PROOF OF INSURANCE (2024 - 2024) CLOSED" ",�, srcrrsalnu iwrls11"F r.
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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 CONTRACTOR OTHER DOCUMENT
WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE 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.
LT'R TYPE OF INSURANCE '. POLICYNUMBER (M M
Lam
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COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
p,
S 100,000
0,
CLAIMS -MADE ® OCCUR
PR LII:. F - � p�,
EXGUded
MED E%P (ARM one oereon)
3
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Y
PHPK2584296
09/01/2023
09/012024
PERSONAL .Y DV IwuRY
$1,000.000
'.. GIENIA "rREOATELUMITAPPUCS,PER:
GENERALAGGREGATE
f 3,000,000
PRODUCTS -COMP) PAGG
S 3,000,000
POLICY J'ECT- E. LOC
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Os 1+ER;
AUTOMOBILE
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SINGLE LIT
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AUTOS ONLY AUTOS
HIRED NO"WNED
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AUTOS ONLY AUTOS ONLY
$
UMBRELLA LIAR ...00CUR
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EACH OCCURRENCE
.. s 5,000,000.,
A
ExCEBBUAB CLAIMS -MADE
PHUS875223
09/012023
09/012024
AGGREGATE
3 5,000.000
DED RETEIIIi'CON f 10,000
3
WORKERS COMPENSATION
PEATUTE ERA
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORMARTNERIEXECUTIVE ❑
NIA
EL EACH ACCIDENT _
S
OFFICERIMEMBER EXCLUDED'!
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EL DISEASE - EA EMPLOYEE
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EL DISEASE - POLICY LIMIT
3
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DESCRIPTION OF OPERATIONS Mlau
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, AddMtlonsl RemMlo SeMdul% My bs &dlidwd B mon HMO Is mqukvd)
[Job m 2039 Job Type: ]
136530 Certificate Holder if listed asAddiUGnal Insured 02030 with respects to PTR Memberp138530 Eric Stenberg
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
The City of El Segundo, its Officers, Officials ACCORDANCE WITH THE POLICY PROVISIONS.
Employees, Agents & Volunteers
AUTHORIZED REPRESENTATIVE
350 Mein Street
EL SEGUNDO CA 90245 QAAJzOJtrt.
n+aRrl_9Ir1R ArnRn rnRPnRATION All rinhfa romrv�l
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POLICY NUMBER: ''i'HPfC2594296 COMMERCIAL GENERAL LIABILITY
CG 20 26 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED
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):
I he City of El Segundo, its Officers, Officials
Employees, Agents & Volunteers
350 Main Street
EL SEGUNDO CA 90245
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 your acts or
omissions or the acts or omissions of those acting
on your behalf:
1. In the performance of your ongoing operations;
or
2. In connection with your premises owned by or
rented to you.
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
requiredby 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 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.
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AL(JKLJ CERTIFICATE OF LIABILITY INSURANCE 0b.9/01r2022
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(les) 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 Ileu of such endorsement a .
PRODUCER c0r, El Mark H. Lincoln
NAM.kL ,........ -
AX
InsureWorkforce, LLC PHONE 615405-7750 q , Hoi
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104 Watldmont Blvd "�° °mlincoln insureworkforce com
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Ste 219 JHSUrIFRfjIeoRr+o c tR�wirE, Nc s
Nashville TN 37205 INSURER A United States Fin: Insurance Colmpany 21113
INSURED
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PhtlSURtPt :.,
LNSURER
Professional Tennis Registry c,
4 Office Way
SIe200
Hilton Head SC 29928 299 INSURER
rnVCOAf=c rrorlrlf`AT= ul luoro. OrVlglrlN NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURMCE LISTED BELOW HAVE BEEN ISSUED TO THE INSORED 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.
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, ALLOWNED SCHEDULED
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( NON -OWNED
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UMBRELLA LIAB 1 OCCUR
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ANY PROPRIETORIPARTNERIEXECUTWE
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OFFICERIMEMBER EXCLUDED? N I Ai
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(Mandatory In NH)
E-LDISEASE -EAEMPLOYEL $
DESCRpN OF OPERATIONS twlav
F L- DISEASE - POLICY LIMIT 5
1
Accident Only Insurance US1833892-00 09/01/2022 0910112023
Accident Medical Expense Limit $25,000
A
audible $100
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101. Additional Remuks Schodufe, If mars apace Is required)
Primary Excess Medical Expense is first $100 or eligible expenses subject to deductible amount.
Additional Expenses paid only when expenses are In excess amounts payable by any other Health Care Plan.
Accidental Death Maximum Benefit: $10.000
Accidental Dismemberment & Paralysis Maximum Benefits: $10,000
CERTIFICATE HOLDER t alvm�o iLL�awluN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZEDREPRESENTATIVE
ACORD 25 (2010/05) 0 1988-2010 ACORD CORPORATION. All rights reserved.
Auto Insurance Confirmation
Please use this as confirmation of auto insurance; however, this doesn't take the place of an
insurance identification card.
Registered owner: ERIC J STENBERG
Address:
EL SEGUNDO CA 90245
Policy number: CIC 006415997 7102
Policy effective date: December 1, 2023
Policy expiration date: June 1, 2024
Vehicle: 2023 TESLA Y 4D
VIN:
Bodily injury liability limit: $30,000
each person /
$60,000 each accident
Property damage liability limit: $50,000 each accident
Comprehensive deductible: $500
Collision deductible: $500
Meets California minimum statutory liability requirements
This confirmation of coverage neither affirmatively nor negatively amends, extends or alters the
coverage given by the policy issued by USAA Casualty Insurance Company.
Flow to Contact U„
Thank you for choosing us for your auto insurance needs. If you have any questions, please contact
us using one of the following options:
Phone: 210-531-USAA (8722), our mobile shortcut #8722 or 800-531-8722
Fax: 800-531-8877
Thank you,
USAA Casualty Insurance Company
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.
(� 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 certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not
e ploy 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 vovisio or the regiment will automatically become void.
Signature of Applicant Date 1
Print Name '
Agreement for:
Dated:
Reviewed by: