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PROOF OF INSURANCE (2024) CLOSEDJOEMPOL-01 TCHAMPLIN �►co�ro,,, CERTIFICATE OF LIABILITY INSURANCE `.�•-- DATE(MM/DD/YYYY) 7/18/2023 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 CONTACT NAME: PHONE FAX (A/C, No, Ext): (866) 276-3775 (A/C, No): (866) 215-5018 PayneWest Insurance - TAG 14900 SW Barrows Rd, Ste 202 Beaverton, OR 97007 ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURERA:Scottsdale Insurance Company 41297 INSURED INSURER B : INSURER 7 Joe Mar Polygrah & Investigation Services Inc INSURERD: 12939 Banyon Rancho Cucamonga, CA 91739 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. 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,500,000 CLAIMS -MADE X OCCUR X X RBS0255461 7/29/2023 7/29/2024 DAMAGE TO RENTED PREMISES Ea occurrence 100 000 $ MED EXP (Any oneperson) $ 5,000 PERSONAL & ADV INJURY $ 1,500,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PELT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 $ OTHER: A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 $ BODILY INJURY Perperson) $ ANY AUTO RBS0255461 7/29/2023 7/29/2024 OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ X PROPERTY DAMAGE Per accident $ HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) N/A E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A Errors & Omissions X X RBS0255461 7/29/2023 7/29/2024 each claim 1,000,000 A Errors & Omissions X X RBS0255461 7/29/2023 7/29/2024 aggregate 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder is additional insured per attached GLS578 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo ty g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 348 Main St El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Underwritten by Scottsdale Insurance Company ENDORSEMENT NO. ATTACHED TO AND FORMING A PART OF ENDORSEMENT EFFECTIVE BATE NAMED INSURED AGENT NO. POLICY NUMBER (12:01 A.M. STANDARD TIME) RBS0255461 7/29/2023 Joe Mar Polygraph & Investigative Services Inc 46722 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED AND WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ERRORS AND OMISSIONS COVERAGE PART A. With respect to this endorsement, SECTION II —WHO IS AN INSURED is amended to include as an additional insured any person or organization whom you are required to add as an additional insured on this policy under a written contract, written agreement or written permit which must be: 1. Currently in effect or becoming effective during the term of the policy; and 2. Executed prior to the "bodily injury," "property damage," "personal and advertising injury" or "damages." B. The insurance provided to these additional insureds is limited as follows: 1. That person or organization is an additional insured only with respect to liability for "bodily injury," "property damage," "personal and advertising injury" or "damages" caused, in whole or in part, by: a. Your acts or omissions; or b. The acts or omissions of those acting on your behalf. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. 2. With respect to the insurance afforded to these additional insureds, the following exclusions are added to SECTION I —COVERAGES, paragraph 2. Exclusions: This insurance does not apply to "bodily injury," "property damage," "personal and advertising in- jury" or "damages" occurring after: a. 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 insureds) at the location of the covered operations has been completed; or b. 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. 3. The limits of insurance applicable to the additional insured are those specified in the written con- tract, written agreement or written permit or in the Declarations for this policy, whichever is less. Includes copyrighted material of ISO Properties, Inc I with its permission Copyright, ISO Properties, Ina, 2004 Na$avnwide" GLS-578-TAG (05-21) Page 1 of 2 0 - These limits of insurance are inclusive of, and not in addition to, the Limits of Insurance shown in the Declarations for this policy. 4. Coverage is not provided for "bodily injury," "property damage," "personal and advertising injury" or "damages" arising out of the sole negligence of the additional insured. 5. The insurance provided to the additional insured does not apply to "bodily injury," "property dam- age," "personal and advertising injury" or "damages" arising out of an architect's, engineer's or surveyor's rendering of or failure to render any professional services including: a. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, re- ports, surveys, field orders, change orders or drawings and specifications; and b. Supervisory, inspection, architectural or engineering activities. 6. Any coverage provided hereunder will be excess over any other valid and collectible insurance available to the additional insured whether primary, excess, contingent or on any other basis unless a written contract specifically requires that this insurance be primary. When this insurance is excess, we will have no duty under SECTION I —COVERAGES to defend the additional insured against any "suit" if any other insurer has a duty to defend the additional insured against that "suit." If no other insurer defends, we will undertake to do so, but we will be entitled to the additional insured's rights against all those other insurers. C. With respect to the insurance afforded to these additional insureds, the following is added to paragraph 8. Transfer Of Rights Of Recovery Against Others To Us Condition of the Commercial General Liability Coverage Form and Errors And Omissions Coverage Form: We waive any right of recovery we may have against an additional insured because of any payment we make under this Coverage Part, to whom the insured has waived its right of recovery. Such waiver by us applies only to the extent that the insured has waived its right of recovery against an additional insured prior to loss, but only with respect to liability for "bodily injury," "property damage," "personal and advertising injury" or "damages" 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. AUTHORIZED REPRESENTATIVE DATE Includes copyrighted material of ISO Properties, Inc I with its permission Copyright, ISO Properties, Ina, 2004 Na$avnwide" GLS-578-TAG (05-21) Page 2 of 2 0 - 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 ATTORNEYS FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: L—) I have and will maintain a certificate of consent ofself-insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work sat 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 Name of Agent Policy Number Expiration Date 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 )INorIrs' compensation provisions of Labor Code § 3700 1 must immediately comply with those 6 isions o,� �a ment."automatically become void. Date Signature of Applicant - 4 Agreement for: Dated: 04-13-2021 Digitally signed by Joseph Lillie DN: cn=Joseph Ullio, O=CitY of El Segundo, ou=Chief Financial officer, Reviewed by: Jose h Lillioemail=jlillio@elsegundo.org, c=US P 5:58 -07'00'