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PROOF OF INSURANCE (2023 - 2024) CLOSED
T 0 DATE(MMDDIYYYY) iC'40RO CERTIFICATE OF LIABILITY INSURANCE 04/10/2023 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 endorsement(s). PRODUCER NONE, IACT Julie R.ybak PHONE aIM E ('909) 792-8950 o N909) 792=2030 Kellogg & Moreland Agency, Inc. DBA ADDRESS: julier a.rrdyoins,com Arroyo Insurance Services INSURER(S) AFFORDING COVERAGE NAIC # 1654 Plum Lane INSURERA: Admiral Insurance Company Redlands CA 92374-4532 INSURED INSURER B : United Financial Casualty CO 11770 INSURER C : State Compensation Ins Fund 35076 California Street Lighting, A California Corp 3200 Guasti Road #100 INSURER D INSURER E r Ontario CA 91761 INSURERF: COVERAGES CERTIFICATE NUMBER: 22/23 GLAU UMB 23/24 REVISION NUMBER: THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOWMAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. Y EF (MW0OfYYYYI LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD X COMMERCIALGENERALLIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE Fx] OCCUR ENTED PREMISES Ea occurrence $ 300,000 MEDEXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 A CA00004375902 12/01/2022 12/01/2023 GEN'L,AGGREGATE LIMITAPPLIES PER: '.. GENERALAGGREGATE $ 2,000,000 POLICY 0JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 $ OTHER,, AUTOMOBILE LIABILITY COMBINEDStNGLEL9Mp%' C000 EARMida.na $ 1,000, BODILY INJURY (Per person) $ X ANYAUTO g OWNED SCHEDULED AUTOS ONLY AUTOS ''... 01957082-1 04/03/2023 10/03/2023 BODILY INJURY (Per accident) $ FROPER9Y DAWwR,AGE E a iden4 $ HIRED NON -OWNED AUTOS ONLY AUTOS AUTOS ONLY Medical payments $ 5,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 2,000,000 X AGGREGATE $ 2,000,000 A EXCESS LIAB CLAIMS -MADE GX00000496202 12/01/2022 12/01/2023 $ DED RETENTION $ O WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/ N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) NIA Y 9332967-23 02/08/2023 02/08/2024 X STATUTE ERH -E.L.EACH ACCIDENT $ 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 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Waiver of Subrogation applies to Workers Compensation Policy. City of El Segundo 350 Main Street ElSegundo CA 90245 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD HOME OFFICE SAN FRANCISCO ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME ENDORSEMENT AGREEMENT BROKER COPY WAIVER OF SUBROGATION BLANKET BASIS 9332967-23 NEW SP EFFECTIVE FEBRUARY 8, 2023 AT 12.01 A.M. PAGE 1 OF 1 AND EXPIRING FEBRUARY 8, 2024 AT 12.01 A.M. CALIFORNIA STREET LIGHTING 3200 GUASTI ROAD #100 ONTARIO, CA 91761 WE HAVE THE RIGHT TO RECOVER OUR PAYMENTS FROM ANYONE LIABLE FOR AN INJURY COVERED BY THIS POLICY. WE WILL NOT ENFORCE OUR RIGHT AGAINST THE PERSON OR ORGANIZATION NAMED IN THE SCHEDULE. THIS AGREEMENT APPLIES ONLY TO THE EXTENT THAT YOU PERFORM WORK UNDER A WRITTEN CONTRACT THAT REQUIRES YOU TO OBTAIN THIS AGREEMENT FROM US. THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 2.00% OF THE TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER JOB DESCRIPTION BLANKET WAIVER OF SUBROGATION NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: FEBRUARY 15, 2023 2572 e�wl.dTl-N�?R17ED 1EP�%ESFN I`�e"E PFi1=1I7FC+4lf AND CEO SCIF FORM 10217 (REV.7-2014) OLD DP 217