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PROOF OF INSURANCE (2024 - 2024)CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 10/09/2023 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 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 CONTACT AUTO CLUB INSURANCE AGENCY LLC/PHS NAME: 72253682 PHONE (866) 467-8730 FAx (A/C, No, Ext): (A/C, No): The Hartford Business Service Center 3600 Wiseman Blvd a -MAIL San Antonio, TX 78251 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURERA: Sentinel Insurance Company Ltd. 11000 David Ebeling INSURER B 3456 LOTUS ST INSURER C : IRVINE CA 92606-2117 - INSURER D INSURER E ,, INSURER F !`AVFRAPFC f_FRTIFIrATF NIIMRFR• 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 INS MMIDDNYYY...... IMMIPPLY Y)00— COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $2,000,000 CLAIMS -MADE �OC'CUR DAMAGE TORENTED PREMISES r .trr $1,000,000 X General Liability MED EXP (Any one person) $10,000 A X 72SBMBC9401 11/07/2023 11/07/2024 PERSON AL aADVINJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY ❑PRO• LOC J'ECT PRODUCTS - COMP/OP AGG $4,000,000 OTHER: AUTOMOBILE LIABILITY _ COMBINED SINGLE LIMIT accident)fEl ANY AUTO BODILY INJURY (Per person) ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) HIRED NON -OWNED PROPERTY DAMAGE AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE AGGREGATE EXCESS LIAB CLAIMS- MADE DPD RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY STATUTE ER E.L. EACH ACCIDENT ANY YIN PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? N/A E.L. DISEASE -EA EMPLOYEE (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT SCRIPTILIN OF OPE TIONS below i :4-J . . . ............ 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. The City of El Segundo its officers, officials, employees and volunteers is additional insured per the Business Liability Coverage Form SS0008 attached to this policy. Coverage is primary and noncontributory per the Business Liability Coverage Form SS0008, attached to this policy. THE 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 90245-3813 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 0f ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 72 SBM BC9401 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - VENDOR CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO CA 90245 Form IH 12 00 11 85 T SEQ. NO. 001 Printed in U.S.A. Page 001 Process Date: 11/05/19 Expiration Date: 11/07/20 THE HARTFORD BUSINESS SERVICE CENTER THE 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 THE CITY OF EL SEGUNDO 350 MAIN ST EL SEGUNDO CA 90245-3813 Account Information: Policy Holder Details: David Ebeling October 9, 2023 0 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 WLTRO05 Interinsurance Exchange of the Automobile Club Automobile Insurance Policy Coverages and Limits Modified Renewal Declarations We are pleased to offer you a renewal for your automobile insurance policy. To renew your policy, send at least the minimum payment on or before the due date. Insurance is in effect only for the vehicles, coverages, and limits of liability shown on this declarations page and as set forth in the insurance policy and endorsements. These declarations, together with the contract and the endorsements in effect, complete your policy. If any change to your policy or to the information we have on file results in a premium decrease during the policy period, the Interinsurance Exchange reserves the right to apply any refund due to your outstanding balance. NAMED INSURED (Item 1.) ........ EBELING, DAVID 3456 LOTUS ST I RV I N E CA 92606-2117 VEHICLES AUTO POLICY NUMBER: CAA 071832643 POLICY PERIOD (PACIFIC STANDARD TIME) POLICY EFFECTIVE DATE: 07-28-23 12:01 A.M. POLICY EXPIRATION DATE: 07-28-24 12:01 A.M. VEH. YEAR MAKE MODEL IDENTIFICATION VEHICLE GARAGE ANNUAL" VERIFIED SALVAGE NO, NUMBER USE ZIP CODE MILES MILEAGE 3 2013 SUBA OUTBACK SW 2.51 go COMMUTE 92606 5,501 - 7,500 VERIFIED NO 4 2013 HOND PILOT EX NMI PLEASURE 92606 17,501 - 20,000 VERIFIED NO 5 2013 VLKS NEW JETTA BASE/S COMMUTE 92606 10,001 - 12,500 VERIFIED NO COVERAGES AND LIMITS ANNUAL PREMIUMS Coverage is not in effect unless a premium or the word "included" is shown. COVERAGES LIMITS OF LIABILITY Vehicle 3 Vehicle 4 Vehicle 5 Vehicle Vehicle Liability ° « " Bodily Injury $500,000 each person/ $500,000 each occurrence $ 621 $ 447 $ 360 Property Damage $100,000 each occurrence $ 360 $ 254 $ 203 ; Medical ' + Excess Medical Payments $2,000 each person $ 15 $ 13 $ 12 Physical Damage (Actual Cash Value unless otherwise stated, less deductible) + e t i + ° u I i Vehicle 3 Vehicle 4 Vehicle 5 Vehicle Vehicle Comprehensive ACV ACV ACV $ 88 $ 58 $ 62 (Less Deductible) $250 $250 $250 (' " Collision ACV ACV ACV $ 512 $ 329 p $ 351 s (Less Deductible) $500 $500 $1000 Car Rental Expense t I (Per Day) $35 $35 No Coverage $ 66 a $ 43 No Coverage Uninsured Motorist ° Bodily Injury- $100,000 each person/ $300,000 each accident $ 314 $ 217 W $ 134 n Uninsured & Underinsured Vehicles y [ Y Uninsured Deductible Waiver W Included Included A Included A Uninsured Collision No Coverage, No Coverage,, No Coverage; ; Total Premium $ 1976 $ 1361 $ 1122 ; PREMIUM DISCOUNTS Please refer to the enclosed document entitled "Premium Discounts Applied to Your Automobile Policy." * If at any time you choose to pay less than the full balance outstanding, finance charges of up to 1.5% per month of the balance outstanding will apply as explained in your billing statements, which are part of these declarations. ** To see the annual mileage for your expiring policy, please refer to the "Notice of Annual Mileage"* page contained in your renewal package. "No Coverage" indicates coverage not purchased. Total Annual Premium* $ 4459 (Includes all applicable discounts.) Less Policyholder Savings Dividend $ 366 Net Premium* $ 4093 CAA000A PROCESS DATE 07-12-23 PLEASE ATTACH TO YOUR POLICY (SEE REVERSE) Interinsurance exchange of the Automobile Club Automobile Insurance Policy Coverages and Limits Modified Renewal Declarations (continued) AUTO POLICY NUMBER: CAA 071832643 POLICY EFFECTIVE DATE: 07-28-2023 DRIVERS (Coverags may differ for each driver. Please see each section of the policy contract for the definition of "Persons lnsured".) DRIVER NAME GENDER MARITAL STATUS YEAR FIRST UCENSED NUMBER 1 FEMALE. MARRIED 1985 2 EBELING, DAVID MALE MARRIED 1985 3 FEMALE SINGLE 2017 4 MALE SINGLE 2022 DRIVER NUMBER 1 2 3 4 DRIVING RECORD NUMBER OF PRINCIPALLY NUMBER OF TRAFFIC CONVICTIONS AT -FAULT ACCIDENTS MINOR I SERIOUS f MAJOR I SEVERE I SUSPENS RATED DRIVER STATUS VEHICLE NUMBER PRIMARY 3 PRIMARY 4 PRIMARY 5 ADDITIONAL 3 ENDORSEMENTS AND CERTIFICATES SPECIAL EQUIPMENT" SOUND EQUIPMENT" NUMBER I TITLE 2011 MEMBER'S AUTOMOBILE POLICY- POLICY NUMBER CHANGE 2298 SELECTION OF UM/UIM COVERAGE ENDORSEMENT 2367 AMENDATORY ENDORSEMENT VEH. NO. CAMPER/ VAN CONV. OTHER 2-WAY RADIO TELE- PHONE RADIO OTHER 3 4 5 ** Coverage is indicated by a "YES" in the appropriate equipment column. Coverage limitations apply unless coverage was purchased specifically for certain equipment. ANY PHYSICAL DAMAGE LOSS MAY BE MADE PAYABLE TO YOU AND ANY INTEREST LISTED BELOW: PERSON DESIGNATED TO RECEIVE NONPAYMENT OF PREMIUM NOTICES: An, individual designated by a policyholderto receive notice of lapse, termination, expiration, nonrenewal, or cancellation of the policy for nonpayment of premium does not have any rights, whether as an additional insured or otherwise, to any benefits under the policy, other than the right to receive notice. CAA0200B Click AAA.com/myaccount to access your policy information online, pay your bill or E20180807 071323 print additional proof of insurance cards 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 Name of Agent Policy Number Expiration Date Phone # 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 s 'et to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with t visions or the agreement will automatically become void. Signature of Ap Print Name Agreement for: Amendment #5808D Dated: In 1: Reviewed by: Date it 1-11