PROOF OF INSURANCE (2023 - 2023) CLOSEDJOEMPOL-01 MMELIT ,4 r�zotl CERTIFICATE OF LIABILITY INSURANCE DATE(M/202YYY) 7/202022 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 riohts to the certificate holder in lieu of such endorsement(s). PRODUCER Pag/ neWest Insurance - TAG 14900 SW Barrows Rd, Ste 202 Beaverton, OR 97007 276-3775 216-5018 INSURED INSURER B : Joe Mar Polygrah & Investigation Services Inc INSURER. C 12939 Banyon INSURER D : Rancho Cucamonga, CA 91739 INSURER E 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. INSR._.....,...__,...,______�,___..,___�.�ADDL SUBR ,�,__�,_,_,_� POLICY EFF POLICY EXP .:L7,R .-, ---- TYPE OF INSURANCE .,15.0 p, wwwwwwWm,,,,,,,,,,,Wn,POLICY NUMBER ....., .. LIMITS A X COMMERCIAL GENERAL LIABILITY (1,000,000 EACH OCCURRENCE..._ ,8 II CLAIMS -MADE mmX OCCUR RBS0116208 7/29/2022 7/29/2023 DAMAGE TO RENTED 100,000 _....._..._._.J � X X MED EXP (Any one erson 51000 ................. PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 Nf % POLICY F] PR'�y" LOC 2,000,000 &EC'G PRODUCTS COMP%OP AGG $ AUTOMOBILE LIABILITY ,SING0. E LIMIT' $ ,_ C�IMBINED ITITX. ANY AUTO BODILY INJURY Per.person) . $ OWNED ISCHEDULED AUTOS ONLY ..... AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED PRO ERTY MADE ,.,.,-.. AUTOS ONLY AUTOS ONLY Per accl- . $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DIED RETENTION $ $ WORKERS COMPENSATION PER OTH- '..AND EMPLOYERS' LIABILITY Y / N STATIJ ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ EL EACH ACCIDENT $ FFI E WMBER EXCLUDED? N / A anfalriry Jn NH) E .DISEASE -EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A Errors & Omissions X X RBS0116208 7/29/2022 7/29/2023 each claim 1,000,000 A Errors & Omissions X X RBS0116208 [7-._._/2022 7/29/2023 aggregate 2,000,000 _......-....__._.._.._.._ ...._......._ .._ _............. __- ..................... DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Certificate holder is additional insured per attached GLS578 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN tY 9 ACCORDANCE WITH THE POLICY PROVISIONS. 348 Main St El Segundo, CA 90245 ......•••• AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Underwritten by Scottsdale Insurance Company ENDORSEMENT NO. ATTACHED TO AND FORMING A PART OF ENDORSEMENT EFFECTIVE DATE NAMED INSURED AGENT NO. POLICY NUMBER (12:01 A.M. STANDARD TIME] RBS-0116208 7/29/2022 Joe Mar Polygraph & Investigative Services Inc 46722 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED AND WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US ENDORSEMENT This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE PART ERRORS AND OMISSIONS COVERAGE PART A. With respect to this endorsement, SECTION II —WHO IS AN INSURED is amended to include as an additional insured any person or organization whom you are required to add as an additional insured on this policy under a written contract, written agreement or written permit which must be: 1. Currently in effect or becoming effective during the term of the policy; and 2. Executed prior to the "bodily injury," "property damage," "personal and advertising injury" or "damages." B. The insurance provided to these additional insureds is limited as follows: 1. That person or organization is an additional insured only with respect to liability for "bodily injury," "property damage," "personal and advertising injury" or "damages" caused, in whole or in part, by: a. Your acts or omissions; or b. The acts or omissions of those acting on your behalf. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. 2. With respect to the insurance afforded to these additional insureds, the following exclusions are added to SECTION I —COVERAGES, paragraph 2. Exclusions: This insurance does not apply to "bodily injury," "property damage," "personal and advertising in- jury" or "damages" occurring after: a. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or b. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. 3. The limits of insurance applicable to the additional insured are those specified in the written con- tract, written agreement or written permit or in the Declarations for this policy, whichever is less. Includes copyrighted material of ISO Properties, Inc., with its permission. Copyright, ISO Properties, Inc., 2004 Nafioov+ride GLS-578-TAG (05-21) Page 1 of 2 0, These limits of insurance are inclusive of, and not in addition to, the Limits of Insurance shown in the Declarations for this policy. 4. Coverage is not provided for "bodily injury," "property damage," "personal and advertising injury" or "damages" arising out of the sole negligence of the additional insured. 5. The insurance provided to the additional insured does not apply to "bodily injury," "property dam- age," "personal and advertising injury" or "damages" arising out of an architect's, engineer's or surveyor's rendering of or failure to render any professional services including: a. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, re- ports, surveys, field orders, change orders or drawings and specifications; and b. Supervisory, inspection, architectural or engineering activities. S. Any coverage provided hereunder will be excess over any other valid and collectible insurance available to the additional insured whether primary, excess, contingent or on any other basis unless a written contract specifically requires that this insurance be primary. When this insurance is excess, we will have no duty under SECTION I —COVERAGES to defend the additional insured against any "suit" if any other insurer has a duty to defend the additional insured against that "suit." If no other insurer defends, we will undertake to do so, but we will be entitled to the additional insured's rights against all those other insurers. C. With respect to the insurance afforded to these additional insureds, the following is added to paragraph 8. Transfer Of Rights Of Recovery Against Others To Us Condition of the Commercial General Liability Coverage Form and Errors And Omissions Coverage Form: We waive any right of recovery we may have against an additional insured because of any payment we make under this Coverage Part, to whom the insured has waived its right of recovery. Such waiver by us applies only to the extent that the insured has waived its right of recovery against an additional insured prior to loss, but only with respect to liability for "bodily injury," "property damage," "personal and advertising injury" or "damages" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations. r AUTHORIZED REPRESENTATIVE DATE Includes copyrighted material of ISO Properties, Inc., with its permission. Copyright, ISO Properties, Inc., 2004 Nationwide` GLS-578-TAG (05-21) Page 2 of 2 vtj Renewal auto policy declarations Your policy effective date is August 11, 2022 Total Amount Due for the Policy Period Please review your insured vehicles and verify their VINs are correct. 1997 Chevv Trk Blazer 2010 Mercedes-B E350 2016 Ram Trucks 1500 2wd California Fraud Assessment Fee Ot il* Page 1 of 7 Information as of June 21, �022 Summary Named Insured(s) doe Delia ,Mailing address Policy number 024 601,607 t Your bill will be mulled separately. Before making a payment, please refer to your Your policy provided by latest b114 which Includes payment options and installment fee information. if you do Allstate Northbrook Indemnity not pay in full, you will be charged an installment feels?. Company See the Important payment and coverage information section for details about Policy period installment fees. Beginning August 11, 2022 through February 11, 2023 at 12:01 a.m. standard time Discounts (included in your total premium) Good Driver (20%) $709.47 Anti -theft $9.81 Distinguished $203.46 Driver Total discounts iI��irviiV'R91r�^^, i��4r I .UPI + wll�reC� Discounts per vehicle 1997 Cheyy Trk Blazer Good Driver (20%) $248.21 2010 (Mercedes-B E350 Good Driver (20%) $2 O S8 2016 Ram Trucks 1'5001 2wd Anti -theft $4.44 Distinguished $203.46 Driver Anti -theft $5.37 Good Driver (20%) $220.38 Surcharge (included in your total premium) 1997 Chev° Trk Blazer Listed drivers an your policy la Joe Delta $922.74 Your Allstate agency is Navarro Ins Svs Inc IF Some or all of the information on your Policy Declarations Is used In the rating of your policy or it could affect your eligibility for certain coverages. Please notify us immediately If you believe that any Information on your Policy Declarations is Incorrect. We will make corrections once you have notified us, and any resulting rate adjustments, will be made only for the current policy period or for future policy periods. Please also notify us immediately if you believe any coverages are not listed or are Inaccurately listed. I 00 Renewal auto policy declarations Policy number: 102460 Policy effective date: August 11, 2022 Page 3of7 WAllstate. Covers a detail for 1997 Chevy Trk Blazer CoKerage �Limits DeductibleITIT..._._....m. .___.... Premium Automobile Liability Insurance Not applicable $594.29 • Bodily Injury $1,000,000 each person $1,000,000 each occurrence • Property Damage $100,000 each occurrence Auto Collision .. ,.... �._...m _ ,.........., µ_. . m....._ .. m....�.... _ . ,...., _ w. ��. .. ._� ._. n Insurance Actual cash value $250 $295.62 Waiver of deductible applies Auto Comprehensive Insurance Actual cash value $0 __..., $..._....1. 70.16 Rental Reimbursement Not purchased* Towing and Labor Costs Not purchased* ......,, .. w _ ....... ........ .... Uninsured Motorists Insurance for Bodily $100,000 each person Not applicable Injury $300,000 each accident Automobile Medical Payments - �$2,000 each personNot applicable Coordinated Medical Protection Not $82.13 $21.48 Sound 7steirn Not purchased* _... _.__._. _.....- _ ...... ........ ,� ..�.._. Tape Not purchased* Total premium for 1997 Chevy Trk Blazer $1,063.68 * This coverage can provide you with valuable protection. To help you stay current with your insurance needs, contact your Allstate agent to discuss coverage options and other products and services that can help protect you. VIN Rating information Your premium is determined based on certain information, including the following: Allstate uses mileage Information as one factor to help determine your premium amount. Important Note: The annual mileage figure applicable to this vehicle for the expiring policy period was: 10,000.10,499. The annual mileage figure applicable to this vehicle for the current policy period is:10,000-10,499. The required odometer information to calculate your annual mileage for the current policy period was not provided, was illegible, could not be obtained or the most recent odometer reading we received was less than a previous reading. If any of the Information shown above is incorrect, missing or changes In the future, please contact your Allstate representative. Please keep in mind that a change in any of the information may result In an adjustment to your premium. Renewal auto policy declarations _ Policy number: 024CI1 ��' Policy effective date: August 11, 2022 Page 4 of 7 Coverage detail for 201.0 Mercedes-B E350 conme u1ni'ts Deductible prernfum Automobile Liability Insurance Not applicable $322.96 • Bodily Injury $1,000,000 each person $1,000,000 each occurrence • Property Damage $100,000 each occurrence Auto Collision Insurance _ Actual cash value �z� _.__.�..�_.�_..... $450:97 Waiver of deductible a Auto Comprehensive Insurance_ � Actual cash value �... ��..._ $0 $101.92.. Rental Reimbursement Nat urchased Towin and Labor Costs Nat purchased* _ __ _ .. .$75. Uninsured Motorists Insurance for Bodily $100,000 each person Not applicable 71 Injury 000 each accident $300,000 each $00, � mm . ..� _ �.� Automobile Medical Payments....._ $2,000 each person $...�. Not applicable 11.97 Coordinated Medical Protection Not purchased* Sound,System Not purchased* Tape Not purchased* Total premium for 20101Nercedes-8 E3SO $%3.5 * This coverage can provide you with valuable protection. To help you stay current with your Insurance needs, contact your Allstate agent to discuss coverage options and other products and services that can hey protect you. VI Rating Information Your premium is determined based on certain information, including the following: Allstate uses mileage Information as one factor to help determine your premium amount. Important Note: The annual mileage m appikableto this vehicle for the expiring policy period was:10,500-10,'999.. The annual mil figure applicable to this vehicle for the current poky period W 10,500-10,999. The following odometer Information was used to determine your annual mileage for current poky period: 0dometer Reading: Odometer heading: Date :31Date :A if any of the information shown above is incorrect, missing or changes in the future, please contact your Allstate represeritative. Plem keep In mind that a change in any of the Information may result In an adjustment to your premium. F t Renewal auto policy declarations Policy number, 024a0� b07 Policy effective date: August 11, 2022 Page 5 of 7 (WAllstate., Coverage detail for 2016 Ram Trucks 1500 2wd Coverage Insurance Limits Not applicable4 Deduttible Automobile Liability $383. 4 • Bodily Injury $1,000,000 each person $1,000,000 each occurrence • Property ce rren Damage $100,000 each occurrence ...n .._ . ®... . Auto Collision . �...._...__..,..._ Insurance Actual cash value $250 $348.50 Waiver of deductible applies Auto Comprehensive Insurance .e..,.. �... _ _.. Actual cash value _... , � .�.. �.�,,.,..... .. ,�.... $0 $84.34 w..e..., ...w®n w_ Rental.... Reimbursement Not purchased and labor Co t 8 Costs Not purchased* �.$100,000 � � � �li � .... _... �, . � Uninsured Motorists Insurance for Bodily l each person 5 Nat applicable $ a4,0 Injury $300,000 each accident Automobile Medical Payments . _." $2,000 each person e _. ,U.. ..... _,. Not applicable $10.38 _. m , a.. _ ._ .... _... _ Coordinated Medical Protection Not purchased* Sound System Not purchased* Tape Not purchased* Total premium for 2016 Ram Trucks 1500 2wd $i18156 * This coverage can provide you with valuable protection. To help you stay current with your insurance needs, contact your Allstate agent to discuss coverage options and other products and services that can help protect YOU. VINE Rating information Your premium is determined based on certain information, including the fallowing: Allstate uses mileage information as one factor to help determine your premium amount. Important Note: The annual mileage figure applicable to this vehicle for the expiring policy period was:13,500-13,999. The annual mileage figure applicable to this vehicle for the current policy period Is:13.500-13,999. The following odometer Information was used to determine your annual mileage for current policy period: Odometer Reading: Odometer Readinw-90111110 Date: Date :41 If any of the information shown above is incorrect, missing or changes in the future, please contact your Allstate representative. Please keep in mind that a change In any of the Information may result in an adjustment to your premium. 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 ATTORNEYS FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: L—) I have and will maintain a certificate of consent ofself-insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work sat 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 Name of Agent Policy Number Expiration Date 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 )INorIrs' compensation provisions of Labor Code § 3700 1 must immediately comply with those 6 isions o,� �a ment."automatically become void. Date Signature of Applicant - 4 Agreement for: Dated: 04-13-2021 Digitally signed by Joseph Lillie DN: cn=Joseph Ullio, O=CitY of El Segundo, ou=Chief Financial officer, Reviewed by: Jose h Lillioemail=jlillio@elsegundo.org, c=US P 5:58 -07'00'