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PROOF OF INSURANCE (2022) CLOSEDA14' 0 CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 8/3/2021 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 NAME: RPS Bollinger PHONE — F/'z 200 Jefferson Park W.—N -5311 (A�c N 973 921 2876 lA tale �t�ttl Whippany NJ 07981 ADDFRE_S$ spoilservll;t@fp,§lns.com 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. ..-... ii ! POLICY NUMBER.........--�... MMIDD/YYYY MM/ POLICY ) r F PC7LI ILTR TYPE OF INSURANCE ADDi.,( iJl 6 r POLICY EFF DryYYy LIMITS A I GENERAL LIABILITY Y 3602AH028574 8/9/2021 8/1/2022 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY -0AM-AGE TC5 RERTELI $ 100,000 --.... CLAIMS -MADE I: X OCCUR PREMI$FS (Fa occucrenoaj MED EXP (Any one person) $ 5,000 X Ind Participant PERSONAL & ADV INJURY I, $ 1,000,000 .---- _.... _ .,., I, GENERAL AGGREGATE $3,000000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $ 1,000 000 PCALpCY 1-1 PRt ^ I. LOC: JLCT __ SexualAbuse/Mal $ 1mdl$2md A AUTOMOBILE LIABILITY 3602AH028574 8/1/2021 8/1/2022 f COMBINED INGL:E. LIMIT acC dnh .� t,,0tao ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per person) $ 11 AUTOS AUTOS - - i, X X NON -OWNED HIRED AUTOS AUTOS BODILY INJURY (Per accident) — - PROPERTY DAMAUIm'••. ,tf er arwCn./c;utp $ ....- -.__..- ----------- ............ $ $ A UMBRELLA LIAB X I OCCUR 4602AH010560 8/1/2021 8/1/2022 EACH OCCU RRENCE $ 1,000 000 X EXCESS LIAB 1 CLAIMS MADE - AGGREGATE DED I X I RETENTION $ 0 1$ — WORKERS COMPENSATION AND EMPLOYERS' LIABILITY I WC STATU- I 10" 11 I -- -TO,RY YIN , ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED9 ❑ N / A E L EACH .LI@htT( ACICDENT $ (Mandatory in NH) E L DISEASE EA EMPLOYEES $ If es, describe under I DEYSCRIPTION OF OPERATIONS below ` '. E.L. DISEASE - POLICY LIMIT $ B ''. Accident Insurance 028573 8/1/2021 8/1/2022 Med Max: $25,000 '.... Full Excess T Ded: $100 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The certificate holder is named as an additional insured under the liability policy. Coverage is provided for sponsored/supervised activities of the named insured. Group Code: EISegRec CERTIFICATE HOLDER CANCELLATION The City of El Segundo, its officers, officials, employees, agents, and volunteers. 401 Sheldon 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. REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved, ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 3602AH028574 COMMERCIAL GENERAL LIABILITY 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 Name of Person or Organization: The City of El Segundo, its officers, officials, employees, agents, and volunteers. 401 Sheldon Street El Segundo CA 90245 (if no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule as an insured but only with respect to liability arising out of your operations or premises owned by or rented to you. CG 20 26 11 85 Copyright, Insurance Services Office, Inc., 1984 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: U 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. (_)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 # a�II certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not employ any person in any manner so as to become bject to the workers' compensation laws of California, and agree that, if I should t)eco subject to the work s' compensatio provisions of Labor Code § 3700 I must immediately comply with th /provisions or the agr rrrent ill auto a ally become void. Signature ofApplicant�� Date L�'. A reement for: � A�_ � � 6 �.. � �` �� 9/24/21 Dated: Reviewed by: