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PROOF OF INSURANCE (2024 - 2024) CLOSEDDATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE A+C y 09/25/2023 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(i es) 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 AHERN INSURANCE BROKERAGE LLC/PHS 72165838 CONIACr PHONE (866) 467-8730 FAX (A/c, No, Ext): (Alc, No): The Hartford Business Service Center 3600 Wiseman Blvd E-MAIL .......... San Antonio, TX 78251 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# ............ ............................ INSURED INSURER A: ................. m... Sentinel Insurance Copany Ltd. 11000 Debra L. Reilly, APLC DBA Reilly Workplace Investigations INSURERB: .......................... 2240 ENCINITAS BLVD STE D104 ...... -- ENCINITAS CA 92024-4345 INSURERC: 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.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 SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVDMMIDD/YYYX, MA„O/Y„YYY(i, COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $2,000,000 CLAIIr S-MAOE x IOCCUR DAMAGE TO RENTED $1,000,000 MI, ., I PREMISESE rr enr. X General Li,abift MED EXP (Any one person) $10,000 A X 72 SBW BB7398 011/22/2123 08/22/2024 PERSONAL 8 ADV INJURY $2,000,000 _.._. ................................ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 . POLICY PRO- [:X]LOC PRODUCTS - COMP/OP AGG $4,000,000 JECT OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT .........accI ANY AUTO IBODILY INJURY (Per person) ALL OWNED I SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) HIRED NON -OWNED PIOPEI27YC7AMAGE AUTOS AUTOS (Per accident) .............._. _...�... .._._ .......... ....... UMBRELLA LIAB ' OCCUR I EACH OCCURRENCE EXCESS LIAB CLAIMS- AGGREGATE MADE ..... ED RETENTION $ .......... .....__ �..�.._..._.._ ........._.__...I WORKERS COMPENSATION PER OTH-' AND EMPLOYERS' LIABILITY STATUTE R ANY YIN E1. EACH ACCIDENT PROPRIETOR/PARTNERIEXECUTIVE NIA •-•••••....•"""""""""""""-•-- OFFICER/MEMBER EXCLUDED? E.L. DISEASE -EA EMPLOYEE (Mandatory in NH) """ If yes, describe under E.L. DISEASE - POLICY LIMIT lE. RIPTION F P..RATIONS below I....._ ... .......... 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. Certificate holder is an additional insured 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 350 MAIN ST BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED EL SEGUNDO CA 90245 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) 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 350 MAIN ST EL SEGUNDO CA 90245 Account Information: Policy Holder Details ; Debra L. Reilly, APLC DBA Reilly Workplace Investigations September 25, 2023 Contact Us Need Help? Chat online or call us at (866) 467-8730. We're here Monday - Friday. 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 W LTRO05 REILMI7 (MMIDACORN: °° CERTIFICATE OF LIABILITY INSURANCE DATE 0416�22612 /Y023 3 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 PRODUCER 4444 CONTACT OUSe CCOU nt Rancho Santa Fe ?HONNe 58 756-4444 `A 85 56 PAX 8 �........... 8 Financial Services, Inc. �. N ----------- Ic P. O. Box 550 �1AIL No�. Rancho Santa Fe, CA 92067 p& ......................_.. __.- House AccountAkic ..........................................�nlu�,Elt(snw FORo�raG.ccwInG.:............................... INSURER A. :, Chubb Groy of Insurance C.o.................................__.......... 20281... INSURED Michael Reilly B INSURE _ Debra Reilly INSURER 3574 Lone lack Rd JJ Encinitas, CA 92024 INSURER D " 1 INSURER F : r"*uf"h1A'CbA.J`."C'e'. rC0T1C1f1A'rr. NJllaat^ 00. CYCttletnhi all 11i1MCM. 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, MAY EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN HAVE BEEN REDUCED BY PAID CLAIMS. mm..........w_.......... ....... INSR TYPE OF INSURANCE ADJNSDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR COMMERCIAL GENERAL LIABILITY E.? D. GIIR.RIl $....... CLAIMS -MADE OCCUR DAMAGE TO RENTED ......... ..,..... _PL�EMIFFc l �� $ MED EXP An one erson $ ...............y, PRNAI :..I& AOV.INJllk3Y�:..Y EN'LAB"+ REI"aATE.LIMITAPPLIESPER: GENERAL. AGGREGATE $. _....._. JECT PR POLICY LOC „PRO DUCTS -COMP IOP AGG -S_.,... OTHER: A „AUTOMOBILE LIABILITY COMBINEDSINGLET LIMIT 1,000,000 ....----...........,..,. X ANY AUTO 1435636903 05/24/2023 05124/2024QDnYIN)uR?',Per erson.­ Js.,,,,,,,,,,,,,,,,,,,,,,,,,,,,m, OWNED SCHEDULED ,_,......„ AIUTOS ONLY .... AUTOS 13,,QC,DILY IN,�,I,,�RY (Per acddgnt) m $ ..., .....,... .. _... Ipy�� �yy ALIT OS ALN"WO'S I' s d DAMAGE ONLY .""... NI.Y' e ..... ---------- _____________ UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB I ( CLAIMS -MADE -AGGREGATE..,".�..WWWW........�WWW.......�-- DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY PER OTH ...�— ..". • ^ ,,,,,,, T ANYOFFICER/MEMBERPR/EXCLUER/E ECUTIVE �L*Y°�II N 1 A E„.L.. EACH ACCIQEN , $ (Mandatory in NH)(�EE� E.L. DISEASE- EA EMPL.....YEE If es, describe under RIPTI N FOPERATIONS below EL.DISE8§E-P2JgYJJLAIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) THE CITY, ITS OFFICERS, OFFICIALS, EMPLOYEES, AND VOLUNTEERS 2020 Tesla Model 3 VIN 5YJ3E1 EASLF612030 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Debra L. Reilly, A ACCORDANCE WITH THE POLICY PROVISIONS. Professional Law Corporation 2240 Encinitas Blvd, Ste D-104 AUTHORIZED REPRESENTATIVE Encinitas, CA 92024-4345 ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD REILL-1 `� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) nR,nRin9 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 endorsementisl.. PRODUCER Ahern Insurance Brokera e 1615 Murray Canyon Rd to 1050 San Diego, CA 92106 Fake Denson r APLC dba Reilly Workplace Investigations INSURER e I Blvd, ate D 104 INSURER c 92024 -9030 son(warierninsfuranoe.aom Nat'l Liability & Fire Ins. Co COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: -9010 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 D CONDITIONS OF SUCH POLICIES, LIMITH WN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DDL UBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY ,EACH QCCURRENGE,,, CLAIMS OCCUR .._. __,.- DAMAGE TO RENTED �� -MADE ..PRE�1I�ES.LE� 4 n $ ... MED_ P (,And qgq persqn)— ......._.. .. .. M PE .. ., .._...RSONA,L B. AAV I N,JUrRX,....._ ...�.................................................................... ENrL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE_ $ POLICY � JECT LOC PRODUCTS COMP/OPAGG $ HER AUTOMOBILE LIABILITY COMBINED SINGLE U M IT ANY AUTO BODILV INJURY.Rersan..._.m� ......................................................................� OWNED SCHEDULED I AUTOS ONLY AUTOSL3y_ ONLY A �6H LY (RPEr AMAGE ......................... ..............2RES $ UMBRELLA LIAB OCCUR CH OCCURRENCE . „$,,. ..............DED... EXCESS LIAB CLAIMS -MADE ..RETENTION.$_............-............................ AGGREGATE is T........ WORKERS COMPENSATION PER I OTI, T1"' AND EMPLOYERS' LIABILITY Y / N "P'' _-" """'- ----- ANY PROPRIETOR/PARTNER/EXECUTIVE EXCLUDED? N I A E,L. EACH ACCIDENT I, _EL DISEASE - EA EMPLOYEE $ aa� n NER If Yes, describe under :DES R PTI IN F.. PERATI. NS below E L DI EA E - POLICY LIMIT A Claims Made Lawyer LP017940 66/2812023 06/28/2024 EACH 1,000,000 Prof Liab Ins AGGREGATE 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) DEDUCTIBLE4EACH CLAIM): $10,000 RETROACTIV DATE:11/15/2017 ELSEGUN City of El Segundo 350 Main Street 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 ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. 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 # Q�) 1 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 P2,�2.CL /— Date ;September 20, 2023 Print Name Debra L. Reill Agreement for: Dated; Reviewed by: