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PROOF OF INSURANCE (2024 - 2025) CLOSEDDATE(MMIDD/YVYY) ACC)R" CERTIFICATE OF LIABILITY INSURANCE 8l1 /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 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 NAME. Tahlna Gonzalez TIB Transportation Insurance Brokers, LLC PHONE 818 246-2800 F.. c N� 818 246 4690 425 W. Broadway E-MAILN East) &. ) ......... _ Suite 300 rtn8o ssjgpnZaIez ac-risure corn Glendale CA91204-1269 .__ .INSURER(S)AFFORD,INGCOVE_. _ „NAIC# RAGE LiC nINSURED LA OUm a27847 O n 04INSURERBTrisua InsU ceComp2225 LA Tours and Charters Inc. . ecial „ Insurance Co BA LA VIP Tours INSURERC Tnsura Sp ty"."...r .. mpany 16188 4900 W. Century Blvd. INSURERD Inglewood CA 90304 INSURER E: COVERAGES CERTIFICATE NUMBER: 580831965 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. LTR ...,..,.....TYPE OF INSURANCE .. ....... ... r - .......,.,M Oucy Y,F f MOLT ... .......... ..... ........... I ------_ ................ NSRADDL SUBR POLICY NUMBER Pwnn yY POLICY EXP LIMITS 1 � Ddrk'Y'MY B )( COMMERCIAL GENERAL LIABILITY Y KGA014292403 5/22/2024 5/22/2025 EACH OCCURRENCE $ 1 „000,000 $ 900 000,.. _� CLAIMS -MADE X_.., OCCUR _PREMISES.,(E� occurrenpe . ........ .... ................ _ ny one a on) A8 $ 5 000 PERSONA ADV INJU Y ... .... 1 $ 000,000 R: GEN L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $1,,000000 X. P"_ ..... PRODUCTS COMP/OPAGG 1.,000000 POLICY .N,E,CT � � LOC ........ _ .... ---- f .. $ 0FHER; B AUTOMOBILE LIABILITY Y i' KAA014292403 5/22/2024 5/22/2025 COMBINED StlNGL1- C.dhtiNT iEa �cuNl4act) $ ANV AUTO BODILY INJURY (Per person) $ ,�.. ALL SCHEDULED OWNED X W ( iden[) BODILY INJURY Per aca I $ �,....... AUTOS X HIRED AUTOS X AUTOS NON -OWNED � OPWRTV014MikGi: arr `{ . $ AUTOS � tP ar�r,Ce�1.1) C UMBRELLA LIAB X CUR Y KXA014292403 5122121124 5/22/2025 URRENCE $ 4,000 000 „ AB ..1, LX. � EXCESS , LIR.. .„..... .k COLAIMS MADE AGGREGATE ..- $ .,.......ro RE.. TENTION $ �. $ A WORKERS COMPENSATION WVE507407700 11/3/2023 11/3/2024 I X STATUTE I, ER AND EMPLOYERS' LIABILITY ...-' M ndANY PXCLUDE/EXECUTIVE YIN EACH ACCIDEN E.L DISEASE EAEMPL $"1wp00p00 �._ ( ry ) { EMPLOYEE $1,000000 yes, desribe OFFICER/MEMBER ocoeD nDnw r.oi..,., llll, 1 mE�L DISEASE POLICY ...._._ .... LICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Workers Comp. Officer Exclusion Applies: Alex Khorasani Excess Liability applies to both Auto & General Liability coverage. Certificate Holder is included as Additional Insured with respects to their interest in the operations of the named insured. CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of El Segundo 250 Main Street AUTHORIZED REPRESENTATIVE El Segundo CA 90245 © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: WFCOL0000000103-03 COMMERCIAL GENERAL LIABILITY CG20261219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. • "` Iw • • • WIF411TV•I This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): The City of El Segundo, its officers, officials, employees, agents, and volunteers � Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Y 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 required by 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; whichever is less. This endorsement shall not increase the applicable limits of insurance. CG 20 26.12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 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 ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: have and will maintain a certificate of consent of self -insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement with the City of El Segundo. Policy No. (A) have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier 7 12. 0 , y r � f L 01 �61 E� G Eh Gv S,Policy Number Expiration Date Name of Agent (fiR Elrs NJ fit Nit �h Phone# LI l$ � i It c- 0) 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 subject to the workers' compensation provisions of Labor Code § 3700 1 must Signature ly cA comply rovision�or the agreement will automatically become void immediately omy . with t ose.& 9 y ppp ant Date Print Name I L11h7 f' N Agreement for: Dated: Reviewed by: