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PROOF OF INSURANCE (2025 - 2025)ACORD 25 (2014101) DATE (MMIDDIYYYY) C(:) .D CERTIFICATE OF LIABILITY INSURANCE 1 11 /01/2024 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 PRODUCER WaterColor Management P.O. Box 1132 Decatur AL 35602- CONTACt ,NAME. Hirt` Seals 1.2.16I NAIc,A_ INSURED - ..... ._.. •............. Consolidated Water Technologies Inc .AISIltIAFI..1#.; World Laboratories & Hydro -Convergent Technologies ,.INSURER ..C_ P.O.Box 1860 INSURERI Simi Valley CA 93062- I1415'UP"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 SUER POLICY LIMBS POLICY EFFw POUCY EXP1113 A X COMMERCIAL GENERAL LIABILITY X X 'LGLEX000340-03 1 1 /01 /2024I1 1/0 1 /2025. EACH OCCURRENCE _, s 1,000,000 CLAIMS -MADE X , OCCUR - DAMAGE TO RENTED PREMISES (Ea acwltance) ; 5 l 00,000_ X Professional Llab._ �Jr • P I, ,y EAR (_ s 10,000 X Contractual Llab. PERSONAL 8 ADV INJURY _..� S 1,000,000 .., CW%r AGGREGATE LIMBAPPLIES PER: .. GENERAL AGGREGATE. S ....... 3,000,0011PRO- X POm.CY JECTT LOC PRODUCTS-CQMPIOPAGG„ S ® aV N!!sAJ3✓Sr, ----IL s 1 AUTOMOBILE LIABILITY COMBINED SNGLE LIMIT S ANYAUTO '... BODILY INJURY(Per person(. S. ._ ALL OWNED SCHEDULED BODILY INJURY (Per accident] S 4. AUTOS ,.. AUTOS : .. ,. S '.. ,... _.;. HIRED AUTOS AUTOS PAERTYDAMAGE .... A UMBRELLA LIAS 1 X OCCUR X X 'ILGLEX000340-03 .. 111/01/202411/01/2025 FACH OOC�JRRENCX-L, ..... 1, 000,000 ,. X EXCESS LIAR ......... . ..... CLAIMS -MADE Ar-G GATE .... ... „ a.(I,il(,I11111-._ DED 7 5 WORKERS COMPENSATION PER OFH. SSATUTE. ER AND EMPLOYERS'LIABRITY ,,,,, _ ANY PROPRIETORIPARTNERIEXECUTNE N I A E & CACH ACCIDENT 5,_, OFFICERiMEMBER EXCLUDED? (Mandatory In NH) , I" t Pdg5;A5E _,_E•R'd;1PLCdY"F'zT:, -- _ _ h• es, describe under Sm E,L ❑ISEA E-POLICY IMR : DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addhlonal Remarks Schedule, may be attached If more space Isrequlred) rPRTtFtr ATF Wnr nr-P CANCELLATION Al 028394 City Of El Segundo Public Works Department 350 Main Street El Segundo CA 90245- AUTHORIZED REPRESENTATIVE ,c6 ' z- ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CERTHOLDER COPY SC P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 01-01-2024 CITY OF EL SEGUNDO SC 350 MAIN ST EL SEGUNDO CA 90245-3813 GROUP: POLICY NUMBER: 9330479-2024 CERTIFICATE ID: 1 CERTIFICATE EXPIRES: 01-01-2025 01-01-2024/01-01-2025 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer, We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2024-01-01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO ENDORSEMENT #1651 - ARTHUR SHERMAN, P,S,T - EXCLUDED. ENDORSEMENT #1651 - DONALD OSBORNE, VP - EXCLUDED. ENDORSEMENT #1651 - ARTHUR SHERMAN, P,S - EXCLUDED. ENDORSEMENT #1651 - DONALD OSBORNE, T - EXCLUDED. EMPLOYER CONSOLIDATED WATER TECHNOLOGIES INC AND/OR (AND/OR) WORLD LABORATORIES LTD (A CORP) PO BOX 1860 SIMI VALLEY CA 93062 [JMJ,CNj (REV.7-2014) PRINTED : 01-12-2024 WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation: 1. Please be advised that a waiver of • o•. •r -• • will be applied by State Fund ONLY to the premium assessed on the payroll of •ur employees earn•t while engaged in workfor •e who requested the waiver. (Note- if you have no employee payroll on that job, then there is no ge.) C To, apply the 3% surcharge, you mu�st also agree to maintain accurately segregated payroll records for employees engaged in work on Job/s for thd certificate holder who has the waiver. The payroll records are subject to verification by • • Example: Payroll for job: Sample Rate: Regular Premium equals: Surcharge: Additional Waiver charge: Total premium equals $5,000.00 13.300 $ 665.00 3.00% $ 19.95 $ 684.95 (665.00 + 19.95)