PROOF OF INSURANCE (2026)DATE (MMIDD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 3/25/2025
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(les) 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 endorsernent(SI.
PRODUCER NAME: Chubb Customer Service Center
AP INTEGO INSURANCE GROUP LLC ac° No Ext : 800-807-6398 (AIC, Na):
375 WOODCLIFF DRIVE SUITE 103 ADDRESS. chubbcsc@,chubb.com
INSURER(S) AFFORDING COVERAGE NAIC #
FAIRPORT NY 14445 INSURER A : ACE Property And Casualty Instlratnce Company 20699
INSURED INSURER B :
SKYEBROWSE INC. INSURER C :
3108 Old Denton Rd Ste 115-342 INSURER D :
INSURER E :
CARROLLTON TX 75007-3961 INSURER F :
__..__..-. ,.......... w�wr.�.w.��....��anr-m....... RFVICIAN 14tG IGVI'Rr2^
THIS IS TO CERTWY 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.
LTR
TYPE OF INSURANCE
INSD
AND
POLICY NUMBER
(MMIDD/YYYY)
(MM/DD
LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
CLAIMS -MADE OCCUR
m
PREMISES (Ea ouour1'oneo)
$ 1,000,000
MED EXP (Any one person)
$ 5,000
A
Y
D02863637
02/26/2025
02/26/2026
PERSONAL & ADV INJURY
$ Included
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,000
PRO-
POLICY PROJECLOC
PRODUCTS - COMP/OP AGG
$ 2,000,000
$
OTHER:
AUTOMOBILE LIABILITY
Ea accacJa�atl)
$
BODILY INJURY (Per person)
$
ANY AUTO
BODILY INJURY (Per accident)
$
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NOWOWNEO
AUTOS ONLY AUTOS ONLY
= -
(Peracrldorl)
$
$
'UMBRELLALIAB
HCLAIMS-MADE
OCCUR
EACH OCCURRENCE
'.$
EXCESS LIAB
AGGREGATE
$
DED I I I RETENTION $
$
- ORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
O ANY PROPRIMB R/PXCLUDE/EXECUTIVE
FFICE in N ER EXCLUDED?
in NH)
NIA
STATUTE ER
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE
$
E.L. DISEASE -POLICY LIMIT
$
�Mandotory
es,describe underSCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
The insurance afforded by the policies described herein is subject to all terms, exclusions and conditions of such policies. The City of El Segundo California is listed as
Additional Insured, as per the terms and conditions of the Chubb Business Owners Liability Extension Endorsement (BOP-47675, or its equivalent) included in the policy.
The City of El Segundo California
350 Main Street
El Segundo, CA 90245
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Jf',
LW-IyOo-LV 1.7 11liVR✓
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.
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 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 tho�e provisions or the agreement will automatically become void.
Signature of Applicant Date 03/20/25
Agreement for: SkyeBrowse, Inc.
Dated: 03/20/25
Reviewed by: