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PROOF OF INSURANCE (2022 - 2022) CLOSEDA "rr^"9 p Ef DATE (MM/DD/YYl'Y) IllCERTIFICATE OF LIABILITY INSURANCE 07/02/2021 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 endorsements . PRODUCER NCONTACT FEDERATED MUTUAL INSURANCE COMPANY PHONE FAx HOME OFFICE: P.O. BOX 328 MA—t B$8w333949 T mC NT R (A/C, No): 507 446-4664 OWATONNA, MN 55060 a npta:cs• Cl IFNTC(�NTACTCENTER rni FEDINS.COM INSURER(S) AFFORDING COVERAGE NAIC # _---...�... .....�� .. INSURER A: FEDERATED MUTUAL INSURANCE COMPANY ................. ... 13935 INSURE.D..._......._.__... 308-577-6 INSURER B: WATERLINE TECHNOLOGIES INC INSURER C: 620 N SANTIAGO ST ........ SANTA ANA, CA 92701-3942 INSURER D: INSURER E: ER F: COVERAGES CERTIFICATE NUMBER: 217 REVISION NUMBER: 0 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. ...... ........TYPE OF INSURANCE INSR ADDLSUBR 6.TR. INSR WVD POLICY ._..._.�... ...................._ ........ POLICY EFF POLICY EXP NUMBER MI .IYYY MM/ OIKXXK LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED $10O 000 CLAIMS -MADE OCCUR P..(7,;.M1:,.„�5.,,.,d 4:�SMLt1n:Rg, ........_..... MED EXP (Any one person) EXCLUDED ''.. A ._.... _------------------------------ . Y N 0623485 08/15/2021 08/15/2022 PERSONAL & ADV INJURY $1,000,000 ..............._. T APPLIES PER: -GEN'L AGGREGATE LIMIT .........................................,.._ GENERAL AGGREGATE $2,000,000 PRO. X POLICY ❑ JECT LOC PRODUCTS -m COMPIOP AGG . $2W000,W000 ... OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT d�. icyrJ1,,,,,,,,,,,-,,,,,„„_,,,,,,,,,,,,,,,,,,,,,, $1,000,000 I „,_„ X ANY AUTO BODILY INJURY (Per person) A SCHEDULED OWNED AUTOS ONLY AUTOS Y N 0623485 08/15/2021 08/15/2022 ,,.w.... _................--- ...................................�. BODILY INJURY (Per accident) ....... NON -OWNED HIRED AUTOS ONLY IAUTOS ONLY 1._sT,E,5,41.........................m.., PROPERTY DAMAGE _. ...,.m............ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $10,000,000 A EXCESS LIAB CLAIMS -MADE N N 0623486 08/15/2021 08/15/2022 AGGREGATE $10,000,000 �. ................� �,.,.,..�..............�........ .DED RETENTION WORKERS COMPENSATION PER STATUTE tlTH- ER AND EMPLOYERS' LIABILITY YIN .__.................. .......... ANY PROPRIETORIPARTNERIEXECUTIVE E.L E ACCIDENT EACH OFFICERIMEMBER EXCLUDED? NIA mmmmmm ........ w....._. E,L., DISEASE - EA EMPLOYEE (Mandatory in NH) ...._............_. It yes, describe under _ E,L DISEASE - POLICY _. LIMIT DESCRIPTION OF OPERATIONS below ET ------------- _ .OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional ___.. W.......... DESCRIPTION OF I Remarks Schedule, may he attached if more space is required) SEE ATTACHED PAGE CERTIFICATE HOLDER CANCELLATION 308-577-6 217 0 CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 MAIN ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EL SEGUNDO, CA 90245-3813 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 308-577-6 LOC# _ —............................�......-.................. AC" RCP ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED FEDERATED MUTUAL INSURANCE COMPANY WATERLINE TECHNOLOGIES INC _-__ mm-�•••••••••--...-- 620 N SANTIAGO ST POLICY NUMBER SANTA ANA, CA 92701-3942 SEE CERTIFICATE # 217.0 RRIER NAIC CODE SEE CERTIFICATE # 217.0 EFFECTIVE DATE... SEE CERTIFICATE # 217.0 ADDITIONAL REMARKS ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 0623485 COMMERCIAL GENERAL LIABILITY CG20100413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES O CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organizations: Location(s) Of Covered Operations .... ........... _._. CITY OF EL SEGUNDO ANY COVERAGE PROVIDED BY THIS 50 MAIN ST ENDORSEMENT APPLIES ONLY WITH RESPECT TO EL SEGUNDO CA 90245 NAMED INSURED'S DELIVERY OF PRODUCTS TO CERTIFICATE HOLDER. ADDITIONAL INSUREDS ALSO INCLUDE: CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES AND VOLUNTEERS. ..................... .. ......... -- --- nform ....fo mm ation required to complete this Schedule, if not shown above, will be shown in the Declarations,,,mm� A. Section II - Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury", This insurance does not apply to "bodily injury" or "property damage" or "personal and advertising "property damage" occurring after: injury" caused, in whole or in part, by: 1. All work, including materials, parts or 1. Your acts or omissions; or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work" out of which the 1. The insurance afforded to such additional injury or damage arises has been put to its insured only applies to the extent permitted by intended use by any person or organization other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured principal as a part of the same project. is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. WATERLINE TECHNOLOGIES INC 620 N SANTIAGO ST SANTA ANA CA 92701 © Insurance Services Office, Inc., 2012 Page 1 of 2 CG 20 10 04 13 Policy Number: 0623485 Transaction Effective Date: 08-15-2021 C. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 04 13 Policy Number: 0623485 Transaction Effective Date: 08-15-2021 POLICY NUMBER: 0623485 COMMERCIAL AUTO CA20481013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Auto Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: WATERLINE TECHNOLOGIES INC Endorsement Effective: 08-15-2021 SCHEDULE Name of Person(s) Or Organization(s): CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO CA 90245 on required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 10 13 9 Insurance Services Office, Inc., 2011 Page 1 of 1 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: , Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. © Insurance Services Office, Inc., 2012 Page 1 of 1 CG 20 01 04 13 Policy Number: 0623485 Transaction Effective Date: 08-15-2021 DATE (MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 06/11 /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 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 Nicole Chow ­11NAME .11,..,..._.., Newfront Insurance Services, LLC PHONE (� 415 754-3635 - FAX 55 2nd Street AIL ADDRES,$: nlcole.chow@nevvfront.corn Floor 18 ,INSURER ($) AFFORDING COVERAGE NAIC # San Francisco CA 94105 INSURERA: Service American Indemnity Co 39152 INSURED wcToro n Waterline Technologies Inc. 620 N Santiago St Santa Ana CA 92701 rnvCoArce rCOTICIrATC MIIRfiIZCD• RFVISIf1N NIIMRFR- 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. JNSR ..ADDI.�$4Yi�Fd ,,,, ...�. �� ,...�,� POLICY F'�'F POLICY EXP .........LIMITS TR TYPE OF INSURANCE POLICY NUMBER MMIDD MMIDD '... COMMERCIAL GENERAL LIABILITY '... EACH OCCURRENCE '... 1 .._. .®,..,, UAMIAZ` L ` b Kt N I`Ei5 I CLAIMS -MADE OCCUR ',. PREMI$.ES fEa acourrQ,nre,M $ MED EXP (Any one person) $ ®.,,,. '... '.. PERSONAL & ADV INJURY ;G GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 'b . POLICY L_� .tlEC:T LOC PRODUCTS-COMPIOP,AGG $ 16 OTHER AUTOMOBILE LIABILITY COMB INEDSINGLE LIMP % (a a cr dentu ANY AUTO '.... BODILY INJURY (Per person) "'.. ALL OWNED �.SCHEDULED BODILY INJURY (Per accident) g.ODILY AUTOS ) AUTOS ..........: NON -OWNED fPROPERdT DAMAGE $ '.. HIRED AUTOS . 'a,®...7 AUTOS '... UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE ''... AGGREGATE DED .. RETENTION $ $ WORKERS COMPENSATION x PER OTH- STATUTE ER AND EMPLOYERS' LIABILITY N .... .. , . 1,000,000 ANYPROPRIETOR/PARTNERIEXECUTIVE A 1 NIA... X SAMTWC0031501 07/01/2021 07/01/2022 E,L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? '""""""' 1 (Mandatory in NH) '., ,d08,800 E.L. DISEASE EA EMPLOYEE $ --- - If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Waiver of subrogation In favor of City of El Segundo. rc OTICIr ATC Uni nCD rANrF1 I ATinhi SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St AUTHORIZED REPRESENTATIVE ElSegundo CA 90245 U'IySS-ZU'14 AGUKL1 UUKI'UKAI IUN. All ngnis reservea. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) 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 per- form 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 otherwise due on such remuneration. Person or Organization 0 . 0 2 0 % of the California workers' compensation premium Schedule Blanket Waiver of Subrogation as required by writtencontract Job Description Contract 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 Date: 0 7 / 01 / 2 0 21 Policy No. SAMTWC 0 0 315 01 Endorsement No Policy Effective Date: 0 7/01/2 02 1 to 07/01/2022 Premium $ Insured: Waterline Technologies, Inc DBA: Carrier Name / Code: Service American Indemnity Company (Method) Countersigned by WC 04 03 06 (Ed. 4-84) 1 of 1