurrences in total for Towing and Nan -Towing Services per policy period. POLICY PREMIUM $ 1722.76 Your producer receives a commission and possible contingent commission for placing your insurance with Mercury.. The commissions depend on the volume and profitability of business placed by your producer with the Company. If the policy premium is paid in installments, an additional $6 service fee will apply to each installment payment. If the policy premium is paid by direct debit installments, the fee for EFT direct debit will be $2, the fee for Recurring Credit Card direct debit will be $6. The service fee will be charged to each installment payment. U-1 12/2020 CA POLICYHOLDER COPY Sc P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 08-11-2021 EL SEGUNDO POLICE DEPT. SC 348 MAIN ST EL SEGUNDO CA 90245-3813 GROUP: POLICY NUMBER. 9270374-2021 CERTIFICATE ID: 1 CERTIFICATE EXPIRES: 02-13-2022 02-13-2021/02-13-2022 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer. We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. EMPLOYER LA UNIFORM & TAILORING INC. SC 15625 HAWTHORNE BLVD STE D LAWNDALE CA 90260 [P18,H0] IREv.7-20141 PRINTED : 08-11-2021 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION 9270374-21 RENEWAL SC 8-54-66-48 PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE AUGUST 12, 2021 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING FEBRUARY 13, 2022 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME LA UNIFORM & TAILORING INC 15625 HAWTHORNE BLVD STE D LAWNDALE, CA 90260 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, EL SEGUNDO POLICE DEPT. WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, LA UNIFORM & TAILORING INC IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03%. NOTHING IN THIS ENDORSEMENT SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS ABOVE STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS IN THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO! 2570 1"�.. AIJ"I`�ORI�ID REPRE»�ENT IVF. SCIF FORM 10217 (REV.4-2018) AUGUST 17, 2021 PRESIDENT AND CEO OLD DP 217