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PROOF OF INSURANCE (2024 - 2025)DATE (MMIDD/YYYY) ,al►I CERTIFICATE OF LIABILITY INSURANCE 10/18/2024 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). SPECIALTY PROGRAM GROUP LLC/PHS ..... . ......... . .... 46505301 PHONE (866) 467-8730 FAX (A/c, No, Ext): (Alc, No): The Hartford Business Service Center 3600 Wiseman Blvd E-MAIL _......_..... San Antonio, TX 78251 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# ...._..__•_....__...._..M............................................._._......._................................................................................................................................_ INSURED . ..................................................._.......... INSURER A: Hartford Underwriters Insurance Company 30104 NMK CORPORATION IN.........SURERR B................. N 2740 N SPRINGFIELD ST ............. ORANGE CA 92867 INSURER C c INSURER D .......... ..�................_.. INSURER E p INSURER F COVERAGES CERTIFICATE NUMBER:. 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 sUBR .................CY' ........ ... .... POLICY POLICY NUMBER POLICY EPF POLICY EXP LIMITS LTR. INSR. WVD MMIDD )._.IMMORY,_._..... ....... .._. ......._........___ ����.... COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $2,000,000 CLAIMS -MADE x OCCUR .............$'11....00...._0.5Q0...6 DAMAGE TORENTED $1 ' I J ?R6IIS�Ikri rencg) X General Liablllty MED EXP (Any one person) $10,000'' A _ X 46 SBM AW6SLF 09/25/2024 09/25/2025 PERSONAL & ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY X PRO LOC PRODUCTSn- COMnP/OPnAGG -- $4,000,000 " i. JECT I OTHER: ... ..... _..... ...... _.... . AUTOMOBILE LIABILITY ..._.._.._.. ........... COMBINED SINGLE LIMIT r gid nl ANY AUTO BODILY INJURY (Per person) ALL OWNED SCHEDULED BODILY INJURY (Per accident) AUTOS AUTOS HIRED '.NON -OWNED WPROPERTYDAMAGE AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR .........._.........._.__._..............� EACH OCCURRENCE EXCESS LIAB CLAIMS- AGGREGATEE.C.E.............................................................................. ... MADE OED RETENTION $ WORKERS COMPENSATION ........_. _. ...m, _ PER OTFI- AND EMPLOYERS' LIABILITY STATUT _ R „, ANY YIN E.L.. EACH ACCIDENT PROPRIETOR/PARTNER/EXECUTIVE NIA ---.................................. OFFICERIMEMBEREXCLUDED? E.L..DISEASE-EAEMPLOYEE (Mandatory in NH) If yes, describe under E.L.. DISEASE -POLICY LIMIT E RIPT._..i.�F AEONS tsg,I,Rw ............... ......................... ......... ...�.....� ......... ..........._..__...._..._..._....___............ 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. Certificate holder is an additional insured per the Blanket Additional Insured by Contract SL 30 32 Form attached to this policy. 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 ......... ........................... ............ ............... ............................................ ................. ................ ................ ............................................... ......... .............................. _.._........................... _........... ........ © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Interinsurance Exchange of the Automobile Club Automobile Insurance Policy Coverages and Limits 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.) KHATRI,NABEEL KHATRI, LUBNA 2740 N SPRINGFIELD ST ORANGE CA 92867-2246 VEHICLES POLICY NUMBER: CAA 093548917 POLICY PERIOD (PACIFIC STANDARD TIME) POLICY EFFECTIVE DATE: 11-13-23 12:01 A.M. POLICY EXPIRATION DATE: 11-13-24 12:01 A.M. VEH. IDENTIFICATION VEHICLE GARAGE ANNUAL** VERIFIED NO. YEAR MAKE MODEL NUMBER USE ZIP CODE MILES MILEAGE SALVAGE 1 2007 TYTA PRIUS HYBRID i COMMUTE 92867 1,501 - 2,500 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 1 Vehicle Vehicle Vehicle Vehicle Liability Bodily Injury $100,000 each person/ $300,000 each occurrence $ 222 t Property Damage $100,000 each occurrence $ 130 Medical Excess Medical Payments $2,000 each person $12 Physical Damage (Actual Cash Value unless otherwise stated, less deductible) i Vehicle 1 Vehicle Vehicle Vehicle Vehicle Comprehensive No Coverage d C k i tl No Coverage (Less Deductible) No Coverage N Collision No Coverage d No Coverage (Less Deductible) No Coverage ; Car Rental Expense (Per Day) No Coverage No Coverage + Uninsured Motorist Bodily Injury - $50,000 each person/ $100,000 each accident $ 131 Uninsured & Underinsured Vehicles Uninsured Deductible Waiver p No Coverage Uninsured Collision $ 6 Total Premium $ 501 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* $ 501 (Includes all applicable discounts.) Less Policyholder Savings Dividend $ 33 Net Premium* $ 468 E220301 PROCESS DATE 10-05-23 PLEASE ATTACH TO YOUR POLICY (SEE REVERSE) 100623 �' .. CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 10/18/2024 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). �........,_ .... ........................... PRODUCER CONTACT NAME: SPECIALTY PROGRAM GROUP LLC 46508269 PHONE (877)907-5267 FAX (A/C, No, Ext): (AIC, No): 203 N LASALLE STREET STE 2000 "' """ ' """' .... E-MAIL ADDRESS: CHICAGO IL 60601 .... m........ .. ........_.... ..................... INSURERS) AFFORDING COVERAGE NAIC# INSURER A:: Hartford Fire Insurance Company "IbybZ �. ............._.... ..............�.. .......................... ........ ............._._.._.._.....� INSURED INSURER B : NMK CORPORATION ................. T _ _ ........ INSURER C w 2740 N SPRINGFIELD ST ......... ..................... ....... _................... ORANGE CA 92867 wsuRER D INSURER E : INSURER F :. COVERAGES CERTIFICATE. NUMBER: REVISION �..... SION NUMBER. ....• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE. .._ UR O 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 - ADDL SUER TYPE OF INSURANCE ••WY POLICY EFF POLICY EXP LIMITS POLICY NUMBER LTR ,!A(A,(;�,„„ MIDDJYYYYl. MN_PJ_y_"�.�j9.f) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE DAMAGE TO RENTED •••• CLAIMS -MADE ❑OCCUR FIR I,•SFSJloccurrence) _............ ............. MED EXP (Any one person) PERSONAL & Al INJURY GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE PRO- POLICY LOC ._... _.._......... .... _ . ... RODUCTS - COMP/OP AGG PRODUCTS OTHER: -......_.... '.. AUTOMOBILE LIABILITY ........................ �• COMBINED SINGLE LIMIT iga IdIdentl ..........................._ ANY AUTO BODILY INJURY (Per person) ALL OWNED .. ••• SCHEDULED BODILY INJURY (Peraccidenl) AUTOS .AUTOS HIRED NON -OWNED 'PROPERTY DAMAGE AUTOS AUTOS (Per accident) ....._._ .,_.-.. UMBRELLA IOCCUR .._................... ._ ._. .............._-... .............. ..._.......... EACH OCCURRENCE ....- _._- „ EXCESS LIAR CLAIMS- AGGREGATE ... MADE ­....�... ECD RETENTION W ..... ... ..... ......... WORKERSCOMPENSATION �_AND ..�........... ..........� ..UP.........._ .�..�.�.�._. PER OTH- EMPLOYERS' LIABILITY STATUTE R ANY YIN. E.L. EACH ACCIDENT PROPRIETOR/PARTNER/EXECUTIVE..... N/ A .............................. - ..... OFFICER/MEMBER EXCLUDED? E.L, DISEASE -EA EMPLOYEE (Mandatory in NH) F If yes, describe under E.L. DISEASE - POLICY LIMIT DES RIPTION.OF OPERATIONS below . . .... ....... Tech E&O Glitch Limit $2,000,000 46TE0281457 10/17/2024 10/17/2025 Retention Each Glitch $5,000 Aggregate Limit $2,000,000 •-•-a -••-•-- ITIT S (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLE (ACORD Those usual to the insured's operations ....... ..._._. CERTIFICATE HOLDER CANCELLATION .. ......._._._. 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 ....... .....__--- © 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. affirm under penalty of perjury under the laws of California one of the following declarations: L_) 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 Al.,Llez4 Date 01/01/2024 Print Name Nabeel Khatri Agreement for: Dated: b Reviewed by: I