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PROOF OF INSURANCE (2022 - 2023) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDNYYY) 12/22/2021 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 endorsement(s). PRODUCER CONTACT NAME.: Hiscox Inc. d/b/a/ Hiscox Insurance Agency In CA PHONE Tad .. .8. ) FAX N,P ( t... . 520 Madison Avenue 888 202-3007 EMAIL c�lntact Wscox,corn 32nd Floor ADDRr:=;s .. ...... New York, New York10022 INSURERI�AFFORDINGCOVERAGE NAIC# 1PJQ1MFQ A • Hiscox Insurance Comoanv Inc ...................... ��__ 10200 INSURED KNB Consulting LLC 1142 S Holt Ave 3 Los Angeles, CA 90035 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, INTSRR ADaIg W -1C- TYPE OF INSURANCE Y]'YF- MMOLIGY POLICY NUMBER MO L009YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 %� RENTED 100,000 CLAIMS -MADE - OCCUR -PREMISEDAMACff'TO Ea occ1JrreMe) $ MED EXP (Any one person $ 5,000 PERSONAL BADVINJURY $ 2,000,000 A _ P100.087.007.2 02/05/2022 02/05/2023 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 �. f PRO.•, POLICY l JEOT LOC X PRODUCTS - COMP/OP AGG $ S/T Gen. ,. $ OTHER, AUTOMOBILE LIABILITY COMBINED SWGV E L..IMIT T Ca ac6denl $ BODILY INJURY (Per person) _ mw....... $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS ............. ..,......'.. NON -OWNED '1c'YOAh1Ai"aC.. $ HIREDAUTOS .. ....i AUTOS (Pot. ...tPee a�.wwdi797 ....... ...... $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ -,. .. � ... ... ..-........... $... ........................... DED... RETENTION$ WORKERS COMPENSATION IPER AND EMPLOYERS' LIABILITY Y / N .-......l...TATE........... _H-.... .................................._ O ICERIMEMB REXCLU ED?ECUTIVE ❑ NIA ...E�.La..DISEASE- ............................................. ...$ ............................... ( Mandatory in NH) EA EMPLOYEE yes, describe under ....:..............................................................._................. DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) r r-PTIPIPATG writ nr-P CANr"-Fl I ATInN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE -, .. F1� U 19SS-2U15 AGURD GURPURATIUN. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD CA H .JCOX Policy Number: Named Insured: Endorsement Number: Endorsement Effective: P 100.087.007.2 KNB Consulting LLC 19 02/05/2022 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGES This endorsement will not be used to decrease coverage, increase rates or deductibles or alter any terms or con- ditions of coverage unless at the sole request of the insured. The following item(s): ❑ Insured's Name ❑ Insured's Mailing Address ❑ Policy Number ❑Company ❑ Effective/Expiration Date ❑ Insured's Legal Status/Business of Insured ❑'' ❑ Payment Plan Additional Interested Parties ❑ ❑ Premium Determination Coverage Forms and Endorsements ®, ❑' Limits/Exposures i Covered Property/Located Description ❑ ❑ Deductibles Classification/Class Codes ❑ Rates ❑ Underlying Insurance is (are) changed to read (See Additional Page(s)): The above amendments result in a change in the premium as follows: I@ NO CHANGES ❑ TO BE ADJUSTED ADDITIONAL PREMIUM RETURN PREMIUM AT AUDIT $ $ CGL E5410 CW (03/10) Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 2 ❑ with its permission. POLICY CHANGES ENDORSEMENT DESCRIPTION All other terms and conditions remain unchanged. CGL E5410 CW (03/10) Includes copyrighted material of Insurance Services Office, Inc., Page 2 of 2 with its permission. For Roadside Assistance: 800-531 -8555 Report a claim, get coverage and deductible information, request a tow from the accident scene, schedule an appraisal or reserve a rental car using: . usaa.com, USAA's Mobile App, or By calling 210-531-USAA (8722), our mobile phone shortcut number #8722 or 800-531 -USAA. California Evidence of Financial Responsibility This ID card is evidence of liability insurance for your vehicle. The card is valid only as long as liability insurance remains in force. Keep a copy of the ID card in your vehicle at all times. You may be required to produce your identification card at vehicle registration or inspection, when applying for a driver's license, following an accident, or upon a law enforcement officer's request. FCA1 Rem.6-13 CALIFORNIA EVIDENCE OF FINANCIAL RESPONSIBILITY Name and Address of Insured NAIC 25968 KRISTEN BERGEVIN 1142 S HOLT AVE APT 3 LOS ANGELES CA 90035-2423 f 0 1 d KRISTEN BERGEVIN Insurance Company USAA CASUALTY INSURANCE COMPANY Policy Number Effective Date Expiration Date 00748 27 03C 7101 1 1 06/01 /22 12/01 /22 cle Make/Vehic This policy provides at least the minimum amounts of liability insurance required by the CA VEH CODE SECTION 16056 for the specified vehicle and named insureds and may provide coverage for other persons and other vehicles as provided by the insurance policy. 50781 -051302 -----------------, -- -- _----- ----,.----...------------- California Evidence of Financial Responsibility Keep this card. IMPORTANT: The California Financial Responsibility Act (Section 16020) of the Vehicle Code requires every owner or operator of a vehicle subject to the requirements of the Financial Responsibility Act to carry evidence of financial responsibility in the vehicle at all times. Under vehicle code (Section 16028) every driver involved in an accident must provide evidence of financial responsibility at the scene. Failure to comply is an infraction and shall be punishable by fines, impoundment or license suspension. Additional copies available at usaa.com CONTACT US: 210-531-USAA(8722) OR 800-531-USAA 9800 Fredericksburg Road, San Antonio, Texas 78288 C CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDNYYY) 12/22/2021 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 endorsement(s). PRODUCER CONTACT NAME.. _ _.............. ._._.__ ..... Hiscox Inc. d/b/a/ Hiscox Insurance Agency in CA PHONE' FAX (888) 202 3007 plC_o 520 Madison AvenueJ" .......____ 32ndFloor ADDR SS: contacterhlscox.com New York, New York 10022 ,,,,,,,,,,,,,,,,,,... INSURER(S) AFFORDING COVERAGE NAIC # INSURER A. Hiscox Insurance Company Inc 10200 INSURED KNB Consulting LLC 1142 S Holt Ave 3 Los Angeles, CA 90035 r_nvPPAnFc rFRTIFICATF NI1fa Rr—R• 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. INSI2-.......... ..._._. ADOUStN _.. POLICY EFF POLICY E'SC...-_-..... ----------------------- ----- LTR, TYPE OF INSURANCE POLICY NUMBER tMMiODMYM (MMIDD.NYYY)LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE E] OCCUR PRLMIS,ES„,(La erccu(reeronge,) ..... $ .___ ......................................... _._. MED EXP (Any one person) ......................................................................... $ ..GE. .. PERSONAL & ADV INJURY $ I.. AGGREfaA1 F LI........_ MIT APPLIES PER: GENERAL AGGREGATE $ r'IRO- POLICY J P LOC ....--------------------------------- -- PRODUCTS - COMP/OP AGG .................................... .............._... -------. ......... $ OTHER. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMP „IEa arcrdanl ................ $ ANY AUTO BODILY INJURY (Per person) $ WWWWWunm,mmmmmmmmmmmm ALL OWNED! SCHEDULED ''...... BODILY INJURY (Per accident) $ ,........ , AUTOS 'AUTOS NON -OWNED mm( ROI C=R'IY &lAluIAOE $ .................... '..... HIRED AUTOS AUTOS ,Per accrd!M-.......-.__.... ... ... OCCUR UMBRELLALIABI_J, EACHOCCURRENCE $ SS LIAB EXCESS CLAIMS -MADE ... AGGREGATE _. . ............. _._ _ $ ...... ........� ..... DED -RETENTION $ $ WORKERS COMPENSATION PER c OTH- STATUTEJI ER. AND EMPLOYERS' LIABILITY y / N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA .--.-._.............. ___.......... _--- (Mandatory In NH) E.L. DISEASE -EA EMPLOYEE $ -... If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ A Professional Liability P100.085.370.2 02/05/2022 02/05/2023 Each Claim: $ 1,000.000 Aggregate: $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD101, Additional Remarks Schedule, may be attached if more space is required) PCOTICWf ATC Yni r1C0 rANrFi I ATInN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE V lyt$U-LUIb AL;UKU t:UKMUKAI IUN. All rignis reserveu. 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 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 # (.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 workers, compensation provisions of Labor Code § 3700 1 must immediately comply with those proves o or(AeEgreement automatically become void.. Signature of Applicant Date 2i8i2021 Kristen Bergevin Print Name Agreement for: Dated: �--• "� . Reviewed by: