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PROOF OF INSURANCE (2023 - 2023) CLOSED'___*4 DATE (MM/DD/YYYY) ,� CERTIFICATE OF LIABILITY INSURANCE 06/24/2022 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 SUBROGATIONIS 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 'UU AU$ MCGRIFF INSURANCE SERVICES INC/PHS NAME: mmITITIT PHONE (86) 467-8730 FAX 22273438 (A/C, No, Ext): (A/C, No): The Hartford Business Service Center E-MAIL 3600 Wiseman Blvd San Antonio, TX 78251 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# .... INSURED ............................... INSURERA: Sentinel Insurance Company Ltd. 11000 TINA GALL INSURER B : 3945 HOLLYLINE AVE - INSURERC: SHERMAN OAKS CA 91423-4603 INSURER D ,. INSURER E : INSURER F 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. NOTWITHSTAN DING 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. INS ......_. TYPE OF INSURANCE _._. ADDL SUER..-___ POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR _ ,(NS;Rs,,,, VI(y,D MMID MMQP1 YYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $2,000,000 CLAMS-•MADE�OCCUR TO °� $1,000,000 PB�t5AMACE X General Liability MED EXP (Any one person) $10,000' A X 22 SBA LD8291 07/23/2022 07/23/2023 PERSONAL a ADV INJURY $2,000,000' GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000' POLICYPROLOC PRODUCTS - COMP/OP AGG $4,000,000 JECT L^ l OTHER: AUTOMOBILE LIABILITY ...-....... .............. ...............� COMBINEDISINGLE LIMIT $2,000,000(Ea acdden ANY AUTO BODILY INJURY (Per person) A ALL OWNED SCHEDULED 22 SBA LD8291 07/23/2022 07/23/2023 BODILY INJURY (Peracdclenl) AUTOS AUTOS HIRED NON -OWNED X X PROPERTY DAMAGE AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR . ....._.._...._..—_._._...----_. '----- ....._.__- EACH OCCURRENCE EXCESSLIAB CLAIMS- ........................................................................................................... AGGREGATE MADE ... .............. DE RETENTION $ Wl71iKEFCS COMPENSgTION PER DTH- OR AND EMPLOYERS' LIABILITY STATUTE ANY Y/N E,L EACH ACCIDENT PROPRIETOR/PARTNER/EXECUTIVE N/ A OFFICERIMEMBER EXCLUDED? E.L. DISEASE -EA EMPLOYEE (Mandatory in NH) - If yes, describe under E.L. DISEASE - POLICY LIMIT DESCRIPTION N F OPERATIONS bellow DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the Insured's Operations. City of El Segundo is named and endorsed as additional insured as respects to general liability as required by contract and per the Business Liability Coverage Form SS0008, attached to this policy. CERTIFICATE HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Attn: City Clerk & Planning Dept BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 350 MAIN ST IN ACCORDANCE WITH THE POLICY PROVISIONS. EL SEGUNDO CA 90245 REPRESENTATIVE /AUTHORIZED ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD THE HARTFORD BUSINESS SERVICE CENTER THE 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 City of El Segundo Attn: City Clerk & Planning Dept 350 MAIN ST EL SEGUNDO CA 90245 Account Information: Policy Holder Details : TINA GALL June 24, 2022 ED Contact Us Need Help? Start a live chat online or call us at (866) 467-8730. We're here weekdays from 8:00 AM to 8:00 PM ET. Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team WLTR005 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 07/25/2022 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 Hiscox Inc. d/b/a/ Hisoox Insurance Agency in CA 520 Madison Avenue 32nd Floor New York, New York 10022 INSURED Tina Gall 3945 Hollyline Avenue Sherman Oaks, CA 91423 202-3007 INSURERS AFFORDING COVERAGE Hiscox Insurance Comoanv Inc COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 10200 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. _._ _ UCY INSR TYPE OF INSURANCE DDT ,,, POLICY NUMBER MM01)( ..__ -MMIDp Ex LTR ....................... LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ F] CLAIMS -MADE OCCUR PREMI E§ Ea occurrence $ ..................... _.........,.,...................._...-..ww......_...�. MED EXP (Any one person) $ .............................. _ PERSONAL & ADV INJURY $ ''. GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY J T LOC PRODUCTS -COMP/OP AGG $ (YrHE.R:: $.... AUTOMOBILE LIABILITY MBINED SIN E LIMIT Ea aordent ...... $ ........................... ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Par acciden-9,_ UMBRELLA LIAB OCCUR .... EACH OCCURRENCE _ $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED I RETENTION $ $ WORKERS COMPENSATION IPER OTH TATI�Tl_ FR AND EMPLOYERS' LIABILITY Y / N .................� ANYPROPRIET�EXECUTIVE EREXCLUDED? N/A E.L. EACH .E....A..... .E.L. $ ..--.......- (Mandatory in E.T..P....L..O. YE D SEASE M E $ If yes, descnioe under DESCRIPTION OF OPERATIONS below E L DISEASE -POLICY LIMIT $ A Professional Liability Y P100.515.496.3 09/08/2022 09/08/2023 Each Claim: $ 1,000,000 Aggregate: $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION The City of El Segundo 350 Main St El Segundo, 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 ' „ r8 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) 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. (U 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 provisions or the agreement will automatically become void. Signature of Applicant Date June 1. 2023 Print Name Tina Gall, CDBG Consultant Agreement for: Dated: _. Reviewed by: