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