Loading...
PROOF OF INSURANCE (2021 - 2021) CLOSEDCERTIFICATE OF LIAB ::....._mm......................................... THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIO THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE C ................................................., IMPORTANT. If the certificate holder is an ADDITIONAL INS subject to the terms and conditions of the policy, certain polici confer rights to the certificate holder in lieu of such endorseme ......................_...................................................... PRODUCER NUTMEG INS AGENCY INC/PHS 76210775 The Hartford Business Service Center 3600 Wiseman Blvd San Antonio, TX 78251 INSURED Jimmy Pete DBA Power of Choice Consultants 3014 N OXNARD BLVD OXNARD CA 93036-5343 ........................... ......... COVERAGES CERTIFICATE NUMBER: ....... THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BEL INDICATED.NOTWITHSTANDING ANY REQUIREMENT, TERM OR COND CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS S INSR TYPE OF INSURANCE POLICY NUMB ;ADDL SUBR ...L.TR ..... ....................� IN R -....... _............................ COMMERCIAL GENERAL LIABILITY _ CLAIM'S -MADE Xmm OCCUR - X General Liability A ---------------------------------- 76 SBU BG8 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY IIXXXXXX PE ® II X I..... LOG OTHER: V II d ._.......m. mAUTOMOBILE LIABILITY ............... ANY AUTO A _ ALL OWNEDHSCHEDULED 76 SBU BG8 AUTOS AUTOS HIRED NON -OWNED X AUTOS AUTOS UMBRELLA LIAB III OCCUR EXCESS LIAB CLAIMS - MADE DEO RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY Y/N PROPRIETOR/PARTNER/EXECUTIVE NIA OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under .............................................. ............................ - ILITY INSURANCE DATE(MMIDDIYYYY) ERTIFICATE URED, es OW HOWN 09/29/2020 N ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. LY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), HOLDER. the policy(ies) must be endorsed. If SUBROGATIONIS WAIVED, may require an endorsement. A statement on this certificate does not nt(s). CONTACT NAME: PHONE (888)925-3137 FAX (888)443-6112 (AIC, No, Ext): (AIC, No): ......................................................... _._.......... _....... ..... �. E-MAIL ADDRESS: .......................... INSURER(S) AFFORDING COVERAGE NAIL# ........�............- INSURERA: Sentinel Insurance Company Ltd. 11000 INSURER B INSURER C : .................... INSURER D .....-.. -- -.... ........ ...................................................... INSURER E ;. INSURER F .: REVISION_ NUMBER: HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD ITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE MAY HAVE BEEN REDUCED BY PAID CLAIMS. ....... ER POLICYEFF POLICY EXP LIMITS ....._ MMIDD NRQfY EACH OCCURRENCE $2,000,000 TTKC ET67WT TED ITITITITITITITIT $1,000,000 P�.� �IaS.FmS...(.F,�.l•?.p,F,yrrSr!,F.��l.. MED EXP (Any one person) $10,000 460 09/05/2020 09/05/2021 PERSONAL a ADV INJURY $2,000,000 ...................._..._....... ^......_ GENERAL AGGREGATE $..._ 4,000,000' PRODUCTS - COMP/OP AGG $4,000,000 COMBINED SINGLE LIMIT $2,000,000' ffig a ri en, BODILY INJURY (Per person) _ ........... 460 460 09/05/2020 09/05/2021 BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) EACH OCCURRENCE AGGREGATE _... ...........................� PER OTH-. STATUTE I IFR�Wu E,L EACH ACCIDENT E,L DISEASE EA EMPLOYEE' WWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWX DISEASE- POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Those usual to the Insured's Operations, ..................................... ....., _ ...... ...... .... CERTIFICATE HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 350 Main Street BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED El Segundo, CA 90245 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE .................................................._. ................... -lye ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Digital y signed by Joseph Joseph L i 111 o Financle, erna 1= fiIfo@ Isegulityodo of El rguc=USou=Director of Date: 2020.,10.08 17:14:02-07'00' Select Customer Insurance Center 3600 WISEMAN BLVD. N SAN ANTONIO TX 78251 Policyholder, please callus at: (877) 287-1316 Agent, please callus at: (888) 925-3137 INSURANCE ENDORSEMENT ATTACHED *** PLEASE REVIEW THE CHANGE *** Enclosed is an endorsement for your business insurance policy. Please review it at your convenience. If you have questions or need to make further changes: Policyholder, please call us at: (8 7 7) 2 87 -1316 Agent, please call us at: (888) 925-3137 between 7 A.M. and 7 P.M. CST. The premium billing will be mailed to you separately. You can expect to receive it soon. Thank you for allowing us to service your business needs. NUTMEG INS AGENCY INC/PHS THE HARTFORD SELECT CUSTOMER INSURANCE CENTER The Hartford Hartford Fire Insurance Company and its Affiliates One Hartford Plaza, Hartford, Connecticut 06155 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGE jz- This endorsement changes the policy effective on the Inception Date of the policy unless another date is indicated below: Policy Number: 76SBUBG8460 DW Named Insured and Mailing Address; JIMMY PETE DBA POWER OF CHOICE CONSULTANTS 3014 N OXNARD BLVD OXNARD CA 93036 Policy Change Effective Date: 10/07/20 Effective hour is the same as stated in the Declarations Page of the Policy. Policy Change Number: 001 Agent Name: NUTMEG INS AGENCY INC/PHS Code: 210775 POLICY CHANGES: SENTINEL INSURANCE COMPANY, LIMITEX ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING I STATEMENT.IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BI ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A BILL. Form SS 12 11 04 05 T Page ool (CONTINUED ON NEXT PAGE) Process Date: 10 / 0 7 / 2 0 Policy Effective Date: 09/05/20 Policy Expiration Date: 09/05/21 POLICY CHANGE (Continued) Policy Number: 76 SBU BG8460 Policy Change Number: 001 BUSINESS LIABILITY OPTIONAL COVERAGES ARE REVISED WAIVER OF SUBROGATION IS ADDED: FORM SS 12 15 LOCATION 001 BUILDING 001 SEE FORM IH 12 00 FORM NUMBERS OF ENDORSEMENTS ADDED AT ENDORSEMENT ISSUE; SS 12 15 03 00 Form SS 12 11 04 05 T Page 002 Process Date: 10 / 0 7 / 2 0 Policy Effective Date: 09/05/20 Policy Expiration Date: 09/05/21 POLICY NUMBER: 76 SBU BG8460 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CITY OF EL • 350 MAIN STREET EL rO CA 90245 Form IH 12 00 11 85 T SEQ. NO. 001 Printed in U.S.A. Page 001. Process Date: 10/07/20 Expiration Date: 09/05/21 n-1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER, OF SUBROGATION This endorsement modifies insurance provided under the following: BUSINESS LIABILITY COVERAGE FORM We waive any right of recovery we may have against: 1. Any person or organization shown in the Declarations, or 2. Any person or organization with whom you have a contract that requires such waiver. Form SS 12 15 03 00 © 2000, The Hartford Page 1 of 1 e ALTERNATIVE MARKET PLACEMENT P. O. BOX 29611 CHARLOTTE, NC 28229-9611 JIMMY PETE DBA POWER OF CHOICE CONSULTANTS 3014 N OXNARD BLVD OXNARD CA 93036-5343 Policy Information: Policy Type: Professional Liability ................................ Issuing Company: RLI Insurance ............................ .._...... _ _............ _........____— ........._-- Policy Term: 11/02/2020 - 11/02/2021 nnnuuuuuunnnnnnWuuuuuunnnnnnWu Wu PolicyNumber:RTP0020655n Dear Valued Customer, December 2, 2020 Contact Us Business Service Center Business Hours: Monday — Friday (8AM - 6PM Eastern Standard Time) Phone: (866) 467-8730 Fax: (877) 905-2772 Email: nutmegins@thehartford.com Website: www.thehartford.com We are pleased to enclose the original copy of the Professional Liability policy you requested. Please review it carefully to see that it meets with your specifications and advise of any corrections or changes that you deem necessary. To facilitate any billing inquiries you may have, please note the following information: For billing inquiries, your Direct Bill Account (TABS) number is 16097094. Please report any losses directly to RLI Insurance. Please contact us for any questions or concerns. Thank you for selecting The Hartford's Alternative Market Placement Team for your business insurance needs. Sincerely, Your Hartford Service Team Please note that we are acting as a broker/intermediary with respect to this policy, and The Hartford is not your insurer. AmpPollnsd Nutmeg Insurance Agency Disclosure Nutmeg Insurance Agency, Inc. (Nutmeg) acts exclusively as a non -agent intermediary or as an agent and representative of the insurers whose products we distribute. We may also provide services to you on behalf of such insurers. Nutmeg does not act as a broker, advisor or representative of the applicant or policyholder. Nutmeg receives compensation from its insurers and other intermediaries for the sale and/or service of their products, including a base commission, compensation based upon the amount of business we place with some insurers and/or the profitability of such business, and other fees and forms of compensation. Nutmeg is a subsidiary of The Hartford. Nutmeg is a subsidiary of The Hartford. Policies offered through Nutmeg are not underwritten by The Hartford, except when placed with Maxum Indemnity Company, Hartford Fire Insurance Company and/or Twin City Fire Insurance Company, which are subsidiaries of The Hartford and affiliates of Nutmeg. CA license #: OC26153 AmpPollnsd Target ProfessionalsTM RLI" Miscellaneous Professional Liability Declarations RLI Insurance Company 9025 North Lindbergh Drive Peoria, Illinois 61615 Phone: (309) 692-1000 A stock insurance company, herein called the Insurer. NOTICE: THIS POLICY COVERS ONLY THOSE CLAIMS FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD AND FIRST REPORTED TO THE INSURER DURING THE POLICY PERIOD, THE AUTOMATIC EXTENDED REPORTING PERIOD, OR IF APPLICABLE, DURING THE EXTENDED REPORTING PERIOD. DEFENSE COSTS SHALL BE APPLIED AGAINST THE DEDUCTIBLE. PLEASE READ YOUR POLICY CAREFULLY. Policy No.: RTP0020655 Item 1. Named Insured: Address: Item 2. Policy Period: Item 3. Limits of Liability: Item 4. Deductible: Item 5. Retroactive Date Item 6. Policy Premium: Surcharges: Total Policy + Surcharges Jimmy Pete DBA Power of Choice Consultants 3014 N. Oxnard Blvd Oxnard, CA 93036 From 12:01 A.M. on 11/02/2020 To 12:01 A.M. on 11/02/2021 Local time at the address shown in Item 1. a. $1,000,000 b. $1, 000, 000 $2,500 Inception $719 $0 $719 Item 7. Forms and Endorsements Effective at Inception: Form Number RTP 101 (02/17) RTP 404 (02/17) RTP 602 (02/17) RTP 624 (02/17) RTP 696 (02/17) RTP 697 (02/17) RTP 707 (02/17) ILF 0001C (04/16) 0000 Form Title each Claim Aggregate each Claim Target Professional Liability Policy California Amendatory Endorsement Additional Exclusions For Blanket Professional Services Waiver Of Application Social Engineering Exclusion Definition Of Professional Services Amended Privacy And Network Security Exclusion Signature Page - Commercial Lines USLI Application RTP 100 (02/17) Page 1 of 2 Insured Item 8. Professional Services: Solely in the performance of providing Refer to Endorsement RTP 697 Item 9. Extended Reporting Period: 1 year for 65%, 2 years for 125% and 3 years for 180 % of the Annual Policy Premium RTP 100 (02/17) Page 2 of 2 Insured 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: L) 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__) 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 # U2/1 '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 becom sa h o the workers' compensation laws of California, and � agree that, if I should become subject to th ,k Co pejisation provisions of Labor Code § 3700 1 must immediately comply with those provisions o�lwe a e0 it tpmatically become void, . w , Signature of Appli nt Date Print Name Agreement for: Jimmy Pete - PSA #5953 Dated: 10-08-2020 Digitally signed by Joseph Lillio ON! en k ph LOW, rr City of El Segundo, Joseph Li0,,q.M�m mrnUlrnrrn e. Reviewed by: � taA 2Q2Q N+lsn17AArrorg ' Us Gl�[P �5�201f1 08 t7�7fl 49 0700'