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PROOF OF INSURANCE (2022 - 2022) CLOSEDJOEMPOL-01 TCHAMPLIN �►co�ro,,, CERTIFICATE OF LIABILITY INSURANCE `.�•-- DATE(MM/DD/YYYY) 7/13/2021 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 CONTACT NAME: PHONE FAX (A/C, No, Ext): (866) 276-3775 (A/C, No): (866) 215-5018 PayneWest Insurance - TAG 14900 SW Barrows Rd, Ste 202 Beaverton, OR 97007 ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURERA:Scottsdale Insurance Company 41297 INSURED INSURER B : INSURER 7 Joe Mar Polygrah & Investigation Services Inc INSURERD: 12939 Banyon Rancho Cucamonga, CA 91739 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 A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR X X RBS0086990 7/29/2021 7/29/2022 DAMAGE TO RENTED PREMISES Ea occurrence 100 000 $ MED EXP (Any oneperson) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PELT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY Perperson) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) N/A E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A Errors & Omissions X X RBS0086990 7/29/2021 7/29/2022 each claim 1,000,000 A Errors & Omissions X X RBS0086990 7/29/2021 7/29/2022 aggregate 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder is additional insured per attached GLS487 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. 348 Main St 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 ENDORSEMENT SCOMDALE INSURANCE COMPANY NO. ATTACHED TO AND ENDORSEMENT EFFECiWE BATE FORMING POLICY MlMBBEROF (72�1 A M SiANDAAd11ME) NAMED INSURED AGENT NO. RBS 6 7/2 /2 21 Joe Mar Polygraph & Investigative Services Inca 46722 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED —OWNERS, LESSEES OR CONTRACTORS — AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU INCLUDING PRIMARY OR PRIMARY AND NON-CONTRIBUTORY AND LIMITED WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILtiY COVERAGE PART ERRORS AND OMISSIONS COVERAGE PART A. SECTION I1--WHO IS AN INSURED is amended to include as an additional insured any person or organization for whom you are performing operations and you and such person or organization have executed a written contract or agreement prior to the time of an "occurrence" giving rise to a claim that such person or organization be added as an additional insured on your policy. Such person or organi- zation is an additional insured only with respect to liability for "bodily injury," "property damage," `error or omission" or "personal and advertising injury" caused, in whole or in part, by: 1. Your negligent acts or omissions; or 2. The negligent acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: 1. "Bodily injury," "property damage," "error or omission" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or sur- veying services, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and b. Supervisory, inspection, architectural or engineering activities. 2. "Bodily injury" or "property damage" occurring after: a. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or b. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. Includes copyrighted material of ISO Properties, Inc., with its permission. Copyright, ISO Properties, Inc., 2004 OLS-487 (6-15) Page 1 of 2 C. With respect to the insurance afforded to these additional insureds, the following is added to SEC- TION 111---LIMITS OF INSURANCE: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contractor agreement you have entered into with the additional insured; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Lin -its of Insurance shown in the Declarations. D. Under SECTION IV —COMMERCIAL GENERAL LIABILITY CONDITIONS; subparagraphs a. Pri- mary Insurance and b. Excess Insurance of paragraph 4.Other Insurance are amended as follows: If you have agreed in a written contract and executed such a contract or agreement prior to the time of an "occurrence" giving rise to a claim, that this policy will be afforded on a primary or primary and non- contributory basis and without right of contribution from any insurance in force for the liability in the performance of your ongoing operations for the additional insured(s), then this insurance will be af- forded on a primary or primary and non-contributory basis, and we will not seek contribution from any other such insurance. E. Under SECTION IV —COMMERCIAL GENERAL LIABILITY CONDITIONS, the following is added to paragraph 8. Transfer Of Rights Of Recovery Against Others To Us: We waive any right of recovery we may have against an additional insured if you have agreed in a written contract, and executed such a contract or agreement prior to the time of an 'occurrence" giving rise to a claim, but only with respect to liability for "bodily injury," "property damage," "error or omission" or "personal and advertising injury" caused by: 1. The named insured's negligent acts or omissions; or 2. The negligent acts or omissions of those acting on the named insured's behalf; in the performance of the named insured's ongoing operations for the additional insured. All other Terms and Conditions of this Policy remain unchanged. AUTHOFUZED REPFESENTAIlVE DA119 .. .. ..XF.7.1 M.BMARfoll-.. ti. Copyright, ISO Properties, Inc., 2004 GLS-487 (6-15) Page 2 of 2 policyRenewal auto a 'Total Amount for the Policy Period Please review our insured vehicles and,m.veri.y� it VINs .,re y verify their VIfVs are correct, h ec1e lovered. _n ..__ l eaatl "c „ tion y!VP,,pum azer 1169� 2010 cdes Bl E35 $1,068.77 r 77 2016 Raufn `rucks 1500 2wd b 851.54 California Fraud Assessment Fee 2.6 _- ..-. ... "1__1_ _..._ _ -..... .- _.-_- _.._-_.w...----.—..., ._-..._._..._ergg w$3,092.7 Mailing address L J * Your bill will be mailed separately. Before making o payment, please refer to your Your policy provided by West bill, whkh includes payineaat options and installment fee information. if you do Allstate Northbrook root pay lan full, you will be charged an installment fee(s)n Company See the Important ipaayra ent avid coverage information section for details about Policy period installs -rent fees, beginning August 11, 2021 through February 11, 2022 at 12:01 a,m. standard Discounts (included in your total prerniurn) Coed Driver (20"/o) $754.81 Anti -theft Distinguished $1194a03 Driver .,....m, ,,.... .......... . ------ Total discounts $960.01 Discounts per vehicle _1297 Chewy O.,Trk Blazer $2,7 73�I Good Driver (20%) $274.73 (,LOIO Mercedes E3 _.._ 73 22 Anti -theft $6.02 Good Driver (20%) $267,20 2016aatta TruclCs 1 2d Anti -theft. $ s.l a Good driver (20 /) $212,8 Distinguished $19 ,0;3 Driver Surcharge(illdVded in your total parerniurrt) 1997 Chevy Trig Mazer Usted drivers on your policy ,doe Delta MM Your Allstate ageancY is NII� Some or all «; the w of your policy or it could affect coverages.eligibility for certain any information o. your Policy corrections «, have notified d , be made only for policy period or for future policy periods. believe any coverages are o listed or listed.are inaccurately P11- 9 Renewal auto policy dec1arations Policy number: f 3 of 6 Policy effective date: AugustPage 11, 2021 sn Allstate You're in gciod hainds, Coy e.IIY*Le, detail for 1997 Chey y._1iLkB1azeir Coverage Limits Deductible Premium - -------- - ------------ - - .. . . ....... ... . ...... .. I .,- Automobile Liability Insurance Not applicable $645,14 Bodily Injury $1,000,000 each peirson $1,000,000 each OCCUrrence ProI:..'�erty Dairri-age $100,000 each, occurrence Auto CoHision lrisurance Actua� cash vakie $250 $321,22 Wanver of deductible. applies Auto Comprehensive lnsurarice ACtL1,11 cash value $0 $75.20 Rental Re4iibffserneint INot prarchased* Towing and I abor Costs Nast PUrchase& Uninsured Motorists irisurance for bodily $100,000, each person Not applicable $102.61 Injury $300,000 Pach acc'ident AutornobflePvl,edicaPayments $2,000 each person Not applicable $25.63 Coordfinated Me&4l Proteclion Not purchased* Sound Systern Not purchased k rape Not purchased* - --------- - -- - - — --- ----- �­ - - ---- . . ....... r'rotal premsum for 1997 Chevy'Trk Blazer - -- — - - ------------- .. ... ... ... This coverake can provide you Wirth valuaWe protection. To help you stay current with your insurance irileeds, contact your Allstate agent to discuss coverage optio(ris and other products and services ghat: can help protect you. VIP Rating information Your premium is determined based on certain information, including the following: Allstate uses mileage information as one factor to help determine your premium arnount. "The ft1lowling odometer Information was usedto determine your aininuall mileage for current pollicy period: AMOMMON& Odometer Reading�a� Odometer Reiiding WWWWWW WMWMMWWMM� Date , Date If any of the information shown above is incorrect, rnissing or changes fin the future, please contact your Allstate representative. (Please keep in mind that a change in any of the Information may result in an adjust.rinent to your preimium. Renewal auto policy declarations Page 4 of 6 Policy number: b24 160�' Policy effective date: August 11, 2021 detailCoverage for 2010 Mercedes-B Coverage Limits Deductible Premium Insurance Automobile Liabilitya Not applicable $361.99 • Bodily Injury $1,000,000 each person $1,000,000 each occurrence • Property Damage $100,000 each occurrence Auto Collision Insurance Actual cash value $250 $491.54 Waiver of deductible applies Auto Comprehensive Insurance Actual cash valu e ursement purchased* Rental Reimb �. Towing and Labor Costs Uninsured Motorists Insurance for Bodilyeach person w. $100,000 a on Injury $300,000 each accident contact* This coverage can provide you with valuable protection. To help you stay current with your insurance needs, • to discuss coverage options and other products and services that can help protect $0 $114.52 Not applicable $86.97 V11 Rating information Your premium is determined based on certain information, including the following: • Allstate uses mileage information as one factor to help determine your premium amount. Important Note., The annual mileage figure applicable to this vehicle for the expiring policy period was,13,500-13,999. The annual mileage figure applicable to this vehicle for the current policy period is:13,500-13,999. The following odometer information was used to determine your annual mileage for current policy period: Odometer Readin : Odometer Readin Date ate : 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. Renewal auto policy declarahons Policy number: 6,0,1 607.) Page 5 Policy effective date: ®f 6 August 11, 2021 ,,�,,WAIIstate, You're in good hands. Covtrm� detail for 2016 Ram Trucks 1500 2wd Coverage . . .... Units Deductible Premium Automobile Liability Insurance Not applicable . .......... .. . . $35&92 • Bodily Injury $1,000,000 each person $1,000,000 each occurrence • Property Darnage $100,000 each occurrence Auto Collision InSUrance Actual cash value $250 $32174 Waiver of deductible applies Auto Comprehensive Insurance AC(UaI vahw $0 $9T86 Rental Reimbi.irsement Niot pkvchased* Fowirsg and Labor Costs Na)i, pw,c�,msedl Uninsured !Motorists lrisurance for Bodily $100,000 each persovI Not applicable $62.84' Injury $'300,000 each accident Automobile Medical Pay$2,000 each person Not aprnents 'licable P $10.18 Coordinated Medical Protection Not purchased* S(!wiund Systoin Not purchased* Not purchased* premiurn for 2016 Rarn Trucks'1500 2wd .... . . . ....... — -------- k This coverage can provide you with valuable protection. To help you stay current with your Insurance needs, contact your Aillisgate agent to discuss coverage options and other products and services that can help protect you.. VIl Rating information Your premiurn is determined based on certain information, including the following: Allstate uses mileage information as one factor to help deterinnin(a your prerniurn amount. Important Note. The annual mileage figure applicable to this vehicle for the expiring policy period was-, 16,SOO 16,999. The annual rnfleage figure applicable to this vehicle for the current policy period is.16,500 16,999., The following odorneter inforimation was used to determine your annual mileage for current policy Period: Odometer Readingdometer Reading. Date .,48100M Date If any of the information shown above is incorrect, milssing or changes in the future, please contact your Allstate representative, Please keep in minid that a change in any of -the inforrnation may result in an adjustment to your premium., 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 ATTORNEYS FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: L—) I have and will maintain a certificate of consent ofself-insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work sat 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 Name of Agent Policy Number Expiration Date Phone# (X) I 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 subject to the workers' compensation laws of California, and agree that, if I should become subject to the )INorIrs' compensation provisions of Labor Code § 3700 1 must immediately comply with those 6 isions o,� �a ment."automatically become void. Date Signature of Applicant - 4 Agreement for: Dated: 04-13-2021 Digitally signed by Joseph Lillie DN: cn=Joseph Ullio, O=CitY of El Segundo, ou=Chief Financial officer, Reviewed by: Jose h Lillioemail=jlillio@elsegundo.org, c=US P 5:58 -07'00'