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PROOF OF INSURANCE (2022 - 2023) CLOSEDDATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 05/18/2022 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 be endorsed. If SUBROGATIONISE -- 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 MCGRIFF INSURANCE SERVICES INC/PHS AkmPHONE (866) 467-8730 FAx (888) 443-6112 22273438 (Alc No Ext) A/C. No). The Hartford Business Service Center, 3600 Wiseman Blvd E-MAIL San Antonio, TX 78251 ADDRESS: _ ,��. ........... INSURER(S) AFFORDING COVERAGE NAIC# . L..... ..��__...�......... .m...................�................. ...,,,,,.. ..�. ................... ,,. .,..._.�._.,, ___ ....., ,. ............. ........ .�...._ NSURED INSURERA Sentinel Insurance Company Ltd.. 11000 :."""."........�......_._... ..............._........... TINA GALL INSURER B.. ....... 3945 HOLLYLINE AVE ........... INsuRERc.�„...,,,_, ��_......��..�.�.�..........A.��, ..,..._. �_ SHERMAN OAKS CA 91423-4603 INSURERo . � ......m...................................................��.�...�.�.................. .-...-................. .......�.�.....�. INSURER E t. INSURER.�F,.�,...�.....�".....,,,,...,....,._.�.............................................. CO��.....��...... A,,._�.m... .�_............................� .........�-., COVERAGES CERTIFICATE NUMBER: _ REVISION NUMBER THIS IS TO CERTIFY THATTHE 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 COMMERCIAL GENERAL LIABILITY ADD. SUBR POLICY NUMBER " MM1pO EFF POLICY EXP LIMITS TYPE OF INSURANCE ...,.t,.TB . ��...��..... INSR..�. VYVD .,..., .(�. OD,�YVVv MM/AO/Y VVY _ �� ,,,, EACH OCCURRENCE........ $2,000,000.. CLAIMS -MADE ,,"( OCCUR DAMAGE TO RENTED $1,000,000 I,,.,,m..� iPREMISES ;a orn.�.E;u.f=rl.............. A,,. X General Liability MED EXP (Any one person) $10,000 A X X 22 SBA LD8291 07/23/2022 07/23/2023 PERSONAL & AUV INJURY $2,000,000 "GENT. AGGREGATE LIMIT APPLIES' GENERAL AGGREGATE $4�.�.�.�,...� ,. .... PER: ,OOO aoo POLIPRO- .OTHER: C� X LOC .. ��...�.. �. .... 6 .�.�.�. ......... A,,...,,,,, . YYPRODUCTS COMP/OP AGG $4 OOO OOO AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $2,000,000 ...m...................... ... ANY AUTO BODILY INJURY (Per person) A AUTOS NEE AUTOS 22 22 SBA LD8291 07/23/2022 07/23/2023 .............. � I� ( --- X... HIRED NON -OWNED rt INJURY (Per accident) NJ u . DAMAGE: AUTOS X AUTOS (Per accident) ............. E �,mm.. OGCUR ......,,,,......m ___�,........ �,�,........." .......�,�,�,..�,�,................... _ .. _ UMBRELLA LIAB .ACH OCCURRENCE EXCESS LIAB CLAIMS- . ___..... m�mm ,AGGREGATE MADE WORKERS AND EMPLOYERS' LIABILITY OOTH...w....,...n. �_...........�,�,__.. ....... ....�.. _..._...........,�....... ,,,..PER ANY YIN E,L.. EACH ACCIDENT PROPRIETORIPARTNER/EXECUTIVE NIA ELL----- DISEASE EMPLOYEE .,. � OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT ............. .„pESCRIPTION OF OPERATIONS,bel,ow..�....E .....,,,,,,,,,,..................�_.�.�..� .. ..�.� ,... ,,,,....,vw ... 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 is an additional insured per the Business Liability Coverage Form SS0008 attached to this policy. Waiver of Subrogation applies in favor of the Certificate Holder per the Business Liability Coverage Form SS0008, attached to this policy. CACELLAT ON City of El Segundo O D R S OULD ANY OF THE ABOVE DESCRIBED POLICIES BEmmmCANC ELLED Attn: City Clerk BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 350 MAIN ST IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE�""""""" EL SEGUNDO CA 90245 O 1988-2015 ACORD CORPOR ATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD DATE (MM/DD/YYYY) _ CERTIFICATE LIABILITY 05/18/2022 _ ,... THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NOR _ O 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 SUBROGATIONIS 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). 22273438........._......... roc No Ext .- -- ...---m..-..... . NITACf MCGRIFF INSURANCE SERVICES INC/PHS NAM PHONE (8fr0) 467f�s"30 FAX (�i88) 443-6112 (AI ) (A/C No). The Hartford Business Service Center ......... ....... _�. ............._.._.. �......�. ...- 3600 Wiseman Blvd E-MAIL San Antonio, TX 78251 ADDRESS ........... .......... �................��..._�__..._�__�_......�� ... INSURER(S) AFFORDING COVERAGE NAIC# INSURE..._.......... ..-........... ..._..,�....... INSURERA: Sentinel Insurance Company Ltd. 11000 TINA GALL INSURER B........................ ............... ......................... ..... 3945 HOLLYLINE AVE ��................................................................................................................ .. INSURER C : SHERMAN OAKS CA 91423-4603 . �.. ...... �.............................................................._.... �_.............,...�_ INSURER..........._�...._..�....... �..__ INSURER E ; INSURERF :..�.....�...,.....�..........................�...,.....,........�...........� ,,,,,.....,. COVERAGES ICAT CERTIF.E..NUMB.....,,,ER: �......�......�........ : REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE .. -.......N NAMED AB _V__��_NXXXN �..____ 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'. ADDL SUER POLICY EFF ......... .......L .. ... POLICY EXP I TYPE OF INSURANCE POLICY NUMBER LIMITS ....�T!2...�.......................��... IN.S�R WVD OMMERCI L.GE:NERAL.L.IABILITY _.�._....� EACH OCCURRENCE $2,000,000 CLAIMS -MADE „X OCCUR IVIdiC~E TC} F2[ IVTLD $1 ,000,000 BUM,' LLvfwuLw X General Liability MED EXP (Any one �_._ ....m.._.,._ _..A......pe..rIUs._o.n.Y.) ......... ...........$'000 ___ ......................$�00,000A O GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL. AGGREGATE m $ ,000,0 ao PRO - POLICY LOC PRODUCTS - COMP(OPAGG $4,000,000 .1E CT I,,,,,,. OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $2,000,000 ANY AUTO BODILY INJURY (Per person) A ALL OWNED SCHEDULED 22 SBA LD8291 1712312021 1712312022 BODILY INJURY (Per accident) AUTOS 'AUTOS .m. HIRED NON -OWNED PROPERTY DAMAGE X AUTOS X AUTOS (Per accident) ............. ................�m�.......___..........................._----___----------- . ....0,..... ....................�.....�........ MBRELLA LIAB OCCUR EACH OCCURRENCE ... ............ .......�..�........... .�. ��.._.. EXCESS LIAB CLAIMS- AGGREGATE,,.,._........�.�.�.�............. MADE 1TED RETENTION $... ........w.W._.......�,�,�,... WORKERS COMPENSATld IPER I OTH- AND EMPLOYERS' LIABILITY STATUTE �ER ANY YIN E'_L. EACH ACCIDENT PROPRIETOR/PARTNER/EXECUTIVE NIA -EA EMPLOYEE �•--------- OFFICER/MEMBER EXCLUDED? L. DISEASE: E: (Mandatory in NH) _..................m-m-_...................-......................-..........--_...__�..M� If yes, describe under E.L.. DISEASE - POLICY LIMIT OF ..................................- ....._.,..........��-. _ DESCPTIOOF O..E.RA.TO./LOCATIONS/VEHICLES (ACORD 101, Addi4ionalRemarksSehedulemaybeattaehed if more space is required).....��_...��_............... .._,�.�._�.....,...... Those usual to the Insured's Operations. Certificate holder is an additional insured per the Business Liability Coverage Form SS0008 attached to this policy. Waiver of Subrogation applies in favor of the Certificate Holder per the Business Liability Coverage Form SS0008, attached to this policy. CERTIFICATE MOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Attn: City Clerk BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 350 MAIN ST IN ACCORDANCE WITH THE POLICY PROVISIONS. EL SEGUNDO CA 90245 AUTHORIZED REPRESENTATIVE �u ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD =TEDDYYY)AC+OR I 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 NATw1E: Hiscox Inc. d/b/a/ Hiscox Insurance Agency in CA PH �� xtl (888) 202-3007 NQI. 520 Madison Avenue ADDRIEss oontact@a hiscoxxom 32nd Floor New York, NY 10022 INSURERISINSURER A----,-- Hiscox-1— AFFORDING Insurance Company Inc1 a ---- --- COVERAGE c al20 INSURED Tina Gall 3945 Hollyline Avenue Sherman Oaks, CA 91423 COVERAGES 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,. AOpI B_ POLICY EFF POLICY EXP R TYPE OF INSURANCE NSD POLICY NUMBER I MMCDOdYYYY MMx1dODJY YYY LIMITS COMMERCIAL GENERALLIABILITY EACH OCCURRENCE S 'i"JIt4dii i wrl }iN i�` ..'..... A a CLAIMS -MADE . w..m..� OCCUR PRLMI,�,nE,Sµ(ia rrcurJ;e�Pcp} _ _S ..... .I. ..., .... T GEN'L AGGREGATE LIMIT APPLIES PER: „I POLICY JEC'T 7 O..00 OTHER: I MED EXP (Any one person) �OIVAL& ADV INJURY PER.,..------ GENERAL AGGREGATE PRODUCTS COMPIOP AGG —j S S S ,...., s ... S AUTOMOBILE LIABILITY `DDMBINEDSINGLE WAIT $ ANY AUTO '.. BODILY INJURY (Per person) S ....,_ OWNED .. ..... SCHEDULED ._ ._._...— ------ .....__ BODILY INJURY (Per accident) ,.. .........�... $ AUTOS ONLY AUTOS ...:)'mCIrP'RrR7YDAIvRAGE;. ..........,. HIRED :..... ....... NON -OWNED S AUTOS ONLY AUTOS ONLY 1p r acc c- Tj � S UMBRELLA LIAB OCCUR I 4 EACH OCCURRENCE E I EXCESS LIAB ----� ------ - CLAIMS MAD....E AGGREGATE _ ...... ..... S .., ,. .. DED RETENTION S I I S WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY Y / N �7TUTE „ .ER ................ ANYPROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $ EXCLUDED? ❑ OFICERIMEMBE(MFand N / A tory in NH) '.. E L DISEASE EA EMPLOYEE $..........,....,.._ If describe under nFRf:RIPTIr1N OF OPERATIONS helnw E.L., DISEASE -POLICY LIMIT A Professional Liability Y UDC-4595166-EO-21 09/08/2021 09/08/2022 Each Claim: $ 1,Q00,000 Aggregate: $ 1,000,000 1 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The Certificate Holder is named Additional Insured but only as respects to the Named Insured's operations. CERTIFICATE HOLDER CANCELLATION City of El Segundo, its officers, officials, employees, agents, and volunteers 350 Main Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE El Segundo CA 90245 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 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. (_) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 forthe 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 subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those provisions or the agreement will automatically become void. July 1, 2022 Signature of Applicant Date Print Name Tina Gall Agreement for: Dated: �z / Reviewed by: