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PROOF OF INSURANCE (2023) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 05/26/2022 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 ICON ACT i Hiscox Inc. d/bla/ Hiscox Insurance Agency In CA PHONE 888202-3007 W Nei 520 Madison Avenue sDDRE tact@ro hiscox cony 32nd Floor H nNsu ..... .... GE .10200 New York, New York 10022 INSURER A ��iscox Insurance Company Inc INSURED Tina Barry 341 Park Ave Long Beach, CA 90814 INSURER B a. INSURER C c INSURER D F: n­^Ar � kl"RAMoo. 17PVICInK1 KIIIMRFRw 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. �..,....._.......... ..-. A �Ue ......._. POLYCYE"'FF' _ ............._......_ ........_.... -- ........" _ _ POLICY EXP INSR TYPE OF INSURANCE POLICY NUMBER MMADD/MYXY MMIDD LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2.000 mm000 BLS 100000 CLAIMS -MADE OCCUR PREMISES ( $ MED EXP (An one person) .....,_, $ 5,000 A Y P100.684.000.1 05/26/2022 05/26/2023 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO LOC PEC r PRODUCTS COMP/OP AGG $ S/T Gen. Agg. ... $ OTH15R., COMBINED GNGLE LIMn' $ AUTOMOBILE LIABILITY „tea �•ccidenl ..„„ INJURY (Per person) $ ANY AUTO........BODILY ._..��.... ...._., .,.._ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ ,.. AUTOS -„ AUTOS NON -OWNED ....,�_�... ..,�.�._ - PROPERTY DAMAGE ---- .-...... ......... $ HIREDAUTOS AUTOS -�e'r-cl'�1enl -•••- .............� $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE _ ........_ AGGREGATE _..................... $ .... •,� DED RETENTION$ WORKERS COMPENSATION PER OTH STATUTE ER AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT .-_...... _- $ ••••„„ ....... •• OFFICER/MEMBER EXCLUDED? (Mandatory in NH) NIA E.L. DISEASE - EA EMPLOYEE - _-------_ $ ••••mmmmmmm• If yes, describe under DESCRIPTION OF OPERATIONS below E L. DISEASE - POLICY LIMIT $ A Professional Liability Y P100.683.999.1 05/26/2022 05/26/2023 Each Claim: $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 of El Segundo is named additional insured subject to policy terms and conditions. CERTIFICATE HOLDER CANC'ELLA I IVN r Segundo St SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE do, CA 90245 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ACORD 25 (2016/03) AUTHORIZED REPRESENTATIVE y D ©1988-2015 ACORD CORPORATION. All rights reserved. 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 unaer penalty of perjury under the laws of California one of the following declarations, I have and will maintain a cartrficale 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' compansation 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 carder and policy number are Carrier Policy Number Expiration Date Name of Agent Phone tf (�) I certify that ,n the performance of the work set forth in the agreement Willi 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 bocome suDiec—Im the workers' compensation provisions of Labor Codo § 3700 1 must immediately comply wit oiwListag tt�e �<-rig �f will automatically become void, Signature of Applicant . F Ili`` Date Print Name a- Agreement for. U Dated, 6— Reviewed by