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PROOF OF INSURANCE (2024 - 2024) CLOSED
WA I C t110 1-1 T i i trr'° CERTIFICATE OF LIABILITY INSURANCE 04/24/2024 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). MCGRIFF INSURANCE SERVICES LLC/PHS A PHONE (866)467-8730 FAX 22273438 (AIC, No): The Hartford Business Service Center 3600 Wiseman Blvd E-MAIL San Antonio, TX 78251 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURED _ INSURER A: Sentinel Insurance Company Ltd. 11000 TINA GALL INSURER B ; 3945 HOLLYLINE AVE SHERMAN OAKS CA 91423-4603 INSURER C : INSURER D INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: wawa 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. TIN _SR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POL ICY EFF POLICY EXP LIMITS ,R _ m COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $2,000,000 CLAIMS MADEOCCUR DAMAGE TO RENTED _ $1,000,000 PSIv)lSE Ea os u re X iGeneraf Liability MED EXP (Anyone person) $10,000 A X X 22 SBA LD8291 07/23/2023 07/23/2024 PERSONALS ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY PRO- LOC El PRODUCTS - COMP/OP AGG $4,000,000 JECT OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT accident) $2,000,000 ANY AUTO BODILY INJURY (Per person) A ALL OWNED SCHEDULED 22 SBA LD8291 07/23/2023 07/23/2024 BODILY INJURY (Per accident) AUTOS AUTOS HIRED NON -OWNED X X PROPERTY DAMAGE AUTOS AUTOS (Per accident) OCCUR UMBRELLA LIAB mm EACH OCCURRENCE EXCESS LIAB CLAIMS- AGGREGATE MADE DEd7 RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY STATUTE ER ANY YIN E.L. EACH ACCIDENT PROPRIETOR/PARTNERIEXECUTIVE N/A OFFICER/MEMBER EXCLUDED? E.L. DISEASE -EA EMPLOYEE (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT DESCRIPTION OF QPERAIION§ below I DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD mm 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. Waiver of Subrogation applies in favor of the Certificate Holder per the Business Liability Coverage Form SS0008, attached to this policy. City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Attn: City Clerk BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 350 MAIN ST IN 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 CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 08/01 /2023 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 endorsements . PRODUCER ....... CONTACT NAME' �.... Hiscox Inc. d/b/a/ Hiscox Insurance Agency in CA PHONE (888) 202 3007 F �o� 5 Concourse Parkway MA f srt)' _.._. w......._... 4 Suite 2150 ADDRES conRact hiscox com Atlanta GA, 30328 (_) NAIc a ......._. INSURERS AFFORDING COVERAGE -, _,,,mmmmm INCIIGFG A • Hiscox Insurance Company Inc 10200 INSURED Tina Gall 3945 Hollyline Avenue Sherman Oaks, CA 91423 ACIlT1�1/�ATC \III\MM=n. B: D: F: 12PUIQlnkl NIIMRFR• 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. _.. _-._.._... .-......... ............... .m._..� ....... .....-'.-'. DDL POLNCY EFF POLICY EXP LIMITS N TR TYPE OF INSURANCE POLICY NUMBER MMIOD. MM/DR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ------. OAMA� "ii' -TED _ CLAIMS -MADE OCCUR PREMlS„(a ......................... .......... MED EXP (Any one�erson) IT$ . ........... PERSONAL & ADV INJURY $ GEN9L. AGGREGATE LIMIT APPLIES PER: GENmERALAGGREGATE $ PRp- POLICY � JECT LOC CTS COMP/OPAGGmm $ m OTHER. C �NWDINEO SpNOL.. LIMIT AUTOMOBILE LIABILITY BODILY INJURY (Per person) ANY AUTO „$ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED PR,OPrR'7YDAMAG'E mm •••••• $ HIREDAUTOS .AUTOS UMBRELLA LIAB _ OCCUR EACH, OCCURRENCE EXCESS LW CLAIMS -MAD E AGGREGATE DIED RETENTION $ WORKERS COMPENSATION PER OTH ER -..-- AND EMPLOYERS' LIABILITY ,�,,STATUTE� ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N /A E.L. EACH ACCIDENT $ (Mandatory in NH) E.L. DISEASE- EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ A Professional Liability P100.515.496.4 09/08/2023 09/08/2024 Each Claim: $1,000,000 Aggregate: $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION The City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 Main St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo, CA 90245 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 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: (_) 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 # ( X) 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 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 �7441 Date April 24, 2024 Print Name Tina Gall, CDBG Consultant Agreement for: Dated Reviewed by: