Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
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'