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PROOF OF INSURANCE (2022 - 2023) CLOSED" DATE (MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 05/12r2022 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 CONTACT KLC Global NAME: Ismart One Insurance o NEE (844) 210 2002 � � FAX Nmi, (213) 335-35500 2501 E. Chapman Ave. E-MAIL IL main@ismartone.net P .��. ..... _ w .. .. ... #25O INSURER(S� AFFORDING COVERAGE NAIC # Fullerton T CA 92831 INSURERA • UNITED NATL INS CO 13064 _ __,_. �._,....- --- , � . _ . ..... � .�� .. „. _...._� .. � � ...— ... INSURED INSURER B : PROGRESSIVE COMMERCIAL_ Paul P W Shin (Dba: Union Construction Company) INSURERC: FALLS LAKE FIRE & CASUALTY COMPANYITmmm.._...._c....__mm15884 1692 Cordova Street., INSURERD: NAUTILUS INS CO Los Angeles CA 90007 INSURERF: COVERAGES CFRTIFICATF NI]MRFR RFVISInm hnimnFR• 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 POLICY NUMBER MM,1 D... „ _LI _....._ INS ( ADDLua- POLICYEFF E1MI7E7 Y K LIMITS i COMMERCIALE 1,OD0,00 0 XLIOCCUR ❑ RAM SLLIES,(IEaEo ti ence]�� ... 5 100.000 _....... w... .._... m.m,.,.---...._--.-.._. .m.m. ,.......,., MED EXP (Any one person) I S _ 5,000 A X X 01CPKP20049951-0 03/21/2022 03l21/2023 PERsoNAL & ADV INJURY Is 1,000,000 _ GEN'L _..... AGGREGATE LIMIT APPLIES PER: �m „ �wwwwwwwwwwwwwwwwwww ...� GENERAL AGGREGATE_ I s 2.000,000 X .� PRO. LILYJECT LOC ,-. _ w .„_ PRODUCTS COMP/OPAGG s 2 000 00.. _.... , OTHER: IS AUTOMOBILE LIABILITY COMBINED SINGLE LIIaICT S 1,000,000 } ANY AUTO BODILY INJURY (Per person) S B _..., OWNED AUTOS ONLY X SCHEDULED AUTOS„,„ 082655706 09l30/2021 09/30l2022 ,,,,,..................._ .,...... ._......_...... ...-.. m.............„ ,...,_._..._. BODILY INJURY (Per accident) � S HIRED 4,4„ 5 P9Fi AUTOS ONLY AUTOS ONLY ..,,., tP!r)DAMAGE UMBRELLA LIAR Y I OCCUR ''� qVa EACH OCCURRENCE I s LI"AB V .l...CLAIMSMADE.. - . EXCES`S�'l .AGGREGATE ....„.,...I? ....... ......... ..,,I 7 DEJ D RETENTION 5 15 WORKERS COMPENSATION N PER II OTH X,y_STAT,UTEi AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE C OFFICERMIEMBEREXCLUDED) 1: NIA X FLA011765-02 06/01/2021 06/01/2022 E L. EACH ACCIDENT is 1,000,000 --- """ ••-••°°'° '-'•�'---• ' (Mandatory In NH) DISEA_SE - EA EMPLOYEE. 5 1,000,000 E.es. desvibp under"L. " L__„„„ 0 ._ „ --- 1,000,000 DESCRIPTION OF OPERATIONS below E L. DISEASE -POLICY LIMIT s Commercial Property BPP 10,000 D NN1365973 01/27/2022 01/27/2023 I BI/EE ` 100,000 k� DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The certificate holder is named as an additional insured to the policy. The waiver of Subrogation and Primary and Non -Contributory endorsement is included. 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 Street AUTHORIZED REPRESENTATIVE ElSegundo CA 90245 ❑� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD POLICY NUMBER:01-C-PK-P20049951-0 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 AVER OF TRANSFER OF R'G....,;S OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Any person or organization with whom the insured has agreed to waive rights of recovery, provided such agreement is made in writing and prior to the loss Information required to complete this Schedule, if not shown above, will be shown in the Declarations, The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV - Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products -completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 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 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 225% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Blanket Waiver of Subrogation As respects to all CA jobs performed by the named insured during the policy period where by written contract a waiver of subrogation is required prior to the commencement of work. 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 06-01-2021 Policy No. FLA011765-02 Endorsement No_ Insured Insurance Company Shin, Paul (An Individual) Falls Lake Fire & Casualty Company Countersigned By ©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved