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PROOF OF INSURANCE (2025 - 2026)CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 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 A NAME,e_ ... _ ,.... BIBERK Nvt! 844 472 0967 Al Not 203 654 3613 Se _OM P.O. Box 113247 E�MaIL customervvc"cx116ER1 arm Stamford, CT 06911 _ INSURERS AFFOR, VERAGE NAIL# IMMIRER n • Berkshire Hathaway Direct Insurance ( �,_.. ,DING CO nce Company . mm10391 INSURED Blackgatecorp Blackgate low voltage 1355 Westmoreland Street Pomona, CA 91766 r�e��ncnr+,a�..� �Illenoco. INSURER B : INSURER C INSURER E : INSURER F : RFVISInN NIIMRFR• 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. ... .. ......... .._ ...-.. ............w INTR ...a"SURANCE---------_. All L �5li�i�.. -- .. 6 MMIDDy YY . tlltM......ae... ..........rrrrr_ TYPEOFIN —POLICY NUMBER Y LICy EXP LIMITS IDOiY"YY'Y X COMMERCIAL LIABILITY E $ 1 X OCCUR D bA'EE�r" SO�OQO A X Primary and Non Contributory X N9BP452395 04/15/2025 04/15/2026 MED PxP (pny one person) s 5,000...._ ----- ..........."." ........rr_ _ PERSONALBADVINJURY_ $ Included OEPI'U- AGGREGATE LIMIT APPLI"ES PER: .GENERAL AGGREGATE �__ 000 000.m_ $ 2r mm-t POLICY 0 j�7 LOG PRODUCTS COMPIOP AGG $ 2,000,00,0 X OTHER': AUTOMOBILELIABILITY MIT ..I,�Irc!'dC1 qN LE...0 .m........... $ _ -------. ............... ANY AUTO BODILY INJURY (Per person)BODILY $ __....— ... ...,..,, OWNED ULED INJURY (Per AUTOS ONLY .._ _... AUTOS HIRED NON -OWNED P'RC??'EFiT"'`f`IFr.iu4FwGEaccident)..,$... $ AUTOS ONLY AUTOS ONLY (per"y°Ldp -.---- __-- UMBRELLA LIAB ICLAIMS-MAR�CCUREACH k ... OCCUR OCCURRENCE _._......_ ........., $ „ ... .... EXCESS LIABAGGREGATE EXC $ �. DED RETENTION $ $ WORKERS COMPENSATION PER OTH- AT�TE AND EMPLOYERS LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBEREXCLUDED? NIA E L EACH.ACCIDENT _ _ $_ (Mandatory in NH) E. L DISEASE - EA EMPLOYEE $mmm If yes, desoibe under DESCRIPTION OF OPERATIONS below LIMIT E.L, DISEASE- POLICYT $ Professional Liability (Errors & Per Occurrence/ Omissions): Claims -Made Aggregate DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101, Additional Remarks Schedule, may be attached if more space is required) The City of El Segundo, its elected and appointed officials, employees as additional insureds. Notice of Cancellation will be provided in accordance with policy provisions. Coverage is Primary and No -Contributory such that any other insurance that may be carried by the City will be excess thereto The City of El Segundo 350 Main Street El Segundo, CA 90245 %1AIY{.CL .M I IVIY 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 (979135-LU15 AGUKU GUKI'UKA I IVIY. An rlgnts reserveu. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD The City of El Segundo 350 Main Street El Segundo, CA 90245 0 DATE (MMIDDIYYYY) A�R" CERTIFICATE OF PROPERTY INSURANCE 05/10/2025 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. PRODUCER NONTPGT PHONE ABC.No1. I"2.031654-361.? rArr u F n• 844) 472-0967 BIBERK P.O. Box 113247 Stamford, CT 06911 . ...�.—......... ........_....... ................�.�.�.�.�.�.�..,.......�.�. INSURED Blackgatecorp Blackgate low voltage 1355 Westmoreland Street Pomona, CA 91766 TICl/�A TL A.1I TAPI I"}C".['Sx F! AFFORDING iawav Dir RGVI_CInIU IUI IMRFR• NAIC # 238210 LOCATION OF PREMISES I DESCRIPTION OF PROPERTY (Attach ACORD 101. Additional Remarks Schedule, If more space is required) Location: 1355 Westmoreland StreetPomona, CA 91766 Bldg #001: Electrical Work - Within Buildings - 7456101 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. ... " ..DATE ........ ......... .....,._, ......,. ................. TYPE OF INSURANCE �........ ...___.... ..„,^..„�.�,�..,...... POLICY NUMBER ............ INSR EC DATE IT TY LIMITS COVERED PROPERTY LTR (MMIDDIYYYY) (MMIDDIYYYY) PROPERTY X..._.'. ........_ BUILDING CAUSES OF DEDUCTIBLES PERSONALPROPERTY $ ----------------- BASIC BUILDING N9BP452395 04/15/2025 04/15/2026 BUSINESS INCOME ......-..... . BROAD-..-.,.,...� 250 ........ EXTRA EXPENSE $ 0 COWp'M`4w•NT'S SPECIAL RENTAL VALUE $ EARTHQUAKE BLANKET BUILDING $ n/ -.., WIND-.........�.. a BLANKET PERSPROP -..,N. ....._T.1/a. ..... ......._ . FLOOD.,.,.,.,..... .. _. _ .... ... BLANKET BLDG & PP � ... ........ra,!a �.. ... .......................... .. $ _. .........._.. $ INLAND MARINE TYPE OF POLICY_ $.... CAUSES OF LOSS $ POLICY NUMBER NAMED PERILS $ $ CRIME $� .. ...W.� .. TYPE OF POLICY $ BOILER & MACHINERY/ $ Y EQUIPMENT BREAKDOWN $ SPECIAL CONDITIONS/OTHER COVERAGES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) CERTIFICATE HOLDER L;ANUELLA I IVI I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street AUTHORIZED REPRESENTATIVE Q El Segundo, CA 90245 ©1995 2015 ACORD CORPORATION. All rights reserved. ACORD 24 (2016103) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: N96P452395 BUSINESSOWNERS BP 04 50 01 06 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Name Of Additional Insured Persons Or Organ izations : Locations Of Covered Operations The City of El Segundo various Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph C. Who Is An Insured in Section II — Liability: 3. Any pprson(s) or organization(s) shown in the Schedule is also an additional insured, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: a. Your acts or omissions; or b. 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) desig- nated above. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury' or "property damage" occurring after: a. All work, including materials, parts or equip- ment 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 b. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. BP 04 50 01 06 © ISO Properties, Inc., 2005 Page 1 of 1 0 BUSINESSOWNERS BP 14 88 0713 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. i A, A 1 0 0 • .. • 11 This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM The following is added to Paragraph H. Other 2. You have agreed in writing in a contract or Insurance of Section III — Common Policy agreement that this insurance would be Conditions and supersedes any provision to the primary and would not seek contribution from contrary: any other insurance available to the additional Primary And Noncontributory Insurance insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: 1. The additional insured is a Named Insured under such other insurance; and BP 14 88 0713 © Insurance Services Office, Inc., 2012 Page 1 of 1 �\"Y_ (,�o� &q I �-- I � q q 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 # 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. - Signature of Applicant Date Print Name Agreement for: Dated: (rjGet your digital proof of insurance & membership card on the AAA App r7 >>>Download the app. Click AAA.com/app75 Electronic proof of insufmce may no be WWI as pmd in all stales. Please keep your hardcopy w on hand. Must be a current AAA member and insured through AAA 10 use Mis Wuaa Avoftlo for iPhone® and smorfphanes for Andtaldw� Messaga,data and roaming rates may apply. _,l 0 California Evidence of Liability Insurance Interinsurance Exchange of the Automobile Club NAIC #: 15598 Named Insured Policy Number: CAA213448179 SOUTHERN, NICOLE Date: 10/29/2024 Expiration Date: 10/29/2025 This policy complies with Sections 16056 or 16500.5 of the California Vehicle Code. Coverage subject to policy terms and limits. VEHICLES ON POLICY YEAR MAKE VEH I.D. # 2015 w of Lu o DRIVERS ON POLICY J O NICOLE SOUTHERN IF YOU HAVE AN ACCIDENT CALL OUR 24/7 AAA CLAIMS HOTLINE 1-800-672-5246 After an accident, exchange information with the other party and follow these 5 easy steps: Step 1: Pull vehicle over to a safe place. Get the names, addresses, and phone numbers of all persons involved in the accident, e.g., w pedestrians, witnesses, other passengers, etc. _ 0 0 Step 4: Take photos of the vehicles involved, damages and surrounding area of the accident, if it is safe to do so. Step 5: Call our AAA Claims Hotline at 800-672-5246 to report the I Step 2: Take photos of or write down the other person's driver's loss. If necessary, we will arrange to have your vehicle towed. Our i license information and other vehicle's license plate number, i provider's tow trucks always display the AAA emblem. { including state of registration. Do not admit responsibility for or discuss the circumstances of the accident Step 3: Take photos of or write down the other person's insurance with anyone other than the police or an authorized Auto Club claims card information. representative. Do not disclose your policy limits to anyone. I For questions or changes to our policy, call 1-877-422-2100, Monday throughy 9 p.m. or Saturday from 8 a.m. to 5 p.m. � q 9 Y P Y Y --------_--___---.....---------_-..,----------------- -------- ----------------------------------------- Evidence � of financial responsibility shall at all times be carried in the vehicle. In addition, we suggest-� that each listed driver carry a card. Under California law, drivers and owners of a motor vehicle must Call our AAA Claims be able to show proof of financial responsibility at all times. Insurance information has already been submitted directly to the DMV electronically, submit this document to DMV only if specifically Hotline at 1-800-672-5246 requested by DMV. These cards become invalid and should be destroyed on the expiration or _-__-----_ -----_------- " tll L B �tSLii�4 --------------- California Evidence of Liability Insurance Interinsurance Exchange of the Automobile Club YEAR MAKE NAIC #: 15598 2015 IF YOU HAVE AN ACCIDENT CALL OUR 24/7 AAA CLAIMS HOTLINE 1-800-672-5246 After an accident, exchange information with the other party and ' follow these 5 easy steps: w Of Step 1: Pull vehicle over to a safe place. Get the names, addresses, = and phone numbers of all persons involved in the accident, e.g., o pedestrians, witnesses, other passengers, etc. o ( Step 2: Take photos of or write down the other person's driver's license information and other vehicle's license plate number, including state of registration. Step 3: Take photos of or write down the other person's insurance card information. Step 4: Take photos of the vehicles involved, damages and surrounding area of the accident, if it is safe to do so. Step 5: Call our AAA Claims Hotline at 800-672-5246 to report the loss. If necessary, we will arrange to have your vehicle towed. Our provider's tow trucks always display the AAA emblem. Do not admit responsibility for or discuss the circumstances of the accident with anyone other than the police or an authorized Auto Club claims representative. Do not disclose your policy limits to anyone. For questions or changes to your policy, call 1-877-422-2100, Monday through Friday from 7 a.m. to 9 p.m. or Saturday from 8 a.m. to 5 p.m. LCAA0805A. E20240909 021125 8165 (10/24) Interinsurance Exchange of the Automobile Club 0 Automobile Insurance Policy Change Confirmation / Named Insured and Mailing Address: SOUTHERN, 1355XXXXXXXXXXXXXXX Pomona, CA 91766 Policy Number: CAA213448179 Policy Term Dates: 10/29/2024 - 10/29/2025 IMPORTANT NOTICE: This will confirm the policy change(s) you recently made effective 02/11/2025. You will be receiving a Policy Change Declaration in the mail shortly. For your protection California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement In state prison. DRIVER INFORMATION: D641na Safdv_&;.p.d. Drivers' Names (Last, First) Date of Birth Gender Rated Veh Year First Licensed GDD Chargeable Citations Chargeable Accidents Southern, 0 0 VEHICLE INFORMATION: No. Year Vehicle Garage Annual Verified (gducti AVI Special Car Rent. Primary Make/Model Zip Code Miles Mileage Salvage Comp. Collision Equip. Expense Driver VEHICLE PREMIUM INFORMATION: Coverages Limits ($) Bodily Injury 100,000/300,000 Property Damage 50,000 Medical Payments Not Wanted Uninsured/Underinsured Motorist Bodily Injury 100,000/300,000 Comprehensive (See Deductibles) Collision (See Deductibles) Car Rental Expense (See Above) Uninsured Collision Uninsured Deductible Waiver Yes 12- MONTH VEHICLE PREMIUM: LIMIT OF LIABILITY (IF APPLICABLE) No. Year Vehicle Make/Model Limit of Liabili POLICY DISCOUNTS: Please review these carefully as you are warranting that you are entitled to the following discounts. Good Good Student Multi - Multi Mature Driving Grp -Deg. Verified Driver Student Away Vehicle Policy Driver Course Loyalty Professional Mileage Yes No No Yes Yes No No No No Yes CURRENT 12-MONTH POLICY PREMIUM TOTAL: $3,937 NEW 12-MONTH POLICY PREMIUM TOTAL after Policy Changes: $5,727 SUBJECT(S) OF POLICY CHANGE: THIS IS NOT A BILL This policy change will increase your premium by $1,276 for the remainder of the term. LCAA0203A Insurance provided to qualified Auto Club members by the Interinsurance Exchange of the Automobile Club. 8010 (1/22) E20211202 CA Dept. of Insurance Oc. #000 259 021125 Page 2 of 2