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PROOF OF INSURANCE (2024 - 2024) CLOSEDj" 6 �1 CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDDIYYYY) 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, subjecl 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 AUT' CLIENT CONTACT CENTER ANCE COMPANY FEDERATEHOME - mm n AC: flap. "ONE OFfDICEUP.O BOX 328TUAL �g Extl: BB8 333�949 507-046 4664 .................................................................... OWATONNA, MN 55060 E-MAIL AoaRess:CLIENTCONTACTCENTER�FE[]INS�.COM _ ....... INSURERS _AFFORDING COVERAGE _ ....__MP ... MAIC;y L I NC INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 30$-577-6M INS INSURER C: WATERLINE TECHNOLOGIES INC 620 N SANTIAGO ST 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 M. 90Y YF y N PO OY P Yi LIMITS EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY C9 NM'S•MADE "CUR DAMAGE TO RENTED PREMISES ..............................M ...... $10O 000 6.R&G11[Mna _.__ MED EXP (Any one person) EXCLUDED A Y N 0623485 08/15/2023 08/15/2024 PERSONA, A ADV lNJ41pY $1,000,000 GENT AD-CRET,AIE LSMIT APPLIES PER : PRODUCTS ISCOMPIOP AGO .. . $2,000,000 ............................... . �.. ( POLICY 1 tp LO,C ._. . lE'CT L....._J OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT lden.....................................�___. $1,000,000 ..�.. .. ............. X 'W�bY AUTO BODILY INJURY (Per Person) BODILY INJURY (Per Accidant) A JyYNoyD Al,iT .ONLY "GU uLED Y N 0623485 08/15/2023 08/15/2024 APRO Ear.Aa!ll DAMAGE dmDU HREDAUTCSONLY 14I TM& X IyryBREPLdV, LIAR U. '�+ OC16t E ACH OCCURRENCE .. ........... $101000 ,000 A EX 'S:ELhE C IdfiBIAAYE N N 0623486 08/15/2023 08/15/2024 AGOREGATE ............ .......................... ........................�......................... $10,000,000 � ....... .......... LIED RETENTION WORKERS COMPENSATION PER STATUTE bTHER AND EMPLOYERS' LIABILITY YIN _ Y PROPRIETORIPARTNERI EXECUTIVE E.L EACH ACCIDENT FFlCERIMEMBER EXCLUDED? N/A '..(Mendetery In NH) E-L DISEASE EA EMPLOYEE Iiyes, describe udder ....................._........... ...................................... !DESCRIPTION OF OPERATIONS below E.L DISEASE • POLICY LIMIT _ ... .............................. ,.............................�..�..� .-......_fl._...........................____.......,__..m,.................................... DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addidorizl Remarks Schedule, may be attached i1 more space is required) SEE ATTACHED PAGE CERTIFICATE HOLDER CANCELLATION CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO, CA 90245-3813 . . . . ..... .... ... . . -_ 217 0 1 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 O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 308-577-6 LOC #: ADDITIONAL REMARKS SCHEDULE Page 1 o1 1 AGENCY....................................._,........................................................................................... NAMED INSURED....�,.___.,.,.,.,.,�,.............�,�,_�,........... FEDERATED MUTUAL INSURANCE COMPANY WATERLINE TECHNOLOGIES INC ............................................................................................................................................................. 620 N SANTIAGO ST POLICY NUMBER SANTA ANA, CA 92701-3942 SEE CERTIFICATE #217.0 ------ - --- - ..._. _.... CARRIER NAIC CODE EFFECTIVE DATE: SEE CERTIFICATE # 277.0 SEE CERTIFICATE # 217.0 ­7 ADDITIONAL REMARKS ACORD 101 (2008101) 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 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or aniz�on(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 re wired 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. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury", This insurance does not apply to "bodily injury" or "property damage" or "personal and advertising "property damage" occurring after: injury" caused, in whole or in part, by: 1. All work, including materials, parts or 1. Your acts or omissions; or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the location of the covered operations has been the additional insured(s) at the location(s) completed; or designated above. However: 2. That portion of "your work" out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured principal as a part of the same project. 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. © 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. _._._. ....... ._ ....... .............r Named Insured: Waterline Technologies Inc Endorsement Effective: 08/15/2023 SCHEDULE Name of Person(s) Or City of El Segundo 350 Main St El Segundo, CA 90245 Information required to complete this Schedule, if not shown 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.I. 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. will be shown in the Declarations. 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 NONCONTRIBLITO Y - 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 C" CERTIFICATE OF LIABILITY INSURANCE DIDD/YYYY) 06/10/210/2022 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 Newfront Insurance Services, LLC PHONE Ext, (415) 754-3635.... ... D. 450 Sansome Street E MALL @ ADDRESS: P is isabel.ta newfront.com Suite 300 INSURER(S) AFFORDING COVERAGE ............ ................ ............NAIC#. ....._ Francesco CA 94111 INSURER Service American Indemnity CO...............................................-39152....._........- San .... m .ry .._.. „ , INSURED INSURER B Waterline Technologies Inc. 620 N Santiago St Santa Ana CA 92701 INSURER C c INSURER D INSURER E :. COVERAGES CERTIFICATE NUMRFR- RFVISION NIIMRFR- 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. ILN.T -- .. .....,..M.... ....... AD OL S OR EFF POLICY TYPE OF INSURANCE POLICY NUMBER.. MM ICY � INSD LIMITS EXP COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 71 CLAIMS -MADE OCCURtYi1C'viX�G'TiiFti RMISESma ouaenrel $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ G.EN`LAGGREGATE LIMIT APPLIES PER: GEN•-- -` ERALAGGREGAT PRO- ,...... ...,. POLICY JECT LOC AGG mmPRODUCTS COMPIO�,�... $... OTHER; $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ .�.-... E,a ag*o . .,.,,,.._.. .............. ....... ANY AUTO BODILY INJURY (Per person) $ ALL OWNED ....- SCHEDULED BODILY INJURY (Per accident) $ ............................................. ............... AUTOS AUTOS NON -OWNED PROPERTYmDAMAGE $ HIRED AUTOS _....._.. AUTOS „Per arc�d?�.. .. ... .................. ....... . UMBRELLA LIAB OCCUR ........ _.....- EACH OCCURRENCE ....,�,.m.. m„e,.,.,.,... $ ,......__ .. .....n...,.. EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED - RETENTION $ $ WORKERS COMPENSATION PER OTH- x AND EMPLOYERS' LIABILITY YIN STATUTE ER _ E.L. EACH ACCIDENT $ 1,000,000 A ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? N/A X SAMTWC0031502 07/01/2023 07/01/2024 E.L, DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory In NH) If yes, describe under 1,000,000 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) Waiver of subrogation applies in favor of City of El Segundo with respect to Workers Compensation. Ut:KI'...tl"lk AIC, MULULK I:ANL;LLLAIIUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 350 Main St /",/ ElSegundo CA 90245 y" ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) 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 . 02 0 % of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Blanket Waiver of Subrogation as required by written contract 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 02 3 Policy No. SAMTWC 0 0 315 0 2 Endorsement No. Policy Effective Date: 07/01/2023 to 07/01/2024 Premium $ Insured: Waterline Technologies, Inc D BA: Carrier Name / Code: Service American Indemnity Company (Method) Countersigned by ...* WC040306 (Ed. 4-84) Page 1 of 1