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PROOF OF INSURANCE (2022 - 2022) CLOSED" DATE (MMOO YYYY) CERT FICATE OF LIABILITY INSURANCE 5/9/2022 THIS CERTIFICATE IS ISSUED AS A MATTERyOF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY O NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF IN'SURANCEDOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificate holder Is an A9DITIONAL INSURED, the pollcy(les) 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 rlitits to the ci rt ficate holder In lieu of such endorsoment(s). PRODUCER UQNIACf NAME: Lynette (Lynn) Eye PIA Scicct Insurance Solutions C rk�Nk.,Exl : 805 975-3531 C, No 1100 Industrial Rd., #3 E-MAIL I enna cc• 1vnn.eve(a).oiaselecLcnm San Carlos INSURED Mark Groh 5481 Vallecito Ave. Westminster THIS IS TO CERTIFY THAT THE POLICIES OF INSI INDICATED, NOTWITHSTANDING ANY REOUIREN CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, EXCLUSIONS AND CONDITIONS OF SUCH POLIM lAuur 'R TYPE OF INSURANCE INSD !17M,:LAIMS-MADE ERCIAL GENERAL LIABILITY FRI OCCUR A '... GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JECT LOC OTHER: AUTOMOBILE LIABILITY ANY AUTO A OWNED SCHEDULED AUTOS ONLY AUTOS HIRED Fx1AUTOS NON-OWNEDAUTOS ONLY ONLY UMBRELLA LIAR OCCUR EXCESS LIAR CLAIMS -MADE RETENTION $ INSURER(S) AFFORDING CA 94070 INSURERA: HiscoxlnsuranceCon ny INSURER B : Scottsdale Indemnity CfYrnp INSURER C ;, INSURER D : INSURER E : CA 92683-2836 INSURERF: NUMBER'. REVISION NUMBER. NCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD r, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS - INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, D POLICY NUMBER (MMIDDIYYYYIMM/DDIYYYY) LIMITS `j 1 1 I SBGL000805-01 EMPLOYERS' LIABILITY Y I N PROPRIETOWPARTNERIEXECUTIVE r CER/MEMSER EXCLUDED? I N / A datory in NH) L.... 1 describe under W IPTION OF OPERATIONS below B I Professional Liability II SBGL000805-01 EK13387974 NAIC 0 OCCURRENCEEACH S 2,000,000 PREMIS ES Ea a°+rm�irrw;sb 100,000 $ MED EXP (Any one pea�son) $ 5,000 07/06/2021 07/06/2022 PERSONAL a ADV INJURY $ Excluded GENERAL AGGREGATE I S 2,000,000 PRODUCTS - COMPIOP AGG IS 2,000,000 07/06/2021 07/06/2022 vrwu..c.n.,-. r. (Ea accident) S 2,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ tPVtKTYUAMAG 'oraccident) I$ Aggregate limit: EACH OCCURRENCE $ 2,000.000 $ AGGREGATE $ E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE'. $ E.L. DISEASE - POLICY LIMIT ^' $ Lltnit° ' $1,000,000 07/11/2021 [07/111/2022 tuctible: $2,500 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACORD 101, AddHlonal Remarks Schedule, may be attached If more space Is required) The City of El Segundo and its officers, employees, elected officials, volunteers, and members of boards and commissions are included as additional insureds, but only insofar as the Operations under this agreement or contract are concerned per endorsement CGL E5421 CW attached. This policy includes a blanket waiver of subrogation. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City ofEl Segundo ACCORDANCE WITH THE POLICY PROVISIONS. I 350 Main Street AUTHORIZED REPRESENTATIVE EI Segundo CA 90245 ; ., / © 1988-2015 ACORD CORPORATION, All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Policy Number: SBGLOQ0805.01 Named Insured: Mark L. Groh Endorsement Number: 0 Endorsement Effective: 07/06/2621 THIS ENDORSEMENT CHANGES THE POLICY. Hiscox Insurance Company Inc. PLEASE READ IT CAREFULLY. '�. • •lip This endorsement modifies COMMERCIAL GENERAL A. Section II — Who Is An to include as an addi'tio sons) or organization(s performing operations o when you and such ps tion(s) have agreed in w agreement that such pE tion(s) be added as an ; your policy. Such parse an additional insured onl bility for "bodily injury', "' "personal and ad'vertisir whole or in part, by your the acts or omissions of behalf: provided under the following: LITY COVERAGE PART isured is amended �l insured any per - for whom you are leasing a premises on(s) or organiza- ing in a contract or on(s) or organiza- Iditional insured on N or organization is with respect to lia- -operty damage" or injury" caused, in cts or omissions or nose acting on your 1. In the performance of your ongoing opera- tions; or 2. In connection with your premises owned by or rented to you. A person's or organizatio I's status as an addi- tional insured under this endorsement ends when your operations or lease agreement for that additional insured are, completed. CGL E5421 CW (02114) Includes copyrighted material of Insurance Services Office, Inc., with its permission. i Page 1 of 1 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 for the 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 # (X) 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. Signature of Applicant Date 6-27-22 Agreement for: M a Dated: r Reviewed by: !