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PROOF OF INSURANCE (2022 - 2023) CLOSEDTIFFHOM-01 . _° 1 DATE IMM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 11 71112021 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 ( . License # 0757776 holder in lieu of such endorsement s this certificate does not confer rights to the certificate � -ITIT__ PRODUCER CONTACT Gourley IA 9) 912-6438 arc hj?I �_�_ HUB International Insurance Services Inc. PHONE PAX 3390 University Avenue NA/CANo, Ext) (90 Suite 300 �tonal com Riverside, CA 92501 F(arenGouurNe� hubinternat���� nir n ....... aloyd's Lonndo__. �........-15792 I-NsURlER_ Unds,rwriters,�„t L INSURED INSURER B . ........''mm Tiffany Home Care INSURER c DBA: Always Right Home Care r 9700 Reseda Blvd., Ste 105 ........... Northridge, CA 91324-5516 INSURERS -----_ - ---------------- INSURER F : COVERAGES .ITITITITITIT.. 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 A ..,.,.. X COMM mm ........- � IINM SUB k� POLICY NUMBER .......... X LILY E F F POLICY EXP -OCCURRENCE OCCURRENCE LIMITS COMMERCIAL GENERAL LIABILITYE. .... ( 1.,000,000. I I PSI RENTED j! 100 000 p X....1 CLAIMS -MADE _mJ OCCUR W2B8EF210201 6/15/2021 6/15/2022 DAMAGE (F L �wrrea 1 X Retro Date 6/15/03 MEO EXP An one, 5,000 ...... _.._,,, ___------ PER5_ NNAt aADV IN�uRY..._ $ Included 'GEN L AGGREGATE LIMIT APPLIES PER: „, 3,000,0_00 Xl POLICY PRCT LOC ,000,000. -.......... &0, B%D SINGLE LIMIT A AUTOMOBILE LIABILITY LE:kd.�1.D1,�,,,,, $ _,„„,,,,,w_ AANY UTOS TO AUTOS W2B8EF210201 6/15/2021 6/15/2022 pODII Y INJURY (PerpeLson) $ X OWNED _I SCHEDULED OD1I X INJURY IPar ana�dent) $ H R NL1p� / SROi"ER Y )AMAGE $ .., ., �........ .... AU7�I)SV8 I- X A ublimit nl $ .. 1........... �TE ONLY ,000,000 UMBRELLA LIAB _ OCCUR EACH OCCURRENCE _$ LIAB CLAIMS MADE .AGGREGATE $ .... EXCESS ......................... �._....__ DED RETENTION$ ........_.... ,_,,, I,.,_,.., ..,........._ ........m..............._ _ _'__ PER OTH WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y../ Al STA....TUTE .AmmR ANY PROPRIETOR/PARTNER/EXECUTIVE N / A E.,L EACH ACCIpENT_„�, id.kory in NHR EXCLUDED? E,,,L DISEASE - EA EMPLOYEE-$.,,,,, If yes, describe under A Prof L aboRD 6115 03OF 1oNs below ---2B8EF210201 6/15/2021 6/15/2022 E L DISEASE - Po�icvw� MIT $ 1,000,000' A Prof Liab RD 6/15/03 w2B8EF210201 6/15/2021 6/15/2022 3,000,000 S . DESCRIPTION OF OPERATION....._.k.._ / LOCATIONS I VEHICLES (ACORD 701, Additional Remarks Schedule, may be attached if more space is required) Sexual/Physical Misconduct (Sublimit) 1M/3M Certificate Holder is included as Additional Insured as respects to the General Liability when required by written contract per policy terms and conditions as respects Senior In Home Care Project for the City SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ty 9 ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo, CA 90245 ....�........................ AUTHORIZED REPRESENTATIVE ...._......... l . ....._ ...................................... ....... _ ..,......................._........................-.._..,........�..-... ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Effective date of this Endorsement: 15-Jun-2021 This Endorsement is attached to and forms a part of Policy Number: W2138EF210201 Syndicate 2623/623 at Lloyd's. referred to in this endorsement as either the "Insurer" or the "Underwriters" BLANKET ADDITIONAL INSURED ENDORSEMENT This endorsement modifies insurance provided under the following: MISCELLANEOUS MEDICAL PROFESSIONAL LIABILITY, GENERAL LIABILITY (INCLUDING PRODUCTS LIABILITY) INFORMATION SECURITY AND PRIVACY AND EMPLOYEE BENEFITS LIABILITY INSURANCE INCLUDING BREACH RESPONSE SERVICES In consideration of the premium charged for the Policy, it is hereby understood and agreed that Clause III. PERSONS INSURED is amended to include any entity for which the Insured has assumed such entity's liability in a written contract or agreement (an "Additional Insured") that is also named in a Claim if all of the following conditions are met: 1. The Claim against the Additional Insured seeks Damages for which the Insured has assumed liability; 2. This Insurance applies to such liability assumed by the Insured; 3. The obligation to defend the Additional Insured has also been assumed by the Insured in the same contract or agreement; 4. The allegations in the Claim and the information known about the incident are such that no conflict appears to exist between the interests of the Insured and the interests of the Additional Insured; 5. The Additional Insured and the Insured ask Underwriters to conduct and control the defense of that Additional Insured against such Claim and agree that Underwriters can assign the same counsel to defend the Insured and the Additional Insured; 6. The Additional Insured agrees in writing to: a. Cooperate with the Underwriters in the investigation, settlement or defense of the Claim; b. Immediately send Underwriters copies of any demands, notices, summonses or legal papers received in connection with the Claim; C. Notify any other insurer whose coverage is available to the Additional Insured; and d. Cooperate with Underwriters with respect to coordinating other applicable insurance available to the Additional Insured; and 7. The Additional Insured provides Underwriters with written authorization to: a. Obtain records and other information related to the Claim; and b. Conduct and control the defense of the Additional Insured in such Claim. All other terms and conditions of this Policy remain unchanged. Authoriz6d Representative E07195-A Page 1 of 1 082015 ed. Effective date of this Endorsement: 15-Jun-2021 This Endorsement is attached to and forms a part of Policy Number: W2138EF210201 Syndicate 2623/623 at Lloyd's. referred to in this endorsement as either the "Insurer" or the "Underwriters" BLANKET ADDITIONAL INSURED ENDORSEMENT - GENERAL LIABILITY COVERAGE ONLY (WITH WAIVER/PRIMARY COVERAGE) This endorsement modifies insurance provided under the following: MISCELLANEOUS MEDICAL PROFESSIONAL LIABILITY, GENERAL LIABILITY (INCLUDING PRODUCTS LIABILITY) INFORMATION SECURITY AND PRIVACY AND EMPLOYEE BENEFITS LIABILITY INSURANCE INCLUDING BREACH RESPONSE SERVICES In consideration of the premium charged for the Policy, it is hereby understood and agreed that, solely in relation to coverage provided under INSURING AGREEMENTS, B. General Liability, Clause III. PERSONS INSURED is amended to include any entity for which the Insured has assumed such entity's liability in a written contract or agreement (an "Additional Insured") solely for services rendered by or on behalf of the Named Insured and that is also named in a Claim if all of the following conditions are met: 1. The Claim against the Additional Insured seeks damages for which the Insured has assumed liability; 2. This insurance applies to such liability assumed by the Insured; 3 The obligation to defend the Additional Insured, has also been assumed by the Insured in the same contract or agreement; 4. The allegations in the Claim and the information known about the incident are such that no conflict appears to exist between the interests of the Insured and the interests of the Additional Insured; 5. The Additional Insured and the Insured ask Underwriters to conduct and control the defense of that Additional Insured against such Claim and agree that Underwriters can assign the same counsel to defend the Insured and the Additional Insured; 6. The Additional Insured agrees in writing to: a. Cooperate with the Underwriters in the investigation, settlement or defense of the Claim; b. Immediately send Underwriters copies of any demands, notices, summonses or legal papers received in connection with the Claim; C. Notify any other insurer whose coverage is available to the Additional Insured; and d. Cooperate with Underwriters with respect to coordinating other applicable insurance available to the Additional Insured; and 7. The Additional Insured provides Underwriters with written authorization to: a. Obtain records and other information related to the Claim; and b. Conduct and control the defense of the Additional Insured in such Claim. All other terms and conditions of this Policy remain unchanged. The Named Insured waives any right of recovery the Named Insured may have against any person or organization, where required by the Insured's written contract with the Additional Insured, because of payments made by the Named Insured for Damages and Claims Expenses arising out of the Named Insured's operations. E08433-A Page 1 of 2 062016 ed. The coverage provided in this endorsement shall be primary and not contributing with any other insurance maintained by the Additional Insured, subject to the provisions set forth above. All other terms and conditions of this Policy remain unchanged. Authoriz6d Representative E08433-A Page 2 of 2 062016 ed. DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 3/3/2022 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 pollcy(les) 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 NAME-�..._.. Dave Terpening Insurance Agency, Inc. PHONE �310} 517 8222 N,pw(310) 517=1702 22850 Crenshaw Blvd., Suite 206 W.- c- , ve Tet ieninc Insurance. com Torrance, CA 90505 INSURER(S) AFFORDING COVERAGE NAICN OG47857 _ _ _ __. _- HomeCareN§URERA_ C ress Insurance Company 10855 INSURED Tiffany , Inc.Ina . INSURER B dba Always Right Home Care INSURER c INSURER D :. _. _. .._...... ........ ....... 9700 Reseda Blvd. Suite 105 _ _ Northridge, CA 91324 INSURER E_...................._ �_.... _-..-......... INSURER F : COVERAGES r..FRTIF1d1ATF ?JI1hilRr-P,, p rzktmnm M lAAAr—'P, 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. NSR .._m...... �,� �� LTR . .. TYPE OF..�._. _.....m,.e. Yii 'AU' .._-_.w,..„,„,„„,„...w...... .....m ...- INSURANCE INaD WVD POLICY NUMBER ...._ .................__..,.,.,.,.,. ...... .�..,.�.........._ ............... ,..... ......_.-. �F•F- --PdL�'CY EXP G WDDIYYYY %WDDIYYYYI LIMFFS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS ( D OCCUR .DA RFRM --.._�®_.. .... — .._.._� -MADE PREMISE .Lk� gngre%p $ . _... MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE _ $ GEN'L AGGREGATE LIMIT APPLIES PER: PR CI ._._..,..�.. .-...-., POLICY JECTO- LOC PRODUCTS - COMP/OP AGG .._,_...ROD $ _.._®.......ww_Wwww�.... OTHER: $ AUTOMOBILE LIABILITY ULE LIMIT S .$... ANYAUTO BODILY INJURY (Per person) OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Par accident) S HIRED NON -OWNED GF$ AUTOS ONLY AUTOS ONLY s UMBRELLA LIAR ...... OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE J,I AGGREGATE �............. $ _...... [--- DE D RETENTION$ $ WORKERS COMPENSATION I STAND ATUTE ER - A ANY PROPRIETORIPARTNERIEXECUTIVE MBEMPLOYERS' LIABILITY Y� OFFICERIMEMBER EXCLUDED? NIA TIWC326242 $ 1 2022 9 1 2023 IL. 00 (Mandatory L DISEASE A EMPLOYE $ 1 f 000 , 000m If yyes, desk pba under DESCRiPTION OF OPERATIONS below _ E.L. DISEASE -POLICY LIMIT - $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Community Development Block Grant Consultant Development Services Department City of El Segundo 350 Main Street E1 Segundo, CA 90245 CERTIFICATE HOLDER CANCELLATION Community Development Block Grant Consultant SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Development Services Department ACCORDANCE WITH THE POLICY PROVISIONS, City of E1 Segundo AUTHORIZED REPRESENT 350 Main Street E1 Segundo, CA 90245 m 1988-2015 ACOYO CORPORAT+'fON. All rights reserved. ACORD25(2016/03) The ACORD name and logo are registered marks of ACORD Important Information Insured Tiffany HomeCare, Inc. 9700 Reseda Blvd Ste 105 Northridge, CA 91324-5516 Agency RT SPECIALTY, A DIVISION OF RSG SPECIALTY, LLC 500 S. Grand Avenue Suite 2100 Los Angeles, CA 90071 Changes to Your Workers' Compensation Policy with Cypress Insurance Company Policy Number TIWC326242 Policy Period From March 1, 2022 to March 1, 2023, 12:01 AM, standard time atthe insured's mailing address. Type of Endorsement Added Forms effective 03/01/2022 WC990402C - CA Waiver Of Right To Recover - Specific Added Waiver of Subrogation effective 03/01/2022 Name: City of EI Segundo; Job Description: Per w ritten contract Added Waiver of Subrogation Class Code effective 03/01/2022 State: CA; Code: 8827 Home Care Services i Premium change: $ 426.00 _....... _ ............ _... _..— ..... ..... This endorsement changes the policyto which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequentto preparation of the policy.) Endorsement Effective See Above Insured Tiffany HomeCare, Inc. Insurance Company Cypress Insurance Company WC 99 00 13 (Ed. 11-14) Policy No. TIWC326242 Endorsement No. 1 Premium Countersigned by WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 04 02 C (Ed. 9-14) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 5% of the applicable manual premium otherwise due on such remuneration subject to a policy maximum charge for all such waivers of 5% of total manual premium. The minimum premium for this endorsement is $350. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule Schedule Specific Waiver Person/Organization: City of El Segundo Job Description: Per written contract Waiver Premium: 350.00 Payroll Subject Class State to Waiver 8827 CA 15, 000.00 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: 03/01/2022 Policy No.: TIWC326242 Endorsement No.: Insured: Insurance Company: Cypress Insurance Company WC 99 04 02C (Ed. 9-14) Countersigned by Premium $