PROOF OF INSURANCE (2022) CLOSEDACORO® CERTIFICATE OF LIABILITY INSURANCE
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DATE(MM/DD/YYYY)
09/15/2021
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
SKS Insurance Agency, Inc
221 Main Street,Box 38
Seal Beach, CA90740
CONTNAME: Kati Thompson
PHONE 562-493-3900 FAX
A/c No EXt: A/C No:
ADDRESS: kati@liveswellinsurance.com
INSURER(S) AFFORDING COVERAGE
NAIC #
License #: OH52941
INSURERA: AMCO Insurance Company #19100
19100
INSURED Monjaras 8r Wismeyer Group Inc.
DBA Return to Work Partners
INSURERB: Sequoia Insurance Company
22985
INSURERC: Unites States Liability Insurance Co
25895
INSURER D:
2201 E Willow St Ste D189
INSURERE:
Signal Hill, CA 90755-2148
INSURER F :
COVERAGES CERTIFICATE NUMBER: 00009453-1337459 REVISION NUMBER: 90
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
MM/DD/YYYY
POLICY EXP
MM/DD/YYYY
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
Y
Y
ACP7814144291
08/29/2021
08/29/2022
EACH OCCURRENCE
$ 2,000,000
CLAIMS -MADE [XIOCCUR
DAMAGE TO
PREM SES (Ea O."'Dence)$
300,000
MED EXP (Any one person)
$ 5,000
PERSONAL & ADV INJURY
$ 2,000,000
AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 4,000,000
GEN'L
X
POLICY ❑PRO- J ECT ❑ LOC
PRODUCTS - COMP/OP AGG
$ 4,000,000
$
OTHER:
AUTOMOBILE
LIABILITY
ACP7814144291
08/29/2021
08/29/2022
COMBIA
(Ea acccidentsINGLE LIMIT
$ 1 000 000
BODILY INJURY (Per person)
$
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
X
HIRED NON -OWNED
AUTOS ONLY X AUTOS ONLY
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LIAB
CLAIMS -MADE
DED RETENTION $
$
B
AND EMPLOYERS' LIABILITY WORKERS COMPENSATION
ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑
QWC1164278
08/29/2021
08/29/2022
X STATUTE EERH
E.L. EACH ACCIDENT
$ 1,000,000
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
N/A
E.L. DISEASE - EA EMPLOYEE
$ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE -POLICY LIMIT
$ 1,000,000
C
Errors 8r Omissions
SP1018321L
08/29/2021
08/29/2022
Occurence
1,000,000
Retention
$5,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
City of El Segundo its officials, and employees are listed as Additional Insureds as per written contract.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of El Segundo
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
350 Main Street
ACCORDANCE WITH THE POLICY PROVISIONS.
El Segundo, CA
AUTHORIZED REPRESENTATIVE —
(KILT)
I `-- 1988--2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
Printed by KILT on September 15, 2021 at 04:04PM
BUSINESSOWNERS
PB60720711
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
AMENDMENT TO OTHER INSURANCE CLAUSE FOR
ADDITIONAL INSUREDS - PRIMARY AND NOW
CONTRIBUTORY WHEN REQUIRED IN A WRITTEN
AGREEMENT OR CONTRACT WITH YOU
This endorsement modifies insurance provided under the following:
PREMIER BUSINESSOWNERS COMMON POLICY CONDITIONS
Only with respect to any additional insured, in the COMMON POLICY CONDITIONS, form PB 00 09, under
condition H. OTHER INSURANCE, paragraph 2.a. is replaced by the following:
H. OTHER INSURANCE
2. Under any liability coverage provided by this policy,
a. If for injury or loss we cover, there is other valid and collectible insurance available to any additional
insured under another policy, our obligations are limited as follows:
(1) Issued by another insurer, or if there is self insurance or similar risk retention that applies to a
loss covered by this policy, then this insurance provided by us shall be excess over such other
insurance, unless you have agreed in a written contract or written agreement signed prior to the
loss that this insurance shall be primary:
(a) Then this insurance is primary. If other insurance is also primary, we will share with all that
other insurance as described in d. below; and
(b) The coverage afforded by this insurance is non-contributory with the additional insured's own
insurance.
Paragraphs (a) and (b) do not apply to other insurance to which the additional insured has been
added as an additional insured to any other person or organization's policy; or
(2) Issued by us or any of our affiliate companies, that applies to a loss covered by this policy, then
only the highest applicable Limit of Insurance shall apply to such loss. This condition does not
apply to any policy issued by us that is designed to provide Excess or Umbrella liability insurance.
All terms and conditions of this policy apply unless modified by this endorsement.
PB 60 72 07 11 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1