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PROOF OF INSURANCE (2025 - 2025) CLOSEDDATE (MM/DDIYYY CERTIFICATE OF LIABILITY INSURANCE 10/18/2024 ..........._ER _ _ _...... _.... _..._ 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 Wholder 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 SPECIALTY PROGRAM GROUP LLC/PHS "j'�""�•-•-•-a — 46505301 PHONE (866) 467-8730 Fq c, No): (A/C. No, Ext): The Hartford Business Service Center 3600 Wiseman Blvd E-MAIL San Antonio, TX 78251 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURED•mm....................��� ... .. ITITITITITITITITIT.. m - INSURERA:W-... .Hartford Underwriters Insurance Company 30104 NMK CORPORATION ...__...,,,-.. _.......... ............ --_° INSURER B t 2740 N SPRINGFIELD ST ®® .°"" "° .. ORANGE CA 92867 INSURER C H. INSURER D : . .................._._A,. ................... INSURER E : ............ ......,_ ... �___.............._ . INSURER F ............... COVERAGES CERTIFICATE NUMBER. REVISION _ NUMBER: _._. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAM � ED 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,mm... ......... •,IN5R ......... S�....._ __............ ADDL UER POLICY EFFPOLICY EXP IT TYPE OF INSURANCE POLICY NUMBER LIMITS LT „„„„ ._,., .. .... _......LWF� MD '. a.,,_„,,,,......,,„,,,,,, IMMIt1DM/YY1 MM/Do/1r.Y)M ._EACH OCCURRENCE $2,000,000 COMMERCIAL GENERAL LIABILITY u- pP�f_96t �O RENTED CLAIMS-MADEp X pGCc,ust $1 000 000 u ......a 'h — X General Luabillty Any one person) $10,000 MEDEXP,�... ..-...,., ............. ......_,,. _... ._ ...�..._._.�.... A X 46 SBM AW6SLF 09/25/2024 09/25/2025 PERSONAL 8 ADV INJURY $2. _.... .000,000 .. ...................... GENERA - AGGREGATE TE $4,000,000 AGGRE ., GEN'L AGGREGATE LIMIT APPLIES PER: POLICY EX PRO ��mml LOC PRODUCTS - COMPIOP AGG $4,000,000 .......� 1 ".AJECT 4..�.�... . ......................... ��� OTHER: ... - ..n._........ ..._............... - ........ ..............,, .................. _......_.. ...._ ................. _ .................... .................... COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY —y.ienll ANY AUTO BODILY INJURY (Per person) .. ALL OWNEDFSCHEDULED .....O �ent ....... _.ITITITITITm BODILY INJURY (Per accident) AUTOS AUTOS -- HIRED NON -OWNED .._.m.MPROPERTY DAMAGE AUTOS AUTOS (Per accident) -..., ............. ...___..._......._ _.�,.......... .......---....., . ................... ............. - ............. UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS- AGGREGATE 1. MADE Df0 RETENTION $ _......_.. ......._.. .. ................ ............ ....... .... ...... PER ...�_. _ ..�....,�....._�...... OTH .................... WORKERS COMPENSATION AND EMPLOYERS' LIABILITY STATUTE ER ••••••••••••••••- ANY YINE,L. EACH ACCIDENT PROPRIETOR/PARTNER/EXECUTIVE NIA _ """""""""""". OFFICER/MEMBER EXCLUDED? E,L. DISEASE -EA EMPLOYEE (Mandatory in NH) IT ........... _ITITITITITITIT If yes, describe under E.L. DISEASE - POLICY LIMIT ,W„ UCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLES (ACORD 101,Addition•�••mm .a....._.. ... ....,.,- ....... ........�...� al Remarks Schedule, maybe be e 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. CERTIFICATE HOLLER _ — ..........................� CANCELLATION CITYOF ELSEGUNDO ITITITITIT„ . ......... 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 POLICY PROVISIONS IN ACCORDANCE WITH THE POLICY AUTHORIZED REPRESENTATIVE C� /c2/7 1 �1�11 eL% ..�......................................... ..........-....._.. _. ...._.._._�........._...._._�.�................ _,..,..,..-..............................._.... , ©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 (MMIDDIYYYY) 10/18/2024 . .............. - T HIS 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 ITITITITITITITITITITIT"ERTIFICAT..... IMPORTANT:certificateholder REPRESENTATIVEAND ....... """ ADDITIONAL INSURED, the polic les 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). .... PRODUCERum .,--....___.......""" CONTACT NAME:..__. SPECIALTY PROGRAM GROUP LLC ac,NN .................... _ _ ._.."'"' 46508269 (87ij907-5267 FAX ( o, Ext): (A/C, No) 203 N LASALLE STREET STE 2000 E-MAILADDRE S _..._______.._ ........ .. _ _...__ mmmss:. CHICAGO IL 60601 INSURER(S) ...... AFFORDING COVERAGE NAIC# ..............""" INSURERA Hartford Fire Insurance Company 169 INSURED INSURER B ---------- - .......................... m............................,.. NMK CORPORATION INSURER C 2740 N SPRINGFIELD ST INSRD _ ............ ORANGE CA 92867 ._..m ....,,..-_ _ ....... INSURER E ; .,.�.-.. _...................... ....... .....m. INSURER F c _ �_------��EITNFICAfiNUREVSON...�NUMBERCOVERAGES.MBER: __ ..............."" ........ 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 U�_...... E BEEN REDUCED BY PAID CLAIMS. TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE INSR ... � ADOL� B ..� R POLICY 9tP LIMITS -.�. L .COMMEPCIALGENERALm .... IT......... IN ,......,,,- �.. .........t�t��vr��i��... .t�tt l�� 4YYtY _.......... ............. E OF INSURANCE POLICY NUMBER POLIEFF POLICY E R EACH OCCURRENCE ...... ...,... ..__._"_ CI..AIMS-I+'4AO3:. OCCUR DAf49••ALrt: 7AD REN1 ED .. Ill�ll MED EXP (Any one person) m...... .----...--... _.. .... ....� PERSONAL h. ADV BhtJURY .........................-...............�...�.,.,.m..-........................... _. GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE pI �g .. .. � . ...�.. ............... POLICY II PERII LOG PRODUCTS - COMP/OP AGO OTHER: VVV..-,.. ...III L 4 ..._.----.,. - .a....._- _...................... .._ ..�. ... C:.uMr,dNFD,__. ..-. AUTOMOBILE LIABILITY _. ANY AUTO BODILY INJURY (Per person) ........... ..................... ALL OWNED WW .._- SCHEDULED BODILY INJURY (Per accident) AUTOS AUTOS HIRED NON -OWNED •PROPFRTY DfwMAAS.+E. AUTOS AUTOS R.Pe�r ttg.r,nduruty ....._.-_.. ..,. ..�...... .............. .._-.... ......--- . ............" - ...... ACH OCCRRENCE UMBRELLA LIAB OCCUV� EU EXCESS LIAB CLAIMS- AGGREGATE MADE - ...... ....... ...................._ ED RETENTION $ WORKERSCOMPENSA"TION PER dO'IH AND EMPLOYERS' LIABILITY --" ETA M1•--I•••• ER ••••••• —•••••• ANY YIN I E..L.. EACH ACCIDENT PROPRIETOR/PARTNER/EXECUTIVE NIAE,L,. DISEASE -EA EMPLOYEE ._...................-..�...�—,-..� OFFICER/MEMBER EXCLUDED? .. (Mandatory in NH) If yes, describe under EL.. DISEASE - POLICY LIMIT DLESCRIPT,12NOF OP RATLQNS bp)pvr _... 46...........A99regate Limit.. Tech E&O TE0281457 10/17/2024 10/17/2025 Glitch Limit $2,000,000 Retention Each Glitch $5,000 $2,000,000 DESCRIPTION OF OPERATIONS "/LOCATIONS/VEHICLES ACORD 101, Additional Remarks Schedule, maybe attached'd more space _ ........-------- ................__.......... ( y required) Those usual to the insured's operations CERTIFICAT)HOLDER .............._ ..q NCELLATb�ih1....� ._...._......m. ...._.. ............... CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 350 MAIN ST BEFPROVISIONS. _ RED EL SEGUNDO CA 90245-3813 N ACCORDANCE WITH THE POLICY NOTICE WILL BE DELIVERED ORE THE EXPIRATION THEREOF, 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 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. It 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.) AUTO POLICY NUMBER: CAA 093548917 KHATRI, NABEEL POLICY PERIOD (PACIFIC STANDARD TIME) POLICY EFFECTIVE DATE: 11-13-24 12:01 A.M. 2740 N SPRINGFIELD ST ORANGE CA 92867-2246 POLICY EXPIRATION DATE: 11-13-25 12:01 A.M. VEHICLES VEH, IDENTIFICATION VEHICLE GARAGE ANNUAL'" VERIFIED SALVAGE YEAR MAKE MODEL NO. NUMBER USE ZIP CODE MILES MILEAGE 1 2007 TYTA PRIUS HYBRID PLEASURE 92867 1,501 - 2,500 VERIFIED NO 3 2018 TESL MODEL 3 EV PLEASURE 92867 15,001 - 17,500 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 3 Vehicle Vehicle Vehicle Liability Bodily Injury $100,000 each person/ $300,000 each occurrence $ 412 $ 349 ; m u Property Damage $100,000 each occurrence a n ,', $ 233 ; $ 222 Medical Excess Medical Payments $2,000 each person ( $ 13 $12 Physical Damage (Actual Cash Value unless otherwise stated, less deductible) ti a d i m Vehicle 1 Vehicle 3 Vehicle Vehicle Vehicle 203 Comprehensive No Coverage ACV No Coverage! $ (Less Deductible) No Coverage $1000 Collision No Coverage ACV No Coverage: $ 910 (Less Deductible) No Coverage $1000 Car Rental Expense $ 58 (Per Day) No Cowrage $45 No Coverage Uninsured Motorist Bodily Injury- $50,000 each person/ $100,000 each accident $ 195 $117 Uninsured & Underinsured Vehicles l Uninsured Deductible Waiver No Coverage,, Included Uninsured Collision $ 12 No Coverage; Total Premium $ 865 $1871 ; 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 $ 2736 (Includes all applicable discounts„) Less Policyholder Savings Dividend $ 153 Net Premium* $ 2583 CAA0200A PROCESS DATE 10-03-24 PLEASE ATTACH TO YOUR POLICY E20210301 100424 (SEE REVERSE) 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 Name of Agent Policy Number Expiration Date 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. s 01 /01 /2024 Signature of Applicant�� Date Print Name Nabeel Khatri Agreement for: Dated: Reviewed by: