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PROOF OF INSURANCE (2025)." CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDNYYY) 08/19/2024 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 endorsement(s). PRODUCER CONTACT NAME. .... ........---- ------ Hiscox Inc. d/b/a/ Hiscox Insurance Agency in CA PHONE (888) 202 3007 FAX 5 Concourse Parkway EMAIL tt corroacIro4soox corn Suite 2150 4�� �._, '°° "' Atlanta GA, 30328 INSURERS AFFORDING COVE PAGE NAIL# 11Jc11aFa A Hiscox Insurance Company Inc 10200 INSURED [—,INSURER NSURER B r. Essential Safety Management, LLC NSURER C r. 715 W Oak Ave ........� El Segundo, CA 90245 NSURERD: E ^c,n� o4t%AVe r.uuAeeo. RFvLCInN N111MIRFR 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. -..-- ... ..-... --------- .._.._......._. - —..... A 7 L BR. .... ....,...-..m..._.. .._PtlLICV EFF POLICIP TR TYPE OF IN SURANCE POLICY NUMBER MM/Dg/ MMk DfYYYY LIMBS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1 Q00 000 '.. CLAIMS -MADE 1,_1 OCCUR PREM.. §,,(Ea„,gccurr nce $ 100,000 MED EXP (/intoneerso pn) $ 5,000 .0 A — Y P103.784.938.1 08/19/2024 08/19/2025 � PERSONAL 8 ADV INJURY $ 1OOQ. .. OENLAGGR' MIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 X POLICY JEt T LOC PRODUCTS COMP/OPAGG $ S/TmmGen. Agg• $ OTHER:: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY _� a aee° .�"rit9 .......... W.............. BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED R0P $ HIRED AUTOS .AUTOS 4 .'AMAGE n $ UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LU\B CLAIMS MADE AGGREGATE �. $ DED RETENTION $ $ WORKERS COMPENSATION PER OTH- ST_.. ?E.... ER ------------- AND EMPLOYERS' LIABILITY Y ! N ANYPROPRIETOR/PARTNER/EXECUTIVE (�""'"�j E.L. ACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? �_] (Mandatory In NH)MPLOYEE N /A E L. DISEASE EA EMPLOYEE E.L. $ ----- -------- If yes, describe under DESCRIPTION OF OPERATIONS below E.L DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) The City of El Segundo, its elected and appointed officials, employees, and volunteers are included as additional insured's - see the blanket Al Endorsement The City of El Segundo will receive thirty (30) days written notice in the event of cancellation, non -renewal, ore reduction Primary and Non -Contributory Endorsement attached City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. 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: 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 carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone # �) 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 Signature ly ppla I ions or a agreement will automatically become void_ f immediate) complywith pate lQ oaPrint Name "' Agreement for: Dated: Reviewed by: