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PROOF OF INSURANCE (2025) CLOSED
CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 02/06/2025 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 SUBR OGATIONIS 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: GORST & COMPASS INSURANCE SERVICES ----- - •• PHONE 818) 507-0900 72250102 (A/C, N ,Ext): No) 5850 CANOGA AVE STE 650 ,IL S WOODLAND HILLS CA91367 ............ _......_ ._._....O INSURERS) AFFORDING COVERAGE NAIC# INSURERA: Hartford Underwriters Insurance Company 30104 '.. ..._.................. _ .... INSURED .....,.�....�..._. ......................IN.�.-.._...., ..�,............ SURER B : DEREK CRAWFORD DBA SOFTWARE SOLUTIONS INS ...... _.__....... URER C &. TEAM _ .... _ ......... 3220 S HIGUERA ST STE 208 INSURER D ; SAN LUIS OBISPO CA 93401-6999 INSURER E : INSURER F ..W... _.... .. ....... 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 pDDL SUBR ................ TYPE OF INSURANCE POLICY NUMBER -- POLICY EFF POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $2,000,000 DAMAGE STO REN�TE X yperson) �._.. ._._ - _...........0 Ar General LN bAo OCCUR MED EXP (Any one parsn $1 $oO,000 ............... A X 72 SBA BE5U04 04/05/2024 04/05/2025 PERSONAL a ADV INJURY $2,000,000 ........... ............. GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL !I......A..G...G_ REGATE _... ....$._4....,_000,000 POLICY I PRO- LOD PRODUCTS-COMP/OPAGG $4,000,000�JECT I.�......... ...._._._........,m.-.. ._._..._.. OTHER: ........... ......... �......... ......... "AU COMBINED IetSINGLE LIMIT 2,000,000 AUTOMOBILE LIABILITY $ '.. ANY AUTO BOD11 I11 LY INJURY (Per person) A AUTOS AUTOS ALL OWNED SCHEDULED 72 SBA BE5U04 04/05/2024 04/05/2025 BODILY INJURY (Per accident)'' HIRED NON -OWNED ..�......__� PROPERTY DAMAGE X AUTOS X AUTOS (Per accident) ....._ .................... ............. .. _..._ ..... _....._.._„ ..... UMBRELLA LIAB OCCUR EACH OCCURRENCE u . .....� .... ........ _. CLAIMS - EXCESS LIAB AGGREGATE MADE ED RETENTION $ ....... ........_ _................._ .. ......... ... ._...... WORKERS COMPENSATION_.... PER OTH- AND EMPLOYERS' LIABILITY STATUTE I ER ANY Y/N E.L. EACH ACCIDENT PROPRIETOR/PARTNER/EXECUTIVE NIA ........ ... OFFICER/MEMBER EXCLUDED? E.L. DISEASE -EA EMPLOYEE (Mandatory in NH) If yes, describe under E,L. DISEASE - POLICY LIMIT DESCRIPTION OF PERATIONS below .._...... ......._�.. _......... ._....... ...... DESCRIPTION OF OPERATIONS/LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Those usual to the Insured's Operations. Please see page two for additional remarks. .... _........... _ ._.. _ .... 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 I EL SEGUNDO CA 90245-3813 WITH THE POLICY PROVISIONS. N ACCORDANCE AUTHORIZED REPRESENTATIVE ........ .......... ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC#:. ADDITIONAL REMARKS SCHEDULE Page 2 of 2__ _............................. __ ....... .............._ ............. ........_._. .AGENCY NAMED INSURED GORST & COMPASS INSURANCE SERVICES DEREK CRAWFORD DBA SOFTWARE SOLUTIONS TEAM POLICY NUMBER ................__ 3220 S HIGUERA ST STE 208 SEE ACORD 25 SAN LUIS OBISPO CA 93401-6999 _.. ............._ CARRIER NAIC CODE SEE ACORD 25 ......... .....................- EFFECTIVE DATE: SEE ACiORD 25 ......................_.._... ..................�... __............ ....�. AnnIT1rWAII REMARKS ACORD 101 (2014/01) © 2014 ACORD CORPORATION. All rights reserved. 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. I 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 i 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 w ,rkers compensation provisions of Labor Code § 3700 1 must immediately comply with thos provisions or the ernent will automatically become void„ Signature of Applicant "� Date 1/23/2025 Print Name Dereff. Crawford Agreement for: Dated: Reviewed by: