PROOF OF INSURANCE (2023) CLOSEDA 10/27I2022 CERTIFICATE OF LIABILITY INSURANCE °ATE`MM/'
022
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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 endorsement(s).
PRODUCER CONTACT Jeff Hayashi
NAME:
Hayashi Insurance Solutions PHONE (831) 840-8131 FAX (831) 603-3211
AIC No zt ; A/ No
777
PO Box 1044 E-MAIL 1eff ha ashiinsurance.com
ADDRESS: @ Y
INSURERS AFFORDING COVERAGE NAIC #
Roswell GA 30077-1044 INSURERA: Twin City Fire Insurance Company 29459
INSURED INSURER B
Yaya Mazurkevich, Inc. INSURER C z
26 Kane PI INSURER D
INSURER E :
Brooklyn NY 11233 INSURER F :
COVERAGES CERTIFICATE NUMBER: CL2210602248 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.
IN'
LTR
TYPE OF INSURANCE
POLICYNUMBER
POLICYEFF
MMIDDIYYYY
POLICY
MM/DDIYYYY
LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
CLAIMS -MADE ❑X OCCUR
DAMAGE1,000,000
PREMISES Ea occurrence..
$
MED EX.P (Any one person)
$ 10,000
PERSONAL&ADV INJURY
$ 1,000,000
A
Y
02SBWAS7ZKF
06/02/2022
06/02/2023
G'EN'LAGGREGATE LIMITAPPLIES PER:
GENERALAGGREGATE
$ 2,000,000
POLICY JEC T LOC
JEC1.
PRODUCTS - COMPAOP AGG
$ 2,000,000
OTHER:
$
AUTOMOBILE LIABILITY
CC'dMBINED SINGI E L�IbA1T
'EA accldrsI0
$ 1,000,000
BODILY INJURY (Per person)
$
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per accident)
$
HIRED + NON -OWNED
AUTOS ONLY AUTOS ONLY
PROPERTY DAMAGE
Per accident
$
$
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
1 $
HCLAIMS-MADE
AGGREGATE
$
EXCESS LIAR
DED RETENTION $
I $
WORKERS COMPENSATION
OTH-
A
'.,ANDEMPLOYERTLIABILITY Y/N
'..ANY PROPRIETOR/PARTNER/EXECUTIVE
'.OFFICER/MEMBER EXCLUDED? Y___
'...(Mandatory in NH)
NIA
02WEGASBAHX
06/02/2022
06/02/2023
XI ER
STA UTE ER
E.EACH ACCIDENT
L,
$ 1,000,000
E.L. DISEASE- EA EMPLOYEE
$ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
A
Cyber/Data Breach
02SBWAS7ZKF
06/02/2022
06/02/2023
Ea. Claim
Aggregate
$500,000
$500,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
City of El Segundo shall be named as Additional Insured as respects General Liability only with respect to all work performed by the Named Insured under
written contract with the Certificate Holder.
City of El Segundo
City of El Segundo Recreation
401 Sheldon Street
ElSegundo
ACORD 25 (2016/03)
CANCELLATION
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
CA 90245
@ 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: 02SBWAS7ZKF
COMMERCIAL GENERAL LIABILITY
CG 20 12 07 98
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURE -
STATP OR POLITICAL SUBDIVISIONS - PERMITS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
State Or Political Subdivision:
City of El Segundo
City of El Segundo Recreation
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
Section II — Who Is An Insured is amended to
include as an insured any state or political subdivi-
sion shown in the Schedule, subject to the following
provisions:
1. This insurance applies only with respect to op-
erations performed by you or on your behalf for
which the state or political subdivision has issued
a permit.
2. This insurance does not apply to:
a. "Bodily injury," "property damage" or "per-
sonal and advertising injury" arising out of
operations performed for the state or munici-
pality; or
b. "Bodily injury" or "property damage" included
within the "products -completed operations
hazard".
CG 20 12 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 0