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PROOF OF INSURANCE (2022 - 2022) CLOSEDC�0 DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12122/2021 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 CONTACTLln D Diaz NAME: D&C Insurance Solutions PHONE _ 88.457.4426n c. Note 323.57 (Air. N� F.f,• 8 6.4552 300 S. Atlantic Blvd., Ste 201-B NAIC# �N.S..RE.RI� AFFORDING COVERAGE...__.....__........................................... ......_ Monterey/I-INSURER13196 mPeny Park ......... ..... _ - _ CA 91754 A�: Western World Insurance Co INSURED INSURER B Tillmann Forensic Investigations, LLC. INSURERC: INSURER D : PO Box 4373 INSURER E : Covina CA 91723 INSURER F COVERAGES CFRTIFICATF N'IIMRFR� RFVISInN 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. IN5R .... A'iSDL SUB POi.NCY EFF POLICY E P POLICY NUMBER -MOLIC YY MM -. -_ . - LIMITS . -. ILTI TYPE OF INSURANCE 4'ODIYYYYY X COMMERCIAL GENERAL LIABILITY A NPP8777585 12/17/2021 12/17/2022 EACHOCCURRENCE $ 1,000.,000 X _ CLAIMS -MADE OCCUR PREMhS�'S-(Eeocckw(rerrc��___. $ 100,000 ..__.______,._........� . E11.EXP (Any one person,)...._. ..M..-............�.,.,.._.......... .,..,..,..,..._... $ 5,000 _ PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN"L AGGREGATE. LIMIT APPLIES PER: ...I POLICY [�ww] PRO - JEC;T LOC PRODUCTS -COMP/OP AGG $ Included OTHER. Errors & Omissions $ Included AUTOMOBILE LIABILITY COMBIN'--EID SINGLE. LIMIT (EAAL4�q.taal). ... ANY AUTO BODILY INJURY (Per person) $ OWNED .__ SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED I�ROP�'i'�"9'Y DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident/ UMBRELLA LIAB OCCUR EACH OCCURRENCE ........................_..................................................................... $ EXCESS LIAB CLAIMS -MADE AGGREGATE...........m OED RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY Y / N STATUTE ,_ ,rER ,,,, ------- ANYPROPRIE'rOR/PARTNER/EXECUTI VE OFFICER/MEMBEREXCLUDED? ❑ N / 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 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Regarding the above referenced General Liability Insurance policy, the certificate holder is included as additional insured, but only with respect to the negligentacts, errors or omissions of the named insured. 1,r_K I II•II;A I t FIULUr-K t.;AN ;tLLA I It. N City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 348 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Lin Dau Diaz tM ., i ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: NPP8777585 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR 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) Location(s) Of Covered Operations Or Organization(s): City of Manhattan Beach Various Locations City of El Segundo Various Locations City of Costa Mesa Various Locations City of Redondo Beach Street Various Locations West Covina Police Department Various Locations Torrance Police Department Various Locations Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured 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. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 04 13 Copyright, Insurance Services Office, Inc., 2012 Page 1 of 2 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 Copyright, Insurance Services Office, Inc., 2012 CG 20 10 04 13 stwwrdrm CALIFORNIA ..... w.._,.... INSURANCE CARD State Farm Mutual Automobile In$ UrOnce Company PO' Box 2358131co in,0ton IL 91702w23 INSURED TILLMANN, STEVEINNIM MUTL VOL POLICY NUMBER 3426877•C29.75Q EFFECTIVE VR 2019 MAKE JEEP MAR 29 2022 TO SEP 29 2022 MODEL WRANGLER VIN ■M� ■� AGENT ME EDITHTHOMPSON 131'7-AE'0 PHONE d9T4�"77 NAIC 23178 Cr3VEtAO P' VI0 0 BY THE 'ALI'CY ME1 TS THE MINIMUM LIABILITY UMRS vti+ Fi'A S 17 01000 H U U1 SEE REVERSE SIDE FOR ANExp UTION, IN " H1CLEjt t'tj tit "t"lit t continued Transportation. Please contact us if you expect your annual µ, mileage to change over the next year. Premium Adjustment Each year, we review our medical payments and personal injury protection coverages claim experience to determine the vehicle safety discount that is applied to each make and model. In addition, we review the comprehensive, collision, o DR1 i .t" ii Ft°tt" . Vll I°ilttllN Assigned Drlver(s) The following driver(s) are assigned to the vehicle(s) on this policy. bodily injury and property damage claim experience annually to determine which makes and models have earned decreases or increases from State Farm's standard rates. If any changes result from our reviews, adjustments are reflected in the rates shown on this renewal notice. Driving Experience as of Marital Name March 29, 2022 Status STEVE TILLMANN Principal Driver & Assigned Drivers premium may be influenced by the information shown for For each automobile, the Principal Driver is the individual these drivers. who most frequently drives it Each driver is designated as an Assigned Driver on the household automobile that they most frequently drive. Your COVERAGE AND LIMl"'11'S See your policy for anexplanation ofthese coverages. A Liability Bodily Injury 100,000/300,000 Property Damage 100,000 C Medical Payments 5,000 D 250 Deductible Comprehensive G 1000 Deductible Collision Road Service U Uninsured Motor Vehicle Bodily Injury 100,000/300,000 U1 Uninsured Motor Vehicle Property Damage Amount Due If any coverage you carry is changed to give broader protection with no additional premium charge, we will give i"YISCOUNTS These adjustments have already been applied to your premium. you the broader protection without issuing a new policy, starting on the date we adopt the' broader protection. Multiple Line (continued on next page) Policy Number: 342 5877-C29-75G Page number 3 of 5 Prepared February 21, 2022 032408 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: (� 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. (U 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 # 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 become s b"ect to the workers" compensation provisions of Labor Code § 3700 1 must immediately comply with those pr dons o e agreement will automatically become void. Signature of Applicant Date / ZOZZ. Agreement for: Dated �- 10 �-Z Z Reviewed by: