PROOF OF INSURANCE (2025 - 2025) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDmYY)
A
12/19/2024
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 have ADDITIONAL. INSURED provisions or 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
CON ACT .....
NANM1E in D DIBZ „_,_,,
D&C Insurance Solutions
PHONE 888 457 4426 AIC N _w 323.576.4552
_....
E �psmm conlactdc! insurance.com
300 S. Atlantic Blvd., Ste 201-B
•••w, INSURER(S)AFFORDING COVERAGE- � .jMIC#
Monterey Park _.....CA 91754
.... ..............
INSURERA: Western World Insurance Company 13196
INSURED
INSURER B: ..........._ _....�.�.�...... ..... .........
Tillmann Forensic Investigations, LLC.
INSURERC:W .............. ........ _•
INSURER D i _ -.. °,,
PO BOX 4373
INSU_..RER E : ................. ......... ..._... .................
........
Covina CA 91723
INSURER F:
nnvooAnec eFRTIICIrteTE 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.
_
.._..,. ............LIMIT ..
.., ° VI .....
AOtSL SUBR POLICY EFF PiYLICY EXP
d 4 TYPE OF INSURANCE
RANCE w.... POLIC'W'NI9MBER MM/ rt5/YYYY MMLD.P )ff1........
S
_
X COMMERCIAL GENERAL LIABILITY A NPP6081725 12/17/2024 12/1712025
EACH OCCURRENCE ($ 1,000 OOOm
....
DIAL FURENNT ,� 100„000
CLAIMS -MADE � OCCUR
M-III, °I'.-� :.�(.FIN+'Ia^cidrcst*nic,e) .......�°..._.
MED EXP (Any oou Pol'$E!) $ 5„000
PERSONAL B ADV INJURY $ 1,IOO,000 '.
....................�_. ....... ._�.,..-.�
..... .,.,..,,,.,_ _. .......
GEN"L AGGREGATE LIMIT APPLIES PER:
_ GENFRALAGGREGATE $ 2,000„000
�y
/+,.. POLICY ❑ JECT ❑ LOG
GG
.........._ - .�._.. Included
Errors & Omissions $ Included
OTHER, w ..
- -
acG1cDrESINGLIw LIMIT $
AUTOMOBILE LIABILITY
ANY AUTO
BODILY INJURY (Per person) $
OWNED SCHEDULED
BODILY INJURY (Per accident) $
AUTOS ONLY AUTOS
HIRED NON -OWNED"(
••••—• —
$
AUTOS ONLY AUTOS ONLY
PI.PA ucIYoMA'E
-- --•••
..
......
UMBRELLA LIAB '.00CUR
EACH OCCURRENCE $,
EXCESS LIAB CLAIMS -MADE
ACCRCGAI°E
DED RETEN11ONS
$
WORKERS COMPENSATION
---._..........
AND EMPLOYERS' LIABILITY YIN
... �.
ANYPROPRJETORVPARI'�NERJEXECIJTIVE
EACH ACCIDENT $
.—._.. ..-........_._..
OFFICERWE-M'BE> EXCLUDED't ❑ NIA
(Mandatory in NH,I
E.L. DISEASE - EA EMPLOYEE S
..... ....._. _-. ....
I! yyes, drsscr6he nawdol
0 SCRII'�'I°lON OF t 1PERATIONS hoiaw
E.L. DISEASE -POLICY LIMIT S
(ACORD 101, Additional Remarks Schedule, may more ...
DESCRIPTION OF OPERATIONS (LOCATIONS /VEHICLES h� attached if oro space is required))
Regarding the above referenced General Liability policy, olic , the certificate holder Is included asadditional insured,
but only with respect to the negligent acts, errors or omissions of the named insured.
CERTIFICATE HOLDER UANUtLL44IIU114
City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
348 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
El Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Lin Dau Diaz -
l7 Tbaa-Zt) ID M%,Vrcv a,vrcrvrcn w.. nu ynw .cao..c...
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: NPP6081725
COMMERCIAL GENERAL LIABILITY
CG 20 10 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following;
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) Location(s) Of Covered Operations
Or Organ ization(s):
City of El Segundo "carious Locations
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
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:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your
behalf;
in the performance of your ongoing operations for
the additional insured(s) at the location(s)
designated above.
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 additional
exclusions apply:
This insurance does not apply to "bodily injury" or
"property damage" occurring after:
1. All work, including materials, parts or equipment
furnished in connection with such work, on the
project (other than service, maintenance or
repairs) to be performed by or on behalf of the
additional insured(s) at the location of the
covered operations has been completed; or
2. That portion of "your work" out of which the
injury or damage arises has been put to its
intended use by any person or organization
other than another contractor or subcontractor
engaged in performing operations for a principal
as a part of the same project.
CG 20 10 04 13 Copyright, Insurance Services Office, Inc., 2012 Page 1 of 2
C. 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 shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable
Limits of Insurance shown in the Declarations.
Page 2 of 2 Copyright, Insurance Services Office, Inc., 2012 CG 20 10 04 13
POLICY NUMBER,., mC29-75G EFFECTIVE
YR 2019 MAKE JEEP MAR 29 2025 TO SEP 29 2025
MODEL WRANGLER VIN 1789
AGENT 1317-AED
PHONE AIG 25178
GGVERAG R 8Y' THE P +LIGY MEETS THE MINIMUM LIA$ILITY LIMITS
PRESCRIE10 0Y LAW.
COVERAGES A C 02 0 G1000 H U U1
SEE REVERSE SIDE FOR AN EXPLANATION.
The premium on the expiring policy term was based on
15,600 miles per year
The premium on the renewal policy term was based on
15,600 miles per year.
Premium Adjustment
Each year, we review our medical payments and personal
a injury protection coverages claim experience to determine
o the vehicle safety discount that is applied to each make and
DWI;;; R A IF, ORMATIO
Assigned Driver(s)
The following driver(s) are assigned to the vehicle(s) on this policy,
&Staf,eFann-'
model. In addition, we review the comprehensive, collision,
bodily injury and property damage claim experience
annually to determine which makes and models have
earned decreases or increases from State Farm's standard'
rates. If any changes result from our reviews, adjustments
are reflected in the rates shown on this renewal notice.
Driving Experience as or Marital
Name Sa ieniber 29, 2024 Status
STEVE TILLMANN
Principal Driver & Assigned Drivers
For each automobile, the Principal Driver is the individual
who most frequently drives it.
Each driver is designated as an Assigned Driver on the
household automobile that they most frequently drive Your
premium may be influenced by the information shown for
these drivers.
COVERAGE AND t,,IIdW..S See yourpo6cytoranexplanation ofUiesecoverages
.
BoIn u tMO„00tfi1300
It t
.... . _ _-
Pro a Dame a 14t1 t1t1d�
2
1 $29.2
C Medical Payments 5,000
$ .
.,.2 79
D 250 Deductible Comprehensive_
8.34
G 1000 Deductible Collision
$193.21
H Emergen Road Service
$3.99
U Uninsured Motor Vehicle
�..�._..BodiN Injury 100,p93tlp�0
_.....$43,38.
U1 Uninsured Motor Vehicle
Properly Damage
If any coverage you carry is changed to give broader
protection with no additional premium charge, we will give
Policy Number 029-75G
Prepared August 7, 242
074393
you the broader protection without issuing a new policy,
starting on the date we adopt the broader protection.
Page number 3 of 5
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:
U 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 s bYect to the workers' compensation provisions of Labor Code § 3700 1 must
i g will automatically become void.
9 immediatelyppcomply �010i/0
Signature Applicant Date
ith those pr sons o e agreement
Agreement for:
Dated:
Reviewed by: