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PROOF OF INSURANCE (2022) CLOSEDOP ID: MN Pt'MMM'DD1YYYY) CERTIFICATE O LIABILITY II SURANCE 8/2022 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 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 endorsements . PRODUCER CONVICT NAME Michelle A Nowell Alliance Mgt. & Insurance Sery PHONE 760-471 7116 N� 760-471-9378 355 Via Vera Cruz #7 (J_c, � xtl. .......... tM91' CA A ent/Broker Lic# 0737966 gg E MAIL mnowell amiscor coin San Marcos, CA 92078 � ... O-1 PRdi�iteBR ADDRE55 _ Michelle A. Nowell cU$TOMER Lc #. _..._ _._ _ _ ........ r INSURERS) AFFORDING COVERAGE NAIC # INSURED ......_18 Group ... .... .... .... ........,,. INSURER„B HSB Spec alty I sUranCe .. .m.. _ Tustin CA 92780..... p Company 8 3411 1831 Bent Twig Lane Co INSURER C : ,.m.m.. n ETMVJ M Ar= 4111aanom. KII IMRFR- 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. ................. ......... _.. ...-.. ,., ........_--- ......... BY;Ci Y CY LIMITS LTR15L.. D TYPE OF INSURANCE POLICY NUMBER M IDDIYYYY MMID GENERAL LIABILITY EACH OCCURRENCE $_ 1,000,00_ A X '' COMMERCIAL GENERAL LIABILITY X PKV0001278 12120/2021 12/2012022 _ IAA T r(( I PRLMs�ES Ea oc+.xlGrr�Ilr�r $ 100,00 CLAIMS -MADE X OCCUR MED EXP (An one person) y $ 5,00 X Errors OmISSOn� PERSONAL&ADVI INJURY U 1,000,00 $...__... _R__ A.G. ,000,0_0_..0 ................. 'LIMIT GEN L AGGREGATE APPLIES PER ,E ...GNERAL COMP/OP AGG ...... _ $ 1000.000 ,,,4. X POLICY PRJF'fCam LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 Ea accident A ANY AUTO PKV0001278 12120/2021 12/20/2022 .'BODILY INJURY (Per person) $ ALL OWNED AUTOS ............... BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X � HIRED AUTOS (PERACCIDENT) ( X $ NON -OWNED AUTOS $ UMBRELLALIABX CL4IMSMADE EACHOCCURRENCE $ 1,000,00 EXCESS LIAB UMV0000337 12120/2021 12/20/2022 AGGREGATE $ m 1000,000 DEDUCTIBLE ,$ RETENTION $ $ WORKERS COMPENSATION II tNC S I`ATU� p 4B'1 I f AND EMPLOYERS' LIABILITY y 4 N ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED?"' F (Mandatory in NH) N/ A " DISEASE - EA EMPLOYEE -- ,... ........ $ ......... ,.... ..., If yes, describe under-- DESCRIPTION OF OPERATIONS below - E,L. DISEASE - OLICY LIMIT $ g 6612216-01 08/18/2021 08/18/20221Cyber 1,000,00 A JCyber Professional Liab PKV0001278 12120/2021 12120/2022 Occ/Agg 1/ OESCRIPTION OF OPERATIONS I LOCATIONS l VEHICLES (Attach ACORD 101, Additional Remarks Schedule„ it more space is required) CIt of El�egtl do is naed audditional insured with respects to the work by tte name nsure pe orme Investigations, CA -- ChK I R-H.;A I L HIL)LUI=11 k AN',r_LLA I IVIV SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. Liana Osborne 350 Main Street AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 (ti f © 1988-2009 ACORD CORPORATION. All ngnts reserves. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PKV0001278 COMMERCIAL GENERAL LIABILITY CIGL 79 03 18 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES O 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 Organization(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. (_) 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 # 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 workers' compensation provisions of Labor Code § 3700 1 must immediately comply with thos rr `si s o the agreement will automatically become void. Signature of Aprlicant Date Print Name Agreement for: Agreemnet No. 6062 Dated 5/3/21 Reviewed by: JL