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PROOF OF INSURANCE (2022 - 2023) CLOSEDDATE (MM/DD/YYYY) �.ACC>RL> CERTIFICATE OF LIABILITY INSURANCE 04/05/2022 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 Laurie Smith NAME' ...'.� State&rrn LYNDA RUMMELHOFF PHONE 805 553 0355 FAX 805 823 4290 WC, No, Ex* _ _ (A/C„ No) r 332 MORPARK AVE E-MAIL laurie@moorparkinsurance com MOORPARK, CA 93021 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: State Farm General Insurance Company 25151 INSURED INSURER P,: SIMONE, OLIVIA INsuRER C DBA OFF THE EATEN TRACK INSURER D INSURER E CA 90027 LOS ANGELES INSURER F 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 INSRR .. .TYPE OF INSURANCE AOOLii5ll'ER.POLIC'Y�E'FF POLICY EXP POLICY NUMBER MM/DO/YYYY MMIDDfYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 OAiMRAGE'i kt.NTL b 300 000 CLAIMS -MADE X. OCCUR }'C�'Eflr%dh�Fn✓arNul?auarrt?f„ , w _ _,. MED EXP IAny one pcm: q) 10,000 A Y Y 92-J7-J396-5 03/01/2022 03/01/2023 PERSONALBADVINJURY $ 1,000,000 _ .......................... .,.', _ . GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 GTPOLICY PRO- I00 ,-COMP/OP AGG5 2,000,000 JrCT 'DRO.ICSO'rHE,S S � AUTOMOBILE LIABILITY COMBINED S R4GLE [_Rd&I S �... ANY AUTO BODILY INJURY (Per person) 5 OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED I NON -OWNED 0 Y5ANJALE AUTOS ONLY AUTOS ONLY _g1erAqr,dqnq UMBRELLA LIAB OCCUR EACH OCCURRENCE " EXCESS LIAB CLAIMS -MADE AGGREGATE DED RETENTONS 5 WORKERS COMPENSATION PER R OTIR• AND EMPLOYERS' LIABILITY Y / N T'A�tY,FE , ' I -- ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E L EACH ACCIDENT 5 OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) E L DISEASE - EA E.,'M "LOYEF S Ifns describe under 0E$ :R1PT"R014 OF OPER2ARJONS I°eq v E L. DISEASE - POLICY LIMIT a DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) The City of El Segundo Community Services Department, its officers, officials, employees and volunteers are to be covered as additional insureds on the CGL policy with respect to liability arising out of work or operations performed by or on behalf of Contractor including materials, parts or equipment furnished in connection with such work or operations, Insurance is Primary and Non-contributory with Waiver of Subrogation. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of El Segundo Community Services Department 300 E,Pine Avenue AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 Completed by an authorized State Farm representative. If signature is required, please contact a State Farm agent. ..._. .............._­.­ . ......... @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849.13 04-22-2020 Evidence of Insurance Here are your Evidence of Liability Insurance Cards. Two cards have been provided for each vehicle insured. One card must be carried in the proper insured vehicle. Proof of insurance is required to register or renew the registration of your vehicle. A law enforcement officer can ask you to prove that you have liability insurance meeting the basic requirements of California law. A violation of these requirements can result in a fine of up to: $1,000 for the first time $2,000 for additional times Also, a judge can have your vehicle impounded. False proof of insurance may result in a fine up to $750 and 30 days in prison. Due to space limitations on the ID card, only the Named Insured and the Co-insured are listed. For a full list of drivers covered under this policy, please reference the Drivers section of your Declarations Page (page 7). If you would like additional ID cards you can go online to geico.com or call us at 1-800-841-3000. MEMOCalifornia Evidence of Liability Insurance e ei0m=0 , 1-800-841-3000 GEICO GENERAL INSURANCE COMPANY P.O. Box 509090 • San Diego, CA 92150' 9090 NAIC Code: 35882 Policy Number Effective Date Expiration Date 4420-95-46-06 03-20-22 09-20-22 Year Make Model Vehicle ID No. 2008 CHEV COBALT LT Insured: Olivia Simone The ccwe� rage. G:rnrvided by his, policy rneE is Itre m'irni nuin re qu'irernenUr of seacV.is:rrns 16056 & 16500 5 of the Cali for uiiia Vehicle. Code, rnirnirn m liability lirrills I:vrerscpiib d by fhe law, OLIVIA SIMONE 4953 FRANKLIN AVE LOS ANGELES CA 90027-4058 GEIC0 California Evidence of Liability Insurance 1-800-841-3000 9�,0 r GEICO GENERAL INSURANCE COMPANY P.O. Box 509090 • San Diego, CA 92150-9090 NAIC Code: 35882 Policy Number Effective Date Expiration Date 4420-95-46-06 03-20-22 09-20-22 Year Make Model Vehicle ID No. 2008 CHEV COBALT LT Insured: Olivia Simone The eraveir age hricrvide.d by I his policy ina ers I1he minimvun requireirienI, of seclior is 16056 & '1 6500 5 ofthe Cal lfoi ni a Vehicle; Code, minimurn Iiabilfty limits pr ar;riib d by lhve law.. Policy No. 92 J`1J396 3 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY CMP-4860.1 ADDITIONAL INSURED — DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 92 J7J396 5 Named Insureds SIMONE, OLIVIA DBA OFF THE BEATEN TRACK IFIIIIII III IIIIII III III migaii, THE CITY OF' EL SEGUNDO COMMUNITY SERVICES DEPARTMENT ITS OFFICERS® OFFICIALS® EMPLOYEES AND VOLUNTEERS 300 E PINE AVE EL SEGUNDO CA 90245 SECTION II — WHO IS AN INSURED of SECTION II — LIABILITY is amended to in- clude, as an additional insured, any person or organization shown in the Schedule, but only with respect to liability for "bodily injury", "property damage", or "personal and advertis- ing injury" caused, in whole or in part, by: a. Premises And Ongoing Operations Your acts or omissions or the acts or omissions of those acting on your behalf: (1) In connection with your premises; or (2) In the performance of your ongoing operations; or b. Products —Completed Operations "Your work" performed for that additional insured and included in the "products - completed operations hazard". However, Paragraph 1. above is subject to the following: a. The insurance afforded to the additional insured only applies to the extent permit- ted by law; I b. If coverage provided to the additional in- sured is required by a contract or agree- ment, the insurance provided to the additional insured will not be broader than that which you are required by the con- tract or agreement to provide for such ad- ditional insured; and c. If the contract or agreement between you and the additional insured is governed by California Civil Code Section 2782 or 2782.05, the insurance provided to the additional insured is the lesser of that which: (1) Is allowed for the satisfaction of a de- fense or indemnity obligation by Cali- fornia Civil Code Section 2782 or 2782.05 for your sole liability; or (2) You are required by contract or agreement to provide for such addi- tional insured. We have no duty to defend or indemnify the additional insured under this endorsement un- til a claim or "suit" is tendered to us. ©, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission. CONTINUED 2. Any insurance provided to the additional in- sured shall only apply with respect to a claim made or a "suit" brought for damages for which you are provided coverage. This endorsement shall not increase the ap- plicable Limits Of Insurance shown in the Declarations. 3. With respect to the insurance afforded to the additional insured, the following is added to SECTION II — LIMITS OF INSURANCE: If coverage provided to the additional insured is required by contract or agreement, the most we will pay on behalf of the additional insured will be the lesser of the amount of insurance: 5. a. Required by the contract or agreement; or b. Available under the applicable Limits Of Insurance shown in the Declarations. This endorsement shall not increase the ap- plicable Limits Of Insurance shown in the Declarations. 4. With respect to the insurance afforded to the additional insured, the following is added to Paragraph 3. Duties In The Event Of Occur- rence, Offense, Claim Or Suit of SECTION II — GENERAL CONDITIONS: The additional insured must: a. See to it that we are notified as soon as practicable of an "occurrence" or an of- fense which may result in a claim. To the extent possible, notice should include: (1) How, when and where the "occur- rence" or offense took place; (2) The names and addresses of any in- jured persons and witnesses; and CMP-4860,1 Page 2 of 2 (3) The nature and location of any injury or damage arising out of the "occur- rence" or offense; b. Tender the defense and indemnity of any claim or "suit' to us and to all other insur- ers who may have insurance potentially available to the additional insured; and c. Agree to make available any other insur- ance the additional insured has for de- fense or damages for which we would provide coverage under SECTION II — LIABILITY. With respect to the insurance afforded the ad- ditional insured, the following replaces SEC- TION II — LIABILITY of Paragraph 7. Other Insurance of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: a. This insurance is primary to and will not seek contribution from any other insur- ance available to the additional insured, provided that the additional insured is a named insured under such other insur- ance. b. Regardless of any agreement between you and the additional insured, this insur- ance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the additional in- sured has been added as an additional in- sured on other policies. There will be no refund of premium in the event this endorsement is cancelled. All other policy provisions apply. CMP-4860.1 1007042 148020 08-26-2014 ©, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission. 48 Policy No. 92 J"7 J396 5 Page 1 of1 g THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY CMP-4787 WAIVER OF TRANSFER OF RIGHTS OR RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy INuimbeir„ 92 37,3396 5 INairned Insured: S::I:MONE, OL VIA DBA OPP THE BEATEN TRACK Nalrne And Address Of Person Or Organization: THE CITY OF EL, SEGUNDO COMMUNITY SERVICE'S DEPARTMENT ITS OFFICERS, OF:F"ICIA1,S, EMPLOYEES AND VOLUNTEERS 300 :E PINE AVE EL S:EGUNDO CA 90245 The following is added to Paragraph 10.b. of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: We waive any right of recovery we may have against the person or organization shown in the Schedule because of payments we make for injury or damage arising out of: a. Your ongoing operations; or b. "Your work" done under 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. All other policy provisions apply. CMP-4787 1006225 137715,.1 11-19-2013 ©, Copyright, State Farm Mutual Automobile Insurance Company, 2008 Includes copyrighted material of Insurance Services Office, Inc,, with its permission.