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PROOF OF INSURANCE (2022 - 2022) CLOSED0 "Y CERTIFICATE OF LIABILITY INSURANCE F 1 /15/2021_ THIS CE10 RTIFICATE 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 p0liCy(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 HUB INTERNATIONAL INS SERVICES INC 4 �- CAJI S 3390 UNIVERSITY AVE, #300 RIVERSIDE CA 92501 INSURERMassachusetts 6 INSURED INSURER' '. JOHNJONES INSURER C JOHN JONES 26545 HAWKHURST DR _LMSURER E 5 INSURERF! CA 9027 THIS IS TO CERTIFY THAT TI IE POLICES OF IN LISTED REVISION NUMBER: INDICATED, NOTWFT'HSTANDING ANY RELiUgRE'MENT, TERM OR 'OW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD CERTIFICATE MAY BE ISSUED OR MAY PEIrTAIN, TMIE INSURANCI CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS EXCLUSNONSAND CONDITPONS OF SUCH POLICIES. LIMITS SHOWN AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, Y HAVE BEEN REDUCED BY PAID CLAIMS, F INSURANCEADDL;DPOUCYEFF P L POLICY NUMB EFR MWI)DW Mr,MD YYYI LIMIT'S COMMRRGIALPENERALLIABIUTY EACH OCCURRENCE 1$ -M0 2,00.0,0. ..0... .0 CLAIMS -MADE OCCUR UT0.......... . ........... I P I,, $ 300,000 A NED EXP (Any one mon) S 5,000 Y N OD3 H790206 00 101072021 10/0712022 PERSONAL 9 ADV INJURY s 2,000,000 GEN% AGGREGATE LIMIT APPLIES PEFL Ne RAL A�r RO >REGA7E_ S 4,000,000 P POLICY 0 JECT- FOLoc, PRODUCTS -COMPMPAGG $ 4,000,000 OTHER.Is AU`rOMIOBILELtABILITY COhMINED SINGLE LfMIT $ ANY AUTO OWNED SCHEDULED BODILY INJURY (Per person) $ AUTOS ONLY AUTOS 1 HIRED NON-OWNFD BODILY INJURY (Per &=idwd) $ AUTOS ONLY AUTOS ONLY PROP DAMAGE r ccwo $ UMBRELLALIAB OCCUR $ EXCESS LIAB HC—LAIM&MAD-E- _S DED AG; RELATE $ WORKERSCOMPENSATION S AND EMPLOYEaw LiABiLirry PER QFW+ ANYPROPRIETORMARTNERiExEcuTtvE YIN STA R ...... . ... . ... OFF10ER#AEMBEREXCLVMD7' NIA, E.L. EACH ACCIDENT jhlanOalory • In NH) S — WSt da ;OT"-Nundar -L'L_RLS �SE.F-A�EMPLOYEE� $ E,L, EVSFASE - PO' UNIT 1$, DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached It more NAMED INSURED CONT.- CATALYST CONSULTING. CITY OF HERMOSA BEACH, its elected or appointed officers, officials, employees, agents, and volunteers are Additional Insured on the General Liability pursuant to the terms and conditions by form 391-1006. CERTIFICATE HOLDER CANCELLATION CITY OF HERMOSA BEACH ATTN: SUJA LOWENTHAL 1315 VALLEY DRIVE HERMOSA BEACH ACORD 25 (2016/03) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE VATH THE POLICY PROVISIONS. A111 CA 90254 0M @ 1988-2016 ACORD CORPORATION The ACORD name and logo are registered marks of ACORD All rights reserved. interinsurance Exchange of the Automobile Club Y � 4 Automobile Insurance Policy Coverages and Limits Renewal Declarations We are pleased to offer you a renewal for your automobile insurance policy. To renew your policy, send at least the minimum payment on or before the due date. Insurance is in effect only for the vehicles, coverages„ and limits of liability shown on this declarations page and as set forth in the insurance policy and endorsements. These declarations, together with the contract and the endorsements in effect, Complete you' policy, If any change to your policy or to the information: we have on file results In a premium decrease during the policy period, the Interinsurance Exchange reserves the right to apply any refund due to ,your outstanding balance, NAMED INSURED (Item 1.) 7PPOUCYUMBER: CAA 073315808 JI N N, WKHURSD(PACIFIC STANDARD TIME) 2545 q-�1'twri�Ni,�I�t bI AN HO PALOS VERDE CA 90275-2441 IVE DATE: 08-26-21 12:01 A.M. TION DATE: 08.26-22 12:01 A.M. VEHICLES NO. YEAR MAID MODEL IDENTIFICATION VEHICLE GARAGE ANNUAL" VERIFIED NUMBER USE ZIP CODE MILES MILEAGE SALVAGE 2 1998 MA TACOMA COMMUTE 90275 10,001-12,500 VERIFIED NO COVERAGES AND LIMITS Coverage Is not In effect unless a premium or the word 'Included" is shown. ANNUAL PREMIUMS COVERAGES LIMITS OF UHBILITY Vehicle 2 Vehicle 5 Vehicle 6 Vehicle Vehicle Llablffty u Bodily Injury $500,000 each person/ $500.000 each occurrence $130 $178 $ 286 a $ 69 $138 $198 Medical Darr' $100,000 each occurrence , e , 9d 9 a Physical Damage (Aca,ei cash vawa rmle,s othanNae stared, lass deductible) o Covers a No Coverage No Coverm e' Vehicle 2 Vehicle 5 Vehicle 6 Vehicle Vehicle I Y { Comprehensive ACV ACV ACV $ 42 $ 56 " (Less Deductible) $250 $250 $250 l M $ 50 a l Collision ACV ACV ACV d $ 62 (Less Deductible) $1000 $1000 $1000 $ 426 $ 329 ; m r Car Rental Expense , Per Da No Coverage No Coveme No 22,nmle No Covers ep No Covers a No Coves e p UninsuredMotorlsl , Bodily Injury - $30.000 each person/ $60,000 each accident Uninsured & Underinsured Vehicles Uninsured Deductible Waiver Uninsured Collision I otai i'remtum $26 1 $62 Included Included a Included LNo Covoragge; No Coverage w No Coverat $ 349 ........... PREMIUM DISCOUNTS Please refer to the enclosed document entitled "Premium Discounts Applied to Your Automobile Policy,- ' if at any time ,you choose to pay less than the full (balance outstanding, finance charges of up to 1.5' per month of the balance outstanding will apply as explained In ,your billing statements, which are part of these declarations. ** To see the annual mileage for your expiring, policy, please refer to the "Notice of Annual Mileage" page contained In your renewal Daclrauee l $ 829 l $ 925 l "No Coverage" indicates Coverage not purchased, Total Annual Premium - (includes all applicable discounts.) $ 2103 Less Policyholder Savings Dividend $ 393 Net Premium* $171q r PROCESS DATE 0745-21 PLEASE ATTACH TO YOUR POLICY (SEE REVERSE) Interinsurance Exchange of the Automobile Club Automobile Insurance Policy coverages and Limits Renewal Declarations (continued) AUTO POLICY NUMBER: CAA 073315808POL�GY -® DRIVERS lCoraaroPo rn ay differ for each driver. Please see each section of the poticy contract for the definition o1 Persons fnswvd":I �� VE DA NAME , JONES,JOHN DRIVER NUMBER Of NUMBER PRINCIPALLY AT-FAULTACCIDENTS ENDORSEMENTS AND NUMBER Tr LE 2011 2052 2143 2298 2367 NUMBER OF TRAFFIC CONVICTIONS MtnaetK'5 AUTOMOBILE POLICY — POLICY NUMBER CHANGE LOSS PAYABLE - NOTICE TO LIENHOLDER LEASED VEHICLE DIFFERENT LIEN SELECTION OF UMIUIM COVERAGE ENDORSEMENT AMENDATORY ENDORSEMENT' GENDER MARrrAL STATUS YEAR FIF Lr EN& ` MALE MARRIED 1973 P.ATED DRIVER STATUS VEHICLE NUMBER PRIMARY 6 PRIMARY 5 SPECIAL EQUIPMENT— " SOUND EQUIPMENTy !EH. CAMPER/ OTHER 2-WAY TELE- N VAN COW RAnln pw� c I RADIO I OTHER Coverage is Indicated by e `(ES" in Ole spprOPI'late equipment column, Coverage fimItadOnS apply unless gage was Purchased specKicstly dca certain equipment. ANY PHYSICAL DAMAGE LOSS MAY BE MADE PAYABLE TO YOU AND ANY IVEHNTEREST LIST YV: PERSON DESIGNATED TO RECEIVE NONPAYMENT OF PREMIUM NOTICES: An Individual das)y naMd by a Poa!icy^hotdrar to mcalve notrco of lapse torrntraatdtan explratW, no�nranelwat or cancelfation of the policy 1W nonpay�nanl of P, duos not have any rights, whether as an ad dfitionjo' insured or drtharWjsa, raalvon hansffts undat the Policy, anther then the right 10 reosh% nntrceto any. 9 atle21 Click AAA.com/myaccount to access your ollcy Informationonline, pay your bill or print addltlonaV proot'ot insurance cards VEHICLES ON PROOF OF INSURANCE 'YEAR MAKEPOLIVECYH I.D. # Intefinsurance Exchange of the Automobile Club 1998 TYTA 4TANL42N6WZ026194 Insured Policy Number: CAA 073315808 JONES, LISA DRIVERS ON POLICY JONES, Date: 08-26-21 Expiration Date: 08-26-22 JONES, JOHN Tbls policy provides at least the minimum amounts of liability insurance required by the, CA VEH CODE SECTION 16056 fw the spectied vehicles and named insureds. Coverage subject to policy terms and limits. RILI Insurance Company RLI" Peoria, Illinois 61615 stock „� PERSONAL insurance company, n..eicalled the Company UMBRELLA LIABILITY POLICY These Renewal Declarations are a part of your policy. All other terms and conditions remain unchanged. RENEWAL DECLARATIONS Policy Number PUP1512503 3/14/2022 Named Insured & Mailing Address Agent JOHN JONES 57009 Auto Club Services LLC LISA 416-2402 26545 HAWKHURST DR 2601 South Figueroa Street PALOS VERDES ESTATES, CA 90275 Mail Stop H302 Los Angeles, CA 90007 Primary Residence Address (if different than above) Same As Above Policy Period — 12:01 A.M. standard time at the address of the Named Insured as stated herein. From 06/22/2022 To 06/22/2023 Limit of Coverage $ 1,000,000 each occurrence Excess Uninsured/Underinsured Motorists Limit of Coverage $ 0 each accident Coverage Rejected Policy Premium $337 Self -Insured Retention: $500 each occurrence Forms included at issue will appear on Page 2 of this Declaration. REQUIRED BASIC POLICIES It is agreed by you that you and any Relative will be covered by an Automobile liability policy for any Automobile you operate or your Relative operates for at least the minimum limits listed below. It is also agreed by you that you and any Relative will be covered by a personal liability policy for at least the minimum limits listed below, If you or your Relatives are not covered under your policies for at least the minimum limits listed below, they must be covered under another Automobile liability policy and another personal liability policy for at least the minimum limits below. If you or your Relatives own a Farm, Seasonal/Secondary/ Rental Properties, Recreational Vehicles or Watercraft, you or your Relatives, as the case may be, agree to cant' the appropriate policy (or endorsements) listed below covering both you and your Relatives for at least the minimum limits listed below. Basic Policy Minimum Limit of Coverage A. Automobile Liability Bodily Injury $ 500,000 each person $ 500,000 each occurrence Property Damage $ 50,000 each occurrence or Bodily Injury and Property Damage Combined Single Limit $ 500,000 each occurrence (continued on page 2) PUP 311 (04/10) Page 1 of 2 DATE ImwDorYYYY) CERTIFICATE OF LIABILITY INSURANCE 1 10/31/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND -CONFERS NORIGHTSUPON 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 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 rights to the certificate holder in lieu of such endorsement(sl. PRODUCER N CONTACT Hiscox Inc- d/b/a/ Hiscox Insurance Agency in CA 14 ME: N 5 Concourse Parkway E PHONE �FAX _=HL�0 A, 0 OL(8i8��)202-300�7��& A1C..yJ Suite 2150 tAORESS, co,ntac.t@tiiscox.com Atlanta GA, 30328 INSURERS AFFORDINa COVIrsuar. INSURERS njURER AFFORDING . ....... --.— -INSURED INSURER A Hiscox Insurance Company Inc 10200 Catalyst Consulting INSURER 8 26545 Hawkhurst Drive INSURER C Rancho Palos Verdes CA 90275 INSURER D INSURER E INSURED K COVERAGES CERTIFICATE NUMBER, THIS IS TO CERTIFY THAT THE �OLICIES -oF INSURANCE LISTED BELOW HAVE REVISION NUMBER: INDICATED. NOTWITHSTANDING ANY REQUIREMENT, BEEN TERM OR CONDITION OF ANY ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. BY LIMITS SHOWN MAY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE AWL 9—Va—ft MWD YYY 0AW LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS 0 EACHOCCURRENCE S -MADE OCCUR 7 -FREM-14u-M MEO E)tp & ADV tN � RY S GENIL AGGREGATE LIMIT APPLIESPER:PERSONAL RdO [—] POLICY 0 IPE LOC GENERAL AGGREGATE $ PRODUCTS - CO2fMAPaOEPA.G$ AUTOMOBILE LIABILITY COMBINED WNGLE LiMit $ ANY AUTO Ocederx $ — OWNED OVvNED SCHEDULED BODILY INJURY (Per person) $ — AUTOS ONLY AUTOS HIRED NON -OWNED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS ONLY P OP GE 1 r idom $ L;BRELLA LIAB OCCUR i FACHOCCURRENCE AGGREGATE CLAIMS MADE WORXERS COMPENSATION AND EMPLOYERS, LABILITY YIN PER OTH- ER ANYPROPRIETOPiPARTNERC-XECUTIVE OFFICEFUMEMBEREXCLUDE07 NIA E,L, EACH A00 Detrr $ (Mandatory in NH) II as, describe under E L. DSEASE - EA EMPLOYEE S scmpnoti OF OPFRA'n0NS below . ............. . — E1- DgSEASE - POLICY LMI 3 DC-5000006-EO-21 U � C 5000006 EO 21 1013112021 10/3112022 Each Claim: $1,000,000 Aggregate: $1,000,000 DESCPJPT10N OF OPERATIONS I LOCATIONS I VENCLES (ACORD 101, Additional Remarks Schedule. may be attached =11-.,..p�-.j.requ=d� CERTIFICATE HOLDER CANCELLATION " SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE MTN THE POLICY PROVISIONS, AUTHORMeOREPRESENTATN'l 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) 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 under penalty of perjury under the laws of California one of the following declarations: U 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 forthe 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 # I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not loy 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 prove ions r the agreement will automatically become void. Signature of Applicant' Date m Print Name Agreement for: �A�I i W4 Dated: Review