PROOF OF INSURANCE (2024 - 2025)THIS CERTIPICATIE tS 1*61101 AS A MATMR OF INFORMATIdN'ONLY AND COVFEJ�S, NO FISHTS UPON TWE 0 .01%7-10009 HOLDEIL Mi
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEOATIVELY AMEND. F-XT9NO OR ALTOR THE COVERACIE AFFORDED- BY THIE POJJCM$
BELOW. , Tilts CERTIFIcATE OF JNSURANCIE DOES NOT CONSTITUTE A CONTRACT BETINEEN THE 16SUING '19SUAIE14(S), A0rmRjzED
R&R1t6EMTArVE OR PRODUCER, AND THE CM71FICATE: HOLDER.
- i 509-9—gublbot to ft.
IMPORcartiticaUTANT* :If the bolder Is an ADD17110RAL INSURED, the pofttles) muqt Im andendorsed.ItSUS A ft IS -WAIVED. -
term and condWafts of the polio, In poIkW* May raqWre on. endorsement A statement on " cqrt1fkmft,do,* not confer rig'Oft 0 ft
c00lcv1q holder In IIo4 ofamth andorsem(n9s).
Vitamem
Paeffic Libre Insurance Agency, Inc.
6330 W Mpents 910., ft. 401
LDS Art'!a1go, Q4 90'040
.9
INSURED
Mr. Fish Aquarium: & Pani&S"m Inc.
622 N.:La Br.ea•Aveme
irt1wmod, CA mm
COVEMOM
r CEffTIFIOTE
NU14MfINEftr
REVISION NUIVIBEM�
TMS
INDICATED.
C
Nc
, _
IS TO CERTIFY THAT THE POLIC1580
NOTNTHSTANDING ANY AEOPIAIW
ERTIFICATE MAY SE, ISWEA 0'fj' MAY,
CLA)SIONSAN64ONtiMOKS OF SOCIJ
IP
,
PERTAJN.
POI IVES
LN'Su
OAK, E LISM SEI, MRSEEN
T, TW OR CONDIT! ON OF ANY
THEN& IRANCE- AFFORDED BY
L"T.0 SHOWN MAY HAVE BEEN
I SSUED TO
CONTRACT
THE POLICIES
REDUCED jSy
THE INSURED
OR OTHER'
DE-SCRIBEO'N
PAID CIAI,"i,
poR, THE #OUG
NAMED ABOVE Y, PERIOD,
WTH �tr*MT TO MICH tH($
..
' MN 1S:8V8At0T*tOAL1 Ettki%k
T9F g-04AWROmm
mim
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ImTs
A
MmmeKCIALGENERAL FRI UpBary
0muit
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y
—
y
7MOC"63
DW=02;3,
'0V=0.2
A
MED;EXP OnTOM 0000M
"s
PERSCkk &ADV' IJVjURY
A!
Xr .:Dedud kft! -0-
dM& AGORMATE umir Aoputs PER:
7 Pouv E Z& Fx- Lee
AUTOM06M9 UASIUTV
AW. AUTO
'X ALL DVMED AUTO$
-5� SCHEOULEBAUTOS
75j- HRED AUTO&
0112=023
01/2(W2024II
SINOLE UmtT
&
Y
PROPERTY aAMAtE
(PQa4dqen#
UifnsUmd Mato6st
1.0ml-000
KOW"EaALFTOS
X
UMORaU LIAB x
OW22)2023
09=024
S. gme 000
AGOROGATe
EXCM,LKS: DS!A!VSqADF-
F7,
Prd�omf10P&Ad9t
-10-001000
s -000.000
DEDUCFZISLE�
Waiver OsuJiMOM aw#9840r genstaIM'0111ty WW Worlkem comperumllon. Coverage la primWand non-=*Utq arm rrggnolnedby over aq)psur
AddlttonM thsured. panoeiation rtca lcs to, 30 days, cm, oallation for non -pa yrnant Is, 10 days. Cartilicerte Haiderii an Ad4ittdrmU (inured.
City of EN %Vndd.
EJ Seguade, CA 90245
=ANY 0VTW AaQV9 00,00AMI), #00Q03J*,CA N'094AXP 0M'm'TKE
1001bAtS TMM0, NOTICS WILL 89 �KWP-, 0 00060041a IN THE
Crawford
AQQRjD1 251200901)- ThmAcokb name and logo are re.glawred itaft of ACORD,
COMMERCIAL GENERAL UASWTY
CQ 20 011044 113
'THIS ENDORSEMENT CHANGES THE POLICY.. PLEASE READ IT CAREFULLY.
This ighdorsementmod!inRes s turoncei V10W Under the lbliomng:
0 " , C
The following is a4ded to ,the ftir Insurance
Con0lon and s.upereades, any provW, on to the:
c 'trar on
Fnmere Aod WoncOntributory'Insumnce
This Insurance is ppm -ary 16, and will n seek
, , ot
oontdb4anlift a'ny'
. ,otber insumnee avolloble
to an addi0ppol insured undef your policy
pro vi� _ thar
(1 -1-- The additional Ingumd. 0 a No -mod Irttured
qrtdorsU h per ift0tefte-and
CG 20:0fi 04 13* 0 Insurance SMICSS OfhW, VIM, 2QI2 Page 1 of
001 ♦ s:..
w • � 4 r�'�� s
POLICY NUMBER: 796BIG07263 CO'MMERMAL GENERAL UABILITY
CG24 040 1.9.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CARSFULLY.
WAIVER OF T:: FE'R + F RIGHTS F RECOVERY
..
AGAINST THERS T US (WAIVER OF SUBROGATION)
N)
Thls erldor hl M. madlfld insurance prqvided under the following:
0 • • -
2 i
may. yy !�
SCHEDULE
Native .Of Per: on(s). Or anizaiian(A'.
,Any s raonisl vs vegan atiori(s) that are shown in. the applicabie Dbc7.arat bns for this
eiidQEselnent .
Infcrmallarm Mulmd W m morn tete this Sjqhadula, if not shown above will be shaven In the Dealar4ons.
+ � �wr Mw �: •+
we - M w w� • �r;,
• w w - w as
�:. .�u w • ws w�i w s'- a, vex.
CC 24 041219 V Insurance Services Office; Inc., 2018 Page 1: Qf 1
Mr_Ash,Urrr& I Pond ervlce lqo.
8
1�110=40i*lbM&O
W. a 2iF6
3 to
COMMORCIAL GENERA*,
L LIAMILITY
CG 40 33 12 19:
THIS ENDORSEMENT CHANGES THE POLICY.. PLEASE RtAD IT CAREFULLY.
This endorsement mod ifiesimrance, provided under the fotloWng'
COMMERCIAL, GENERAL UAOuTy COVERAGE PART
11. Ybar octs or omissions; or
.2. The. acts. or omissions of.these a 0-Ing on your
behalf,
in the perfoonance of your ongoing ,operations for
ft additional insured,
Fjw*veri the Insurance Aftbrded -to such
i3dditibnal Insured:
1. Onty. -alpplies to the extent permitted by low,
40d
2. Will not be broader than that: WhIch you are
required 4y $0 contrw or agreement to
provide forsuch additional insured'.
A parsons or oroantzation*9 statas as an
,additional Insured; LOddr this endorsement ends
when your operations fur that, addifional Inured
am completed-,,
001 20 33 1.;2-10 0 Insurance 3ervices:01ficeP Inc., 26115 Pea 1 of. 2
Mr.FM* lilr=17=114M
FA awo ID
2. "Bodily injury' or "poperty damage' occun,ing
a. All watk, including ittatedals, parts or
e4viphient furnished in: connection wah
such work, o.. the prqj�. (,*or then
Servioei m9IhWnanc6 or tqmirs) 0 be,
performed by or on 00aff of the additional
insuro*) it the location of the covered
o0rdtions has been CQMOWWor,
b-. TW portion of Na"Ur WOW out of,which the
injUry or damage been pvt th fts
interideO Lm by any person Or organization
other than another contmtor or
subcontractor engaged in performing
opet6tions: for, -a principal as a pad of the
$me project.
C. With respect to the. insurance. aftfolixi to the
addMonal insureds, the folloWirig, Is added -to
Section III:— UMIts, Of Ineuranow
The most we will pay on baW of Ow 401WOrtal:
Insured Is the amfait oflft,ow.
Re4ulted by the contract or qgreament,you,
have anterad tnto With the Ato,�si, lnt ured;
or
2. Available under the. applicable limits c!
in urance,
.6.
whichever is less.
This• endor-serned xhilll. not increase the.
applicable limits of Insurance.
Page. 2 of 2 Ginsuranpe SerAces; Office, Int. 2010 0G.20-33 12 19
mmii 42 #T C M $ WA 4
WORKERS: COMPENSATION AND EMPLOYERS LIABILITY JNSU` WC.'04 03.10111 ROWCE POLICY'
(is di
WAIVOt OF OURRIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIF0,01A
vfthava the right to rec!orovr payments -from anyone lii-b.l.efor aninjury covered -by this pollcy. WenvAll n6t_W0(;o our right
against fife pmori, or organigatton named WtheSichadule. (This agreement applies only to tho:extentthat,yp'Li'O-OrforMwork: under
a written dontract that- req ires yaw to obtain this agreement from us.)
Y04 mustmpintain payroll recOrds-somimVery repo 'ngthe so dl remuneration of yogr empl.Wom whilo angWd in the work
d6s&00 in the Schedde.
The additional. PrOnilum:Nr this endorsement shall be 2% of thd California workers' compensation ptemloM dtherwiseduoien such
Schedule
ftraort or Oroanizedon Job Descrfptlon
Arfyperton,dr prgginizallon as required by written contract.
This endorsement: rphan porra Id. which it is attached and is effeative ort tie. daft. LftU I a . 0,
_@e.s the ed unless therwis.. gta_
(The.Information, ha(oW. ti reqUIMd only when this andarsoment *19, Issiled subsequent to prepay-affan -of"the pulley,).
Endorsement Effeetve 617=23 Niiey Nd. TWC4280946 Endammont No. 0
Insured Mr Fish Aquarium A Pond, Servlce� Inc. (A Corp) Premium 3,830
insurance Compahy Technology Insurance CoMpany,. In
Countersigned by
WC .04,03 06
(8d, 6.4,84)
CC>R ' CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDIYYYY)
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(les) 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
J-Mac Insurance Agency
""'"" ^"
NAME.
ate owltt
FAX
27943 Seco Canyon Road, Suite 504
PHONE
�
(818)JSFu'1869' - I818 e 1 1258
Santa Clarita, CA 91350
E-MAILQ.B
ADra—atieqO"'E°r`'
License #: 0761135
INSURERS AFFORDING COVERAGE NAN,
_
INsuRER A :
California„-Automobile.ins,urance Company 3 34
INSURED
INSURER B :
Mr. Fish Aquarium and Pond Service, Inc
INSURERI�;
._�
622 N La Brea Ave
INSURER D :
Inglewood, CA 90302-3007
INSURER E :
COVERAGES CERTIFICATE NUMBER: 00001713-0 REVISION NUMBER: 1
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICYPERIOD
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.
tlNSR
LTNt
'
TYPE OF INSURANCE
b DL
NUMBER
POLICY_
POL CY EFF
M DD
POI LICY EX'P
� ._._..
LIMIT S
EACH OCCURRENCE_ $
COMMERCIAL GENERAL LIABILRY
CLAIMS MADE OCCUR
pREMY EccurtNt $ ._,_
MED EXP (Any one person) $
PERSONAL a ADV INJURY $
AGGREGATE LIMIT APPLIES PER:
GENERALAGGREGATE s
_GEN'L
PRE LOC
El JECT
PRODUCTS COMPIOP AGG $
PRODL ......�
OTHER
A
AUTOMOBILE LIABILITY Y
Y
BA040000086639
01/20/2024
01/20/2025
-COML ?... BIKED SINGLE LIME
...
$ 1 0 0t 0
ANY AUTO
BODILY INJURY Per arson)
( �
$
._. OWNED W SCHEDULED
ide
BODILY INJURY (Per accident)
t)
$
AUTOS ONLY AUTOS
HIRED NON -OWNED
PRONERTY DAbNAGE
AUTOS ONLY 1, AUTOS ONLY�
Para • kNJaR
.-
-•
UMBRELLA LIAB y I OCCUR
EACH OCCURRENCE
$
EXCESSLIABwIGLAIMS -MADEI
AGGREGATE
$
DED RETENTION $101
$
WORKERS COMPENSATION
STATUT ER
AND EMPLOYERS' LIABILITY YIN
"
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. EACH ACCIDENT
$
OFFICER/MEMBER EXCLUDED? NIA
(Mandatory In NH)
E.L. DISEASE - EA EMPLOYE
$
Use, describe under
DESCRIPTION OF OPERATIONS below
E,L. DISEASE -POLICY LIMIT
$
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
Certificate Holder is Additional Insured with Waiver of Subrogation
CERTIFICATE HOLDER CANCELLATION
City of El Segundo
350 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
............
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.
(_4 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: S IQ��
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 subject to the workers' compensation provisions of Labor Code § 3700 1 must
immediately comply with thos r isions or the agreement will automatically become void.
Signature of ApOoLylv11�
cant Date
Print Name '''
Agreement for: MY
Dated:
- -100
Reviewed by: [01MA