PROOF OF INSURANCE (2023) CLOSEDWYATT-2
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CERTIFICATE OF LIABILITY INSURANCE 08/0212022
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 rights to the certificate holder in lieu of such endorsernent(s).
PRODUCER
Alliance Mgt, & Insurance Sery
355 Via Vera Cruz #7
CA A ent(Broker Lic# 0737966
San Marcos, CA 92078
Michelle A. Nowell
Investigative
CA 92513
-7116
�q ; 760-471-7116
mnowel aiamii
Insurance Com
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760-471-9378
34118
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,
EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN HAVE BEEN REDUCED BY PAID CLAIMS. —.......
--LIMITS
_
INSR ADDL SUB POLICY EFF POLICY E%P
TM�E OF INSURANCE POLICY NUMBER m
P
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
„$ 1,000,000
.- .-
.
CLAIMS -MADE X OCCUR
X
PKV0000776
07/31/2022
07/31/2023
DAMAGE TO RENTED
i�f%�i'3.4 r��a��k_ar_
105,000
X.
........
tors &Omission
Errors
MED EXP (MgmonP pgrson
5,000
1,000,000'
PERSONAL & ADV INJURY
$
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5,000'OOO
GEN1
ACGR LIMIT ES PER: APPLIES
GENE_
RAL AGGREGATE m
$
X
�GATE
POLICY JECT PRO- I LOC
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mm
$ 1,000000
A
COMBINED SINGLE LIMIT
1,000,000
AUTOMOBILE LIABILITY
.... ANY AUTO
PKV0000776
07/31/2022
07/31/2023
BODILY, q) RY(Perperson
$ wwwww„�ym„
OWNED SCHEDULED
AUTOS ONLY AUTOS
YINJIJRY Pereccidrnt
$ .��. ...s
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$
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UMBREL LIAB OCCUR
EACH OCGURREN GE
$
EXCESS LAB CLAIMS MADE
......
AGGREGATE,
.--, -
DED RETENTION $
WORKERS COMPENSATION
PER OTH
AND EMPLOYERS' LIABILITY
I
ANY PROPRIETOR/PARTNER/EXECUTIVE
F L. EACH ACCIDENT,__
$ __
C?FF&GER/MEMBER EXCLUDED. [
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If yes, describe under
Fg CRIPTIONF P RATIONS. below
.,, -P LI YLIMIT
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
City of El Se undo, their officials,officers,agents and employees are named
as additlona?insured with respect to the work perforrned 61y the named
insured.
Investigations, CA --
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of El Segundo
350 Main Street
El Segundo, CA 90245
AUTHORIZED REPRESENTATIVE
a
ACORD 25 (2016/03) 9)1983-2015 ACORD CORPORATION. All rights reservea.
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: PKV0000776
COMMERCIAL GENERAL LIABILITY
CIGL 79 03 18
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL. INSURED - OWNERS, S, LESSEES OIL
CONTRACTORS - SCHEDULED PERSON OIL
ORGANIZATION.
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organlztion s Location(s) Of Covered Operations
Blanket as required by valid written contract. Blanket as required by valid written contract.
Additional Information:
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II — Who Is An Insured is amended to include as an additional insured the person or organization
shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and
advertising injury" arising out of:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your behalf;
in the performance of your operations for the additional insured at the location shown in the Schedule.
However:
a. The insurance afforded to such additional insured only applies to the extent permitted by law;
b. If coverage provided to the additional insured is required by a contract or agreement, the insurance
CIGL 79 03 18 Includes copyrighted material of Insurance Services Office, Inc. Page 1 of 2
afforded to such additional insured will not be broader than that which you are required by the contract or
agreement to provide for such additional insured; and
c. Regardless of the date of occurrence or when the injury or damage first occurs or is first discovered, a
person's or organization's status as an additional insured under this endorsement ends upon the earliest
of:
(1) The completion or termination of the contract or agreement between you and the additional insured
for the location shown in the Schedule;
(2) The date you cease actively performing operations for the additional insured at the location shown in
the Schedule; or
(3) The expiration or termination date of the policy or this endorsement.
B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply:
This insurance does not apply to liability or damages for "bodily injury", "property damage", or "personal and
advertising injury":
1. Caused by, arising from, or included in the "products -completed operations hazard";
2. Arising out of the additional insured's sole negligence;
3. Arising out of work or operations performed by you that were completed prior to the effective date of this
endorsement; or
4. Which continues or progressively deteriorates after you cease actively performing operations for the
additional insured at the location shown in the Schedule, even if the injury or damage first occurred, or is
alleged to have first occurred, during the course of your operations for the additional injured.
C. Solely for purposes of this endorsement, the following definition is deleted in its entirety and replaced by the
following:
1. ""Products -completed operations hazard":
a. Includes all "bodily injury" and "property damage" occurring away from premises you own or rent and
arising out of "your product" or "your work" except:
(1) Products that are still in your physical possession; or
(2) Work that has not yet been completed or abandoned. However, "your work" will be deemed
completed at the earliest of the following times:
(a) When all of the work called for in your contract has been completed;
(b) When all of the work to be done at the location shown in the Schedule has been completed if
your contract calls for work at more than one location; or
(c) When that part of the work done at the location shown in the Schedule has been put to its
intended use by any person or organization other than another contractor or subcontractor
working on the same project.
Work that may need service, maintenance, correction, repair or replacement, but which is otherwise
complete, will be treated as completed..
D. With respect to the insurance afforded to these additional insureds, the following is added to Section III —
Limits Of Insurance:
If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on
behalf of the additional insured is the amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits of Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.
CIGL 79 03 18 Includes copyrighted material of Insurance Services Office, Inc. Page 2 of 2
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.
C-_) 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 #
KI certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not
oy 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 g ppP Y P g � Y void.
Amply with thus rovisiora or t e a reement will automatically become v Date y
licant
Agreement for:
Garon Wyatt - Agreement
Dated: 4/17/2020
Joseph Lillio�
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Reviewed by:
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