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PROOF OF INSURANCE (2022 - 2022) CLOSEDOP ID: DR D,,CERTIFICATE OF LIABILITY INSURANCE 07/22/2021 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 endorsements .. PRODUCER .......... Alliance Mgt. 8, Insurance Sery CONaACa NAME;. Michelle Nowell 355a Vera Cruz#7 CAA. ntdBroker Lic# 0737966 PRONENa 7..... . pAtc �L 7a116 -93T8 _ . ) _ _ naWellWYENNiscor.com DR i'cfimelle i4Nta112076 .. __. .._ CyPRICI._... _....... � _� �� — .� INSURED Associates INSURER(S) AFFORDPNG _ ENAIC B ��1A .� E 141118... ^^ leus Ins UPanCR ('iOm n RA Pe._, 815 Central Ave 920 R e 'INSURERS, _._.,. I ,.�..m... Glendale, CA91204 INSURRC: INSURER ERE ......... .., _,......._ COVERAGE$ CERTIFICATE NUMBER: INSGU'R'E RMSION 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 ._ HAVE BEEN REDUCED BY PAID CLAIMS. OF SUCH POLICIES LIMITS SHOWN MAYfti �, ._e7�D'S POLICY TYPE OINS �LPF� - 11- CE INS WWI ER _-- POL ICY �r' POEM Mrlo w M _. uMl I GENERAL LIABILITY _ A X f COMMERCIAL EACH �r=URRENCE $ 1100010( . OENERAL LIASILnY X D3/06/2021 03/06/2022 �..DRMA s r "TEA $ 10 I CLAIMS -MADE OCCUR ) m ,0I ...... Errors Omission : MED EXP (Any one Person;) $ 5,®( PERSONAL & ADV INJURY $ 1,040,0( GEN'LAGGREGATEPR� APPLIE µ .... y__ S PER: �.. GENERAL AGGREGATE 8,000,0( 1 X 1 1,000, PRODUCTS COMPlOP AGG � _._ _ . m^m^ POLICY f :, LOG, ___... i $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) S BODILY INJURY (Per $ ALL OWNED AUTOS person) x SCHEDULED AUTOS BODILY INJURY (Per ac�Gdent)U $ HIRED AUTOS PROPERTY DAMAGE (PERACCIDENT) $ � :NON -OWNED AUTOS $ a. mm 0 �S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB �.. CLAIMS�uIAD E ., _ [ m _ .m ..., _ ..,,m w „� , _.- DEDUCTIBLE $ AGGREGATE„ . . RETENTION$ _ . WORKERS COMPENSAMN---'WCSTATU- AND EMPLOYERS' LIABILITY t YIN ! 1 CiTH- TO(1LIIIIS Eft.. ANY PROPRIETORIPANTNERIEXECLrt VE (�PfICER+�MI?NiSER EXCLUDED? N i A - _ i , E L EACH ACCIDENT $ (Ma ulatory In NH) if Iy r E L DISEASE EA EMPLOYEE $ � RIdescrib Gi�ES�P"rI0fi1 OP ERATEONS below � 1_al OP iE.LDISEASE-POLiCYLimrr Aggirega DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Addlllonal RemarWe Schedule, Ifmore space Is required) e%undo Ilea DepIartment atllCials,C rs, aft nd em IoyBaBs are anI Ime s a d�tional I'tasured vw)th respect to ae Vv Per orrnecf lacy the named El Segundo Police Department Assistant to the Captains 11114!17] SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCts WITH THE POLICY PROVISIONS. ..................... Amanda O'Donnell AUTHORIZED REPRESENTATIVE 345 Main Street I Segundo, CA 90245 11 VWAU3LV.J Q 01988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PKV0000355 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL AL. INSURED - DESIGNATED PERSON OIL ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Section II - Who Is An Insured is amended to in- clude as an additional Insured) the persons) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury"", '"property damage' or 'personal and advertising Injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 202607 04 0 ISO Properties, Inc., 2004 Page 1 of 1 El Fold here Cut along edge ♦ Ix Allstate. You're in good hands. Please use the printed Insurance Cards below. Please use the printed Insurance Cards below. California Proof Allstate, If Auto Insurance Card you have an accident or loss: Cau^npa Allstate Northbrook ltnde nrriYti ny PO Box 660598, Dallas, TX 7 7Ga6.059ti Ya„°re una�dl g�w�uermdg WAN • Get medical attention if needed. Notify the police immediately. lcel W erra II � Obtaw names, aGtftesses, phone nurnbfrs (work & home) and kc,ense plate numbers of all persons involved, including passengers, and witnesses. • Call1-800-ALLSTATE (1-800-255-7828), This policy meets the requirements of the applicable California financial logon to allstate.com or contact your Allstate agent responsibility law(s). as soon as possible. POLICY NUMBER YEAR/ MAKE / MODEL Mike Krupka Inc 934426951 EFFECTIVE DATE 09120M 2D20"dal Nadq VEHICLE ID NUM8111— (818) 4071b71 EXPIRATION DATE 03120/22 1965 Yosemite 4210 This card must be carriedin the vehicle aiu r ,, , cn : ofinsurance. Simi Valley, CA 93063-5220 California Proof of Allstate, If you have an accident or loss: Auto Insurance Card Allstate ftort4 brooc Int6e;mnrky Co crpanyIsomPO You're in good hands. • Get medical attention if needed. Box 660598, Dallas, TX 75266.059N' Notify the police immediately. 1mrtVM Obtain names, addresses, phone numbers (work & home) and license plate numbers of all persons involved, including passengers and wilness,es. • Call 1-800-ALLSTATE (1-800-255-7828). This policy meets the requirements of the applicable California financial logon to allsiate com or contact your Allstate agent responsibility law(s). as soon as possible. POLICY NUMBER YEAR / MAKE / MODEL Mike Krupka Inc 934 426 951 EFFECTIVE DATE 03120/2l 1999 ih7 Trk. $10 VD N (818) 407-1671 EXPIRATION DATE tarro'e122 �UICL 1965 Yosemite #210 This card must be crsrred an the vehicle of a rr , evr erne of insurance. Simi Valle CA 93063-5220 y. California Proof of Allstate. If you have an accident or loss: Auto Insurance Card You're in good hands. • Get medical attention if needed. Allstate Northbrook lnidern t Compa 1 I PO Box 660!,9ll, Dallas, TX TS2t6,059 Notify the police immediately. A NI • Obtain names addresses, phone numbers (work & home) and license plate numbers of all persons involved, including passengers and wiloemes,. • Call1-800-ALLSTATE (1-800-255-7828), This policy meets the requirements of the applicable California financial logon to allstate.com or contact your Allstate agent responsibility law(s). as soon as possible. POLICY NUMBER YEAR / MAKE / MODEL Mike Krupka Inc 934 426 9S1 EFFECTInDATE 09/20/21 1992 BMW 3181 (818) 407-1671 (818)41965 7-1671emite EXPIRATION DATE C13120/22' #210 This card rriust be carried'' in the vehicle art ONtirraez os eva. encc of insurance. Simi Valley, CA 93063-5220 Amended auto policy declarations Policy number: 4269rc1 1 tate Policy effective date: March 20, 2021 Page 7 of 8 1t,, Q A You're in good hands. Covers a detail for 2020 Hyundai loni coveme Limits Aeducftle Premium Automobile Liability Insurance Not applicable "I - Bodily Injury $500,000 each person $500,000 each occurrence • Property Damage $100,000 each occurrence Auto Collision Insurance _ Actual cash value $500 9M Waiver of deductible Auto Comprehensive Insurance Actual cash value $0 Rental Reimbursement up to $30 per day for a maxim um of 30 Not applicable low Towingand Labor Costs Not purchased'* Uninsured Motorists Insurance for Bodily $500,000 each person Not applicable OWN Injury $500,000 each accident Automobile Medical Payments Not purchased* Coordinated Medical Protection Not purchased* Lease/Lo.. _.. _ ... W __....._ an Gap See Form AU14628-1 Not applicable Sound System Not purchased* Tape Notpu * Total premium for 2020 Hyundal Ionlq $�, * This coverage can provide you with valuable protection, To help you stay current with your Insurance needs, contact your Allstate agent to discuss coverage options and other products and services that can help protect YOU. VIN Lienholder Hyundai Lease Titling Trust Rating information Your premium is determined based on certain information, including the following: • This vehicle is driven 3-9 miles to work/school, married person licensed 56 years. Allstate uses mileage information as one factor to help determine your premium amount. The estimated number of miles that this vehicle Is driven annually Is 6,000 - 6,499. If any of the information shown above Is incorrect, missing or changes in the future, please contact your Allstate representative. Please keep in mind that a change In any of the information may result in an adjustment to your premium. Additional coverages Automobile Death Indemnity Insurance Not purchased* Automobile Disability Income Protection Not purchased* (continued) 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: (J l have and will maintain a certific ate�cdeo§ elf-insure for workers' compensation, issued by the Director of industrial Relations as provided for700 forthe performance of the work set forth the agreement with the City of El Segundo. Policy No. (_) I have and will maintain workers' corn of the work for which the agreement with carrier and policy number are: Carrier Name of Agent required by Labor Code § 3700 for the performance is executed. My workers' compensation insurance Policy Number Expiration Date Phone # Pmp4certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not lo any person in any ma er o as to become subject to the workers' compensation laws of California, and agree that, if I should beco a sou ject to the workers' om,pensation provisions of Labor Code § 3700 1 must immediately comply with tho a pro isions or the moot will automatically become void. Signature of Applicant Date 6 Agreement for: Dated:..` 4a �` I Reviewed by: �'� .... V