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PROOF OF INSURANCE (2023 - 2024) CLOSEDA/-�"�sr'�aiKJY P L 4�FlY CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDNYYY) 1 07/18/2023 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 NAME CT CLIENT CONTACT CENTER FEDERATED MUTUAL INSURANCE COMPANY HOME OFFICE: P.O. BOX 328 A CNNo, Ext): 888-333-4949 INC, No): 507-446-4664 ADORIESS:CLIENTCONTACTCENTER FEDINS.COM OWATONNA, MN 55060 INSURERS AFFORDING COVERAGE NAIC # INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 308-577-6 INSURER B: WATERLINE TECHNOLOGIES INC 620 N SANTIAGO ST INSURER C: — SANTA ANA, CA 92701-3942 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 217 REVISION NUMBER: 0 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF YI (MPM'/LD'CY EXPYY1 LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR Y N 0623485 08/15/2023 08/15/2024 EACH OCCURRENCE $1,000,000 DAMAGE ToccurreO RENTED PREMISES $100,000 MED EXP (Any one person) EXCLUDED GEN'L X PERSONAL& ADV INJURY $1,000,000 AGGREGATE LIMIT APPLIES PER: POLICY PECT LOC OTHER: GENERAL AGGREGATE $2,000,000 PRODUCTS & COMP/OP AGG $2,000,000 AOWNED AUTOMOBILE LIABILITY JANYAUTO AUTOS ONLY gCHESULED HIREDAUTOS ONLY NON -OWNED AUTOS ONLY Y IN0623485 08/15/2023 08/15/2024 COMBINED SINGLE LIMIT Ea accident $1,000,000 BODILY INJURY (Per Person) BODILY INJURY (Per Accident) PROPERTY DAMAGE A X UMBRELLA LIAB EXCESSLIAB X OCCUR CLAIMS -MADE IN IN0623486 08/15/2023 08/15/2024 EACH OCCURRENCE $10,000,000 AGGREGATE $10,000,000 DED RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNERI EXECUTIVE OFFICER/MEMBER EXCLUDED? L (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A PER STATUTE OTHER E.L EACH ACCIDENT E.L DISEASE EA EMPLOYEE E.L DISEASE POLICY LIMIT DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) SEE ATTACHED PAGE CERTIFICATE HOLDER CANCELLATION 308-577-6 CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO, CA 90245-3813 217 0 I 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 kJ-L © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 308-577-6 LOC #: ADDITIONAL REMARKS SCHEDULE Page 1 of AGENCY NAMEDINSURED FEDERATED MUTUAL INSURANCE COMPANY WATERLINE TECHNOLOGIES INC 620 N SANTIAGO ST SANTA ANA, CA 92701-3942 POLICY NUMBER SEE CERTIFICATE # 217.0 CARRIER NAIC CODE EFFECTIVE DATE: SEE CERTIFICATE # 217.0 SEE CERTIFICATE # 217.0 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE ALL OPERATIONS TO VARIOUS LOCATIONS IN CA. CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSURED UNDER THE GENERAL LIABILITY ON A PRIMARY AND NON-CONTRIBUTORY BASIS. THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED ON GENERAL LIABILITY SUBJECT TO THE CONDITIONS OF THE ADDITIONAL INSURED - OWNERS, LESSEES, OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION ENDORSEMENT. THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED ON BUSINESS AUTO LIABILITY. ACORD 101 (2008/01) O 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 0623485 COMMERCIAL GENERAL LIABILITY CG 20 10 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR 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 City of El Segundo Any Coverage Provided by This Endorsement 350 Main St Applies Only With Respect to Named Insured's El Segundo, CA 90245 Delivery of Products to Certificate Holder. Additional Insureds Also Include: City of El Segundo, its Officers, Officials, Employees and Volunteers. 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 B. include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance 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. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. © Insurance Services Office, Inc., 2018 Page 1 of 2 CG 20 10 12 19 Policy Number: 0623485 Transaction Effective Date: 08/15/2023 C. 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 Insured: Waterline Technologies Inc 620 N Santiago St Santa Ana, CA 92701-3942 2. Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. Page 2 of 2 © Insurance Services Office, Inc., 2018 CG 20 10 12 19 Policy Number: 0623485 Transaction Effective Date: 08/15/2023 POLICY NUMBER: 0623485 COMMERCIAL AUTO CA20481013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Auto Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Waterline Technologies Inc Endorsement Effective: 08/15/2023 SCHEDULE Name of Person(s) Or Organization(s): City of El Segundo 350 Main St El Segundo, CA 90245 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1 COMMERCIAL GENERAL LIABILITY CG 20 01 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. © Insurance Services Office, Inc., 2018 Page 1 of 1 CG 20 01 12 19 Policy Number: 0623485 Transaction Effective Date: 08/15/2023 DATE (MMIDDNYYY) A� L CERTIFICATE OF LIABILITY INSURANCE 06/10/2022 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 endorsement(s). PRODUCER CONTACT Isabel Tapia NAME: P 41..... — Newfront Insurance Services, LLC PHONE ( 5) 754-3635 1 FAX —C t . ftq.,wtt)M 450 Sansome Street E-MAIL isabei,tapia@new(ront.com INSURER...........................................--------- ------ -- Suite 300 S AFFORDINGCOVERAGE NAIC# San Francisco ranclsco .... CA 94111 INSURERA Ser vice American Indemnity Co 9152 _ ....................... INSURED Waterline Technologies Inc. INSURER C : INSURER D : 620 N Santiago St INSURER E:................................................................................................�.�.. Santa Ana CA 92701 ��W�.....,.,.,..a 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. 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, INSR ADOL ut.V'&tili POLICY EFF 'POLICY EXP TR TYPE OF INSURANCE INSD WD POLICY NUMBER (MMIDPNYYY MMIDO. LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ I CLAIMS -MADE OCCUR MI SlEaooccurrence ...._.� --........................................--....... MRE on).-..- Y....._$........_..._-...................................... GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 1:1 POLICY PRO, LOC ,PRODUCTS, :.COMP/OP AGG...................................................- OTHER: $ AUTOMOBILE LIABILITY ( I7 $ ANY AUTO ^BODILY INJURY (Per pers( $ .. ALL OWNED SCHEDULED BODILY INJURY $ AUTOS AUTOS (Per accident) NON -OWNED ROPERTY'DAMAGE $ HIRED AUTOS ._ _.....'..... AUTOS ,,-QPew zaccirJm ......... .... .$... ......,.,... ......... UMBRELLA LIAB EACH OCCURRENCE $ $ .._ _.....__ .,.... .......... ......., ..........HOCCUR EXCESS LIAB CLAIMS -MADE ......... .....,.... AGGREGATE ..............-----.-............... DED ! D RETENTION $ $ WORKERS COMPENSATION x STATUTE ER � [[ AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE '/'N� .i ER ,.,E.L.ACH ACCIDENT _____ __ 1,000,000 A IOFFICERIMEMBEREXCLUDED? N/A$ X SAMTWC0031502 O7/O1/2022 O7/O1/2023 $ 1,000,000 '',,(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE If yes, describe under DESCRIPTION OF OPERATIONS below ................................— E.L. DISEASE - POLICY LIMIT . . S 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Waiver of subrogation applies in favor of City of El Segundo with respect to Workers Compensation. City of El Segundo 350 Main St 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 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT— CALIFORNIA 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 per- form work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 0 . 020% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Blanket Waiver of Subrogation as required by writtencontract Job Description Contract This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Date: 0 7 / 01 / 2 0 2 2 Policy No. SAMTWC0 0 315 02 Endorsement No. Policy Effective Date: 07/01/2022 to 07/01/2023 Premium $ Insured: Waterline Technologies, Inc DBA: Carrier Name / Code: Service American Indemnity Company (Method) WC 04 03 06 (Ed. 4-84) Countersigned by Page 1 of 1