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PROOF OF INSURANCE (2023 - 2024) CLOSED"^ DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 111812022 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: Lin D Diaz D&C Insurance Solutions IAIC. Nagle 323.576. ................ HON �Ir, 888.457.4426 FAX 4552 300 S. Atlantic Blvd., Ste 201-B Monterey Park CA 91754 INSURED Tillmann Forensic Investigations, LLC. A: Western World Insurance INSURER D PO Box 4373 1 INSURER E Covina CA 91723 INSURER F COVERAGES CFRTIFICATF Nt1MRFR- RFVICIAN NIIIMRFR- NAIC # 13196 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. a4,'1'L S.JB'Ft. ..... POLICY EFF POLICY EXP.�___......... LTR TYPE OF INSURANCE POLIC....... .. ......-......,. POLICYNUMBER MM DD MM DD Y LIMITS IX !�. COMMERCIAL GENERAL LIABILITY A NPP8920372 112/17/2022 12/17/2023 EACH OCCURRENCE '$ 1,000,000 _. �/.... ETO-�-�`NST _bAMAPREMISES ...— . CLAIMS -MADE �/� OCCUR jEa occurtence) $ 100,000 MED EXP (And one person) $ 5 000 .....,...,......... "1 .......................... PERSONAL & ADV INJURY _.-............•.. $ 1,000,000 GEN'L.�.... AGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE 2,000,000 $ X POLICY ❑ PRC` ❑ JLCT Loc . GG....� $ Included . .... OTHER: En-orso& Omissions $ Included AUTOMOBILE COMBINED SINGLE 'LIMIT $ _4E}s alnl) '.._._.. ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED B BODILY INJURY (Peraccident) $ ,.�... AUTOS ONLY AUTOS _.. HIRED NON -OWNED E $ „ AUTOS ONLY AUTOS ONLY ......... .,tP dGnDAM4AG.. $ UMBRELLA LIAB OCCUR EACH OCCURRENCE - -$ $ EXCESS LIAB CLAIMS -MADE AGGREGATE DED RETENTION $ $ WORKERS COMPENSATION j PER OTH- AND EMPLOYERS' LIABILITY Y f N STATUTE ERmm ANYPROPRI ETOR/PARTNER/EXECUTIVE E.L. EACH OFFICE I OFFICERIMEMBEREXCLUDED� BE � IN/A' E L DISEASE �IEA EMPLOYEE $ m (Mandatory ) If yes, describe under ...... .... ....... ...... ..."...... DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may beattached if more space is required) Regarding the above referenced General Liability Insurance policy, the certificate holder is included as additional insured, but only with respect to the negligent acts, errors or omissions of the named insured.. lh3:iIIaLhXt;v;Lei Ill NJaC� City of El Segundo 348 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 Lin Dau Diaz ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: NPP8920372 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 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 Various Locations 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: 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. B. 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. CG 20 10 04 13 Copyright, Insurance Services Office, Inc., 2012 Page 1 of 2 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 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Page 2 of 2 Copyright, Insurance Services Office, Inc., 2012 CG 20 10 04 13 o S frii':? te Fia", rrn I Oli�VER Oiflf��OiUWIJIOIlq Assigned Driver(s) The following driver(s) are assigned to the vehicle(s) on this policy, Driving Experience as of Marital Name setkonbet 29,, 2023 Status STEVE TILLMANN Di? Principal Driver& Assigned Drivers premium may be influenced by the information shown for For each automobile, the Principal Driver is the individual these drivers. who most frequently drives it Each delver us designated as an Assigned Driver on the hou,%hM automobile that they most frequently drive. Your COV,'::RAGE AND LINUTS See your poky for an expienatfon of These coverages. A LaWfty . . ....... .... Bodily, Inj 100,0001300,000 — - - ----- - 42 Property Damage 100,000 . $237 . ..... $1034 C Medical Payments 5,000 It any coverage you carry is changed to glee broader plotecNin with no addibonal prerniurn charge, we will give [,°Il ";iiuCC hP"14" a^o These adjustments have afready been applied to your premium. Multiple Line Multicar Vehicle Safety Driving Safety Record you the broader protection without issuing a new policy, starting on the date we adopt the broader protec;liun, California Good Driver Loyalty 17,091.611 Total Discounts Policy Number7513 Page number 3 of 5 Prepared August B. 2023 0353W """°'"��:"%��lldu+�'m�ru°z✓._.-r�.w,(.�,r,. w.as,..mn. u��v»»VPu9�;,",."'^„,.,..,�;._._�,w��.�...�� StateFaWrtirt CALIFORNIA INSURANCE CARD State Farm Mutiva!l Automobile Insurance Company • Box 2358 Bloomington IL 6 02-2358 INSURED TILLMANN, 101 R 9 JEEP I' 1' wry o � w r a� v. g ' L 1 PHONE (62%974-55'77 NAIC 25178 COVEVAGE 'V'IDEID BY THE .O 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 insuranceas 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 # 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 s b'ect to the workers' compensation provisions of Labor Code § 3'700 I must immediately comply with those pr ions o e agreement will automatically become void.. Signature of Applicant bate Agreement for: W.-k('3� Dated:—� q Z Z Reviewed by: 4C.-