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PROOF OF INSURANCE (2022) CLOSEDDATE (MMIDDIYYYY) CERTIFICATE CERT OF LIABILITY INSURANCE 11/02/2021 o, 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. ..v...._..__ .....� _ .. IMPORTANT: ff the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATIONIS 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 NUTMEG INS AGENCY INCIPHS PHONE (888) 925-3137ITYmm FAX (888) 443-6112 76210797 (AIC, No, Ext): (AIC, No): The Hartford Business Service Center 3600 Wiseman Blvd E-MAIL San Antonio, TX 78251 ADDRESS INSURER(S) AFFORDING COVERAGE NAIC# INSUREINSURERA: Sentinel Insurance Company D 11000 Dawn Whitneyhall INSURER B 401 SHELDON ST INSURER c EL SEGUNDO CA 90245 INSURER D INSURER E : INSURER F ;, ....ww,....._,.,,.......„w,...,�.w......_... ........ _.................... ........ ,.. 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 INS ITRADDL SUBR POLICY TYPE OF INSURANCE POLICY NUMBERPOLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 �r CLAIMS -MADE FOCCUR DAMAGErOR$1000,000 X General Liability MED EXP (Any one person) $10,000 A X 76 SBU BH7561 11/02/2021 11/02/2022 PERSONAL a ADV INJURY $$1 000,000 GEN'L AGGREGATE LIMIT APPLIES PER, GENERAL AGGREGATE $2 00D 000 I POLICY q Y, PRO- ODAE'.R; @. k toc I PRODUCTS COMPIOP AGG $2,000,000 ...... AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANYAUTO BODILY INJURY (Per person) ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accidenl)^ HIRED NON -OWNED PROPERTY DAMAGE AUTOS .AUTOS (Peraccidenl) UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LIAB AGGREGATE MADE NCO RETENTION $ .- —__.. ENSATION PER O rH- AND EMPLOYERS' LIABILITY '�. STATUTE . ANY YIN E.L EACH ACCIDENT _.... PROPRIETOWPARTNEWEXECUTIVE NIA OFFICERIMEMBER EXCLUDED? £.t DISEASE -EA EMPLOYEE (Mandatory in NH) if yes, describe under IEL DISEASE -POLICY LIMIT DESCRIPTI N F P RATI NS below . _____......._. ..........,.._.-...... .............. __ - I DESCRIPTION OF OPdRA71ONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the Insured's Operations. The City of El Segundo, its officers, officials, employees, agents and volunteers are additional insured per the Business Liability Coverage Form SS0008 and the Hired Auto and Non Owned Auto Endorsement SSO436, attached to this policy, The classrooms are at : 401 Sheldon St, El Segundo, CA 90245 CERTIFICATE HOLDER ._. CANCELLATION LATION The City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 3501 MAIN ST BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED EL SEGUNDO CA 90245 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD GEICOGEICO GENERAL INSURANCE COMPANY POBox 5O9O9O NAIC 1-800-841-3000 San Diego, CA 92150-9090 35882 California Evidence of Liability Insurance Policy Number Effective Date 4526837499 07/24/2021 Insured 091111111111111�� DAWN CWHITNEYHALL Expiration Date 01/24/2022 View M I Active D rivers X V I N Year Make Model 2012 JEEP LIBERTY 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: (_) 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. C___) l 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 # 91 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 shoal%eccrne subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply wVr o A'b:r,thjp agreement wfiLautomatically become void. Signature of Applicant Print Name lagio- Agreement for: -k #I -1 6 Z 11 Dated: 11/10/21 a Reviewed by: Date I L