PROOF OF INSURANCE (2023) CLOSED/
A� " CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
04/11/2022
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 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 endorsement(s).
PRODUCER
CONTACT Nicole Klink
NAME:
Merriwether & Williams Insurance Services
HCNE. (213) 258-3083 q/c, (213) 258-3083
Ext : No):
License No.: OCO1378
E-MAIL nicole@imwis.com
ADDRESS:
INSURER(S) AFFORDING COVERAGE
NAIC #
44 Montgomery St., Ste. 940
San Francisco CA 94104
INSURERA: Hiscox Insurance Company Inc.
10200
INSURED
INSURER B
Jeff Cason
INSURER C
531 Main Street #412
INSURER D :
INSURER E :
ElSegundo CA 90245
INSURER F :
COVERAGES CERTIFICATE NUMBER: CL2241118687 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE 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
LTR
TYPE OF INSURANCEAUULbUBK
INSD
WVD
POLICY NUMBER
POLICY EFF
MM/DD/YYYY
POLICY EXP
MM/DD/YYYY
LIMITS
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
CLAIMS -MADE FX OCCUR
PREM SDA AGES Ea oNcurDrence
$ 100'000
MED EXP (Any one person)
$ 5,000
PERSONAL & ADV INJURY
$ 1,000,000
A
Y
P100-194-024-2
04/06/2022
04/06/2023
GEN'LAGGREGATE LIMITAPPLIES PER:
GENERAL AGGREGATE
$ 2,000,000
El PRO
JECT LOC
PRODUCTS-COMP/OPAGG
S/TGENAGG.PX
$POLICY
$
OTHER:
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
Ea accident
$ 1,000,000
BODILY INJURY (Per person)
$
ANYAUTO
A
OWNED SCHEDULED
AUTOS ONLY AUTOS
Y
P100-194-024-2
04/06/2022
04/06/2023
BODILY INJURY (Per accident)
$
X
PROPERTY DAMAGE
Per accident
$
HIRED �/ NON -OWNED
AUTOS ONLY X AUTOS ONLY
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LAB
CLAIMS -MADE
DED I I RETENTION $
$
WORKERS COMPENSATION
PER OTH-
AND EMPLOYERS' LIABILITY Y / N
STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE ElN
OFFICER/MEMBER EXCLUDED?
/A
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE
$
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$
PROFESSIONAL LIABILITY
A
$500 DED.
P100-194-989-2
04/06/2022
04/06/2023
PER CLAIM
$1,000,000
AGGREGATE
$1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The Certificate Holder is added as Additional Insured with respects to our Insured's operations only. This insurance is primary and non-contributory as
required by written contract.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of El Segundo
ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Stret
AUTHORIZED REPRESENTATIVE
ElSegundo CA 90245
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
40
HIO
Policy Number: P 100. 194.024.2
Named Insured: Jeff Cason
Endorsement Number: 7
Endorsement Effective: 04/06/2022
Hiscox Insurance Company Inc.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - AUTOMATIC STATUS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A. Section II — Who Is An Insured is amended
to include as an additional insured any per-
son(s) or organization(s) for whom you are
performing operations or leasing a premises
when you and such person(s) or organiza-
tion(s) have agreed in writing in a contract or
agreement that such person(s) or organiza-
tion(s) be added as an additional insured on
your policy. Such person or organization is
an additional insured only with respect to lia-
bility for "bodily injury", "property damage" or
"personal and advertising injury" caused, in
whole or in part, by your acts or omissions or
the acts or omissions of those acting on your
behalf:
1. In the performance of your ongoing opera-
tions; or
2. In connection with your premises owned by or
rented to you.
A person's or organization's status as an addi-
tional insured under this endorsement ends
when your operations or lease agreement for
that additional insured are completed.
CGL E5421 CW (02/14) Includes copyrighted material of Insurance Services Office, Inc., with its Page 1 of 1
permission.
40
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Policy Number: P 100. 194.024.2
Named Insured: Jeff Cason
Endorsement Number: 17
Endorsement Effective: 04/06/2022
Hiscox Insurance Company Inc.
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
A. 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, pro-
vided:
1. you have agreed in a written contract or
agreement to add such additional insured to
a policy providing the type of coverage af-
forded by this policy; and
2. you have agreed in a written contract or
agreement with such additional insured that
this insurance would be primary and would
not seek contribution from any other insur-
ance available to the additional insured.
CGL E5581 CW (03/16) Includes copyrighted material of Page 1 of 1
Insurance Services Office, Inc., with its permission
40
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Policy Number: P 100. 194.024.2
Named Insured: Jeff Cason
Endorsement Number: 17
Endorsement Effective: 04/06/2022
Hiscox Insurance Company Inc.
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
A. 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, pro-
vided:
1. you have agreed in a written contract or
agreement to add such additional insured to
a policy providing the type of coverage af-
forded by this policy; and
2. you have agreed in a written contract or
agreement with such additional insured that
this insurance would be primary and would
not seek contribution from any other insur-
ance available to the additional insured.
CGL E5581 CW (03/16) Includes copyrighted material of Page 1 of 1
Insurance Services Office, Inc., with its permission
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 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 #
(X ) I 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 should beco a su " ct the workers' compensation provisions of Labor Code § 3700 1 must
immediately comply with those r i n o the agreement will automatically become void„
Signature of Applicant Date 5-6-21
Print Name
Agreement
Dated: b4 bi., yi
Reviewed by; ��