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PROOF OF INSURANCE (2024 - 2025) CLOSEDp DATE (MMIDD/YYYY) ,. CERTIFICATE OF LIABILITY INSURANCE r7A22 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 pollcy(ies) 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 Ileu of such endorsement(s). HAYS COMPANIES INC/OHS FmAmr PHONE(866) 467-8730 FAX 41716730 (A/C, A/C, No, Ext): I AIC, No): The Hartford Business Service Center E-MAIL 3600 Wiseman Blvd San Antonio, TX 78251 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURER A; Sentinel Insurance Company Ltd. 11000 HR DYNAMICS & PERFORAMANCE & MANAGEMENT INSURER B : 461 GREEN ORCHARD PL RIVERSIDE CA 92506-7590 INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBERa 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. INS TYPE OF INSURANCE ADDL SUBIR POLICY NUMBER POLICY EFF POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $2,000,000 CLAIMS-POADr: OCCUR DAMAGE TO RENTED $1,000,000' General Liability y MED EXP (Any one person) $10,000 A X 41 SBANN0763 01/09/2024 01/09/2025 PERSONAL & ADV INJURY $2.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 '. POLICY PRO- LOC JECT I u PRODUCTS - COMP/OP AGG $4,000,000 OTHER"^ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Me amweal) $2,000,000 ANY AUTO BODILY INJURY (Per person) .,,... A ALL OWNED SCHEDULED AUTOS AUTOS 41 SBA NN0763 01/09/2024 01/09/2025 BODILY INJURY (Per accident) X HIRED NON -OWNED X PROPERTY DAMAGE AUTOS AUTOS (Per accident) .... UMBRELLA UAB OCCUR. EACH OCCURRENCE EXCESS LIAR CLAIMS - MADE AGGREGATE ED RETENTION $�.... WORKERS COMPENSATION PER OT'H- AND EMPLOYERS' LIABILITY TATUTF�,, 8,,,,,, ANY Y/N PROPRIETOR/PARTNER/EXECUTIVE , E.L. EACH ACCIDENT OFFICER/MEMBER EXCLUDED? N/A E.L. DISEASE -EA EMPLOYEE (Mandatory In NH) If yes, describe under E.L. DISEASE -POLICY LIMIT DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS ILOCATIONSI 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. City o ,.._., .undo : ,., ... rYk�="A4 l mVfv f EI Seg SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 350 MAIN ST BEFORE THE OF 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 (2016/03) The ACORD name and logo are registered marks of ACORD HR Dynamics & Performance Management, Inc. 461 Green Orchard PI Riverside, CA 92506 POLICY CHANGES POLICY NUMBER POLICY CHANGES EFFECTIVE COMPANY N9PL832476 11/08/2023 National Liability & Fire Insurance Company NAMED INSURED PREMIUM CHANGE HR Dynamics & Performance Management, Inc. $0.00 Additional Insureds Added Name of Person or Organization Address: 350 Main Street City: El Segundo State: CA Zip: 90245 city search: CHANGES City of El Segundo Policy Forms Added Additional Insureds (MPL 00 24 11 15) MPL MTC 1218 Page 1 of 1 MISCELLANEOUS PROFESSIONAL LIABILITY MPL 00 24 11 15 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: Miscellaneous Professional Liability Insurance Policy SECTION V — DEFINITIONS, Section M. "Insured" of the policy is amended to add the following: The Additional Insured stated below, but only for liability arising solely out of Wrongful Acts in the performance of Insured Services by the Named Insured or the Individual Insureds: City of El Segundo It is also agreed the policy does not apply to any Claim which includes allegations or facts indicating actual or alleged independent or direct liability on the part of an Additional Insured. All other terms and conditions of this policy remain unchanged. MPL 00 2411 15 Page 1 of 1 BUSINESS LIABILITY COVERAGE FORM 2. Applicable To Medical Expenses Coverage We will not pay expenses for "bodily injury": a. Any Insured To any insured, except "volunteer workers". b. Hired Person To a person hired to do work for or on behalf of any insured or a tenant of any insured. c. Injury On Normally Occupied Premises To a person injured on that part of premises you own or rent that the person normally occupies. d. Workers' Compensation And Similar Laws To a person, whether or not an "employee" of any insured, if benefits for the "bodily injury" are payable or must be provided under a workers' compensation or disability benefits law or a similar law. e. Athletics Activities To a person injured while practicing, instructing or participating in any physical exercises or games, sports or athletic contests. f. Products -Completed Operations Hazard Included with the "products -completed operations hazard". g. Business Liability Exclusions Excluded under Business Liability Coverage. C. WHO IS AN INSURED I. If you are designated in the Declarations as: a. An individual, you and your spouse are insureds, but only with respect to the conduct of a business of which you are the sole owner. b. A partnership or joint venture, you are an insured. Your members, your partners, and their spouses are also insureds, but only with respect to the conduct of your business. c. A limited liability company, you are an insured. Your members are also insureds, but only with respect to the conduct of your business. Your managers are insureds, but only with respect to their duties as your managers. d. An organization other than a partnership, joint venture or limited liability company, you are an insured. Your "executive officers" and directors are insureds, but only with respect to their duties as your officers or directors. Your stockholders are also insureds, but only with respect to their liability as stockholders. e. A trust, you are an insured. Your trustees are also insureds, but only with respect to their duties as trustees. 2. Each of the following is also an insured: a. Employees And Volunteer Workers Your "volunteer workers" only while performing duties related to the conduct of your business, or your "employees", other than either your "executive officers" (if you are an organization other than a partnership, joint venture or limited liability company) or your managers (if you are a limited liability company), but only for acts within the scope of their employment by you or while performing duties related to the conduct of your business. However, none of these "employees" or "volunteer workers" are insureds for: (1) "Bodily injury" or "personal and advertising injury": (a) To you, to your partners or members (if you are a partnership or joint venture), to your members (if you are a limited liability company), or to a co -"employee" while in the course of his or her employment or performing duties related to the conduct of your business, or to your other "volunteer workers" while performing duties related to the conduct of your business; (b) To the spouse, child, parent, brother or sister of that co - "employee" or that "volunteer worker" as a consequence of Paragraph (1)(a) above; (c) For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in Paragraphs (1)(a) or (b) above; or (d) Arising out of his or her providing or failing to provide professional health care services. If you are not in the business of providing professional health care services, Paragraph (d) does not apply to any nurse, emergency medical technician or paramedic employed by you to provide such services. (2) "Property damage" to property: (a) Owned, occupied or used by, Page 10 of 24 Form SS 00 08 04 05 DATE (MM/DD/YYYY) AC"RO CERTIFICATE OF LIABILITY INSURANCE 11/07/2023 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 rr BIBERK 8ustomer......:e@bIBERK com I.Cxa/c N� 203 6 PHONE FAX .(AIQ,S�.Q Fnb)�� ....... 3 P.O. Box 113247 E-MAIL 54 361 Stamford, CT 06911 Art(Fr ss:.., ------ .._-_ --- National Liability & Fire Insurance Company 20052 INSURED INSURER B I HR Dynamics & Performance Management, Inc. m- ---- ---- -------- INSURER C 461 Green Orchard PI INSURER D Riverside, CA 92506 INSURERE: INSURER F : rnvDDAr_CQ ri=DTIFIr'ATG KIIIMRF:P- RFVISION 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. ... ........... tit?®Lv P ,........POLICY LIMITS" ILTR F� TYPE OF IN WM NUMBER------...._ MMiDQWYK� MM/DD/YY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ D MAG r K W E. ....... __ CLAIMS -MADE -� OCCUR PMISF,(Fa rren) ....-! $ ..........(A.. one person) $ PERSONAL & ADV INJURY $ ................ ......... GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO. � � LOC ECT _-_ PRODUCTS COMPIOP AGG ' $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY (Per person) 1 $ _-- ........ ....... OWNED SCHEDULED BODILY INJURY (Per accident $ AUTOS ONLY AUTOS . HIRED NON -OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY ac ode, P�r S no --,_ _ UMBRELLA LIAB OCCUR I EACH OCCURRENCE $ EXCESS LIAB L.ICLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION PER TIJTE�__.�ERHAND EMPLOYERS LIAILITY YIN ...,. ANYPROPRIIE70R/PARTBNER/EXECUTIVE ENT EL EACH ACCIID '$ . .......... IOFFICER/MEMBER EXCLUDED? ❑ NIA n----- (Mandatory in NH) E,L DIS EMPLOYEE -- -�� $ -- --- IIf yes, describe under DESCRIPTION OF OPERATIONS below E L. DISEASE - POLICY LIMIT $ Professional Liability (Errors & Per Occurrence/ $2,000,000/ A Omissions): Claims -Made N9PL832476 02/20/2023 02/20/2024 Aggregate $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) 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: L_) 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. (J 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 # )(i I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, 11 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 l must immediately comply with those provisions or the agreement will automatically become void„ °.,_ 1 Signature of Applicant` gate - Print Name Agreement for: I C S -f Dated: l(( -7 (1-3 0/'UEGeriJ,-",-f,u r- AJ Reviewed