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PROOF OF INSURANCE (2024) CLOSEDDATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 6/21 /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 GouldEdg-. P.O. Box Hers Ins. Center E a70 FAX Nro 70„ 364-97 my ANQNq_ 2-364-4727 C 2- 27w Pearl River NY 10965 ADDARIESS: Tarrimy Gould( epicbrokers com RAGE AIC # „AFFORD e1WI ..1 .. I a,del hla llndemnl Insurance CO 8058 Dom. INSURE ALLILIM INSURERINSURER B Alliance I_ImOUSlnemml Inc ...��.. 15934 Arminta St INSURER C : ................................................. Van Nuys CA 91406 JNSURERD „ INSURER E ........... �. ,...... ...................... ......... ... _ INSURER F : COVERAGES CERTIFICATE NUMBER: 1470160108 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. ............ .. ........ _ yy --- —---------..... ......... ......... AOL1L 5'YHR�,........... EXP INS.ftLL... .. .....TYPE P"RDCiYJYYY LTR OF INSURANCE POLICY NUMBER.... Y^ jY LIMITS A X COMMERCIAL GENERAL LIABILITY PHPK2538490 4/8/2023 4/8/2024 EACH OCCURRENCE ff $1,000,000 i5AM7�D�� i� r�ERiE CLAIMS -MADE X OCCUR PREMISES LEa occurrenrp $ 100 000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY _ $ 1 000 000 ....... ................. ....— ...................... ....... ....-- - .. ..,.. ,..,.,. GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 POLICY PRO _X... LOC ❑ JECT CAI PRODUCTS COMP/OP AGG $ 2 000,000 OTHER, t $ A AUTOMOBILELIABILITY PHPK2538490 4/8/2023 4/8/2024 COM13INinD SINOIIE LIMIT _t s aQP49rl ........ $ 1,500,000 .... ANY AUTO BODILY INJURY (Per person) $ OWNED X SCHEDULED BODILY INJURY $ AUTOS ONLY , AUTOS (Per acGdent) HIRED NON -OWNED,. " f CFAMA AUTOS ONLY AUUTOS ONL e eY Is .. .... .... UMBRELLA LIAR EACH OCCURRENCE $ ......-[:CCUR ....„ EXCESS LIAB AIMS -MADE . . AGGREGATE.......... .... ....... ...... -- ..,,,,,,,.,_ ------- .......................................... DED RETENTION $ �.... $ WORKERS COMPENSATION PER OTH- �ER AND EMPLOYERS' LIABILITY Y / N STA TUTE ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? NIA E AC H ACCIDENT -$ (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under --- --- DESCRIPTION OF OPERATIONS below E.L. DISEASE.- POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The certificate holder is listed as additionally insured. CERTIFICATE HOLDER 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. City of El Segundo 250 Main St. AUTHORIZED REPRESENTATIVE El Segundo CA 90245 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: WFCOL0000000103-03 COMMERCIAL GENERAL LIABILITY CG 20 26 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): The City of El Segundo, its officers, officials, employees, agents, 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 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 your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. 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. B. 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 2. Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. CG 20 26 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 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: 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 Not'. j () '2 (,www 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 I 4"S,Policy Number Expiration Date )2 101 12 02 3 Name of Agent M 0 411 s"Jt� 'FV (-Phone # � u � Li 9 c 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 i g ro�aon oor the agreement will automatically become void. f Signature of Applicant those, Date Print Name Agreement for: Dated: Reviewed by: