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PROOF OF INSURANCE (2023 - 2023) CLOSED=OT MIDDNYYY) AC`"R" CERTIFICATE OF LIABILITY INSURANCE 8/2022 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 JOHN WILLHITE NAME: WILLHITE INSURANCE AGENCY, INC PHONE ;�_No, xti, 951-682-8297 N��. 951-682-7297 6117 BROCKTON AVENUE STE 206 EMAIL ohnW illhiteinsurance.com nDDRss.. j.�....-..__.. RIVERSIDE, CA 92506 INSURER(S) AFFORDING COVERAGE NAIC� INSURED DENNIS GRUBB AND ASSOCIATES 6560 VAN BUREN BLVD. STE. B RIVERSIDE, CA 92503 INSURERA: THE HARTFORD INSURANCE COMPANY 29424 INSURERS: SEQUOIA INSURANCE COMPANY 22985 INSURERC.- LLOYDS OF LONDON INSURANCE CO 15642 INSURER D INSURER E : CAVFRAnPR CFRTIFICATF NIIMRFR- 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. INSR TYPE OF INSURANCE..... ...,.,. A4D�'Y�.. SUi3R ._._ POLICY NUMBER LTR MOLICY/YYYY MM DD/YYYY LIMITS A K COMMERCIAL GENERAL LIABILITY Y Y "' 83SBANX2247 01/13/202201/13/20231 EACH OCCURRENCE S 2,000,000 ..... X.... ,..._0AMAGE Y"'(R Ni I`..... CLAIMS -MADE OCCUR PlafrvdlSkf,.ICancccGlrrl^ncey 5....1,000,000,,, ...1 ....MLD EXP (Any cane person) $ 0,000.. PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GE14ERAI...AUGREGATE $ 4,000,000 f�I fh' x POLICYL.OC I I JE.C"I .'. PRODUCTS COMP /OF'AGG S 2, 000,000 OTHER, S AUTOMOBILE LIABILITY FMA NNED SINGLE: LIVAIT $ (F I aacg4onlj ANY AUTO BODILY INJURY (Percnrson) $ OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY ,. AUTOS ....., HIRED NON -OWNED _PROPERTY'DAPxM1r�GE.... .........., AUTOS ONLY ,..... ... AUTOS ONLY ...IF nr rtcvof+rll.h S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS -MADE AGGREGATE DED RETENTION'S S B WORKERS COMPENSATION Y QWC1204923 04/01/2022 04/01/20231 X PER OTH- AND EMPLOYERS' LIABILITY Y% 1,000,000 ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NIA-- (Mandatory in NH) E L EACH ACCIDENT S - EL DISEASE- EA EMPLOYEE S 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below EL DISEASE- POLICY LIMIT S 1,000,000 C PROFESSIONAL LIABILITY PSK0139434376 03/17/2022 03/17/2023 OCCURRENCE 1,000,000 AGGREGATE 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) THE CITY, ITS OFFICIALS, AND EMPLOYEES ARE ADDITIONALLY INSURED WITH RESPECT TO LIABILITY ARISING OUT OF WORK OR OPERATIONS PERFORMED. rr-RTII ICAT'F Hni nFR CANCELLATION CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS. EL SEGUNDO, CA 90245 AUTHORIZED REPRESENTATIVE JOHN WILLHITE ©1988-2015 ACORD CORPORATION. All rights reserved.. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2009/01) POLICY NUMBER: 83 SBA NX2247 THE HARTFORD INSURANCE CO. COMMERCIAL GENERAL LIABILITY NAMED INSURED: DENNIS GRUBB & ASSOCIATES ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - ONGOING AND COMPLETED OPS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Name of Person or Organization: CITY OF EL SEGUNDO THE CITY, ITS OFFICERS, OFFICIALS AND EMPLOYEES (If no entry appears above, information required to complete this endorsement will be shown in the Declaration as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in Schedule, but only with respect to liability arising out of "your work" for that insured by or for you. PRIMARY INSURANCE AND NON CONTRIBUTORY CLAUSE Such insurance as is afforded by this policy is primary insurance and non- contributing coverage for "ongoing" and "competed operations". No other insurance of the Additional Insureds will be called upon to contribute to a loss. Such Insurance as is afforded by this policy for the additional insured shown in the schedule of this endorsement shall apply as primary insurance and will not seek contribution from any other insurance maintained by such additional insured for "ongoing" and "completed" operations. WAIVER OF SUBROGATION General Liability Insurance and Workers Compensation policy shall include a WAIVER OF SUBROGATED ENDORSEMENT whereby the subcontractor waives any right or claim to be subrogated on payment of loss or otherwise to any claim against the contractor or owner and waves any right against contractor or owner. CG2010 10/01 Copyright, Insurance services office, Inc., 1984 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS LIABILITY COVERAGE FORM We waive any right of recovery we may have against: 1. Any person or organization shown in the Declarations, or 2. Any person or organization with whom you have a contract that requires such waiver. Form SS 12 15 03 00 © 2000, The Hartford Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed� 04.84) 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 poticy„ 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 2% of the California workers' compensation premium otherwise due on such remuneration_ Schedule Person or Organization Job Description Any person or organization as required by written 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 4/1/2022 Policy No. QWC1204923 Endorsement No. 0 Insured DENNIS GRUBB AND ASSOCIATES LLC Premium $ 500 Insurance Company Sequoia Insurance Company ";r Countersigned by — WC 04 03 06 (Ed. 04-84) Dennis Grugbb and Associates, LLC sisff:tf Cities Build Safi? Communities 14 w May 18, 2022 City of El Segundo Fire Department Attn: Liz Lydic 314 Main Street El Segundo, CA 90245 Subject: Confirmation Request As requested, this letter will serve as confirmation that Dennis Grubb and Associates will not come onsite to provide our services. Respectfully, Dennis Grubb Dennis Grubb & Associates, LLC 6560 Van Buren Blvd, Ste B, Riverside, CA. 92503 (951)772-0007