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PROOF OF INSURANCE (2026)CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 07/05/2025 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 .. CONTACT NAME: Nit.".__....._ Hiscox Inc. d/b/a/ Hiscox Insurance Agency in CA PHONE (888 ) 202-3007 ....... � F AX 5 Concourse Parkway E-MAM ..t@ Suite 2150 ADDmaEsscontact@hiiscox.com hlscoX.Com ,_,,,,,,,,,,,,„_,,,, -_ Atlanta GA, 30328 _ INSURER(S)AFFORDING COVERAGE NAIC# INSURERA• Hiscox Insurance Company Inc 10200 ......................... INSURED INSURER B : Essential Safety Management, LLC INSURER C : 715 W Oak Ave INSURER DT� El Segundo, CA 90245 IN INSURER E : rrtlsr Cif%wrc r11IRAMC . RF'VIRInNN N UMRFR- NSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD �THIS9ISPOLICIES OF INSURANCE 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 ADD-d.StfR�R.ITIT LIMITS TYPEOFINSURANCE POLICY NUMBER MMAUCY"EF NYNYDD LTRiNsn X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1 000 0 CLAIMS -MADE LX,.. I OCCUR PA A4-9 I�"i-N W_�_ . ._k.Fs r urw rcr5.:1,"...... _0_O $ 100,000 ...... ......... .._.m. ..._...a MED EXP (Any one person) $ _5,000 A — —....., .,...� ......._. Y P103.784.938.2 08/19/2025 08/19/2026 PERSONAL & ADV INJURY $ 1,000,000 ...".___........ GEN L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE m $ 2,000,000 POLICY PRO. LOC JECT PRODUCTS COMP/OP AGG $ S/T Gen Aggµ ... __.. X G,'MTfIEfd.�, COMBINED Dtl'SING.E LIMIT $ AUTOMOBILE LIABILITY erson person) BODILY INJURY (Per ) $„ ANY AUTO ALL OWNED SCHEDULED '.. BODILY INJURY (Per accident) $ ........_ AUTOS ......... AUTOS NON -OWNED _ PROPERTY -..................._..., $ HIRED AUTOS AUTOS ii r a zlaG ... .._........� ......... L $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE ........ ........ AGGREGATE "$QED .._-. RETENTION $ $ WORKERS COMPENSATION PER OTH : STATUT AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N / A EL DISEASE - EA EMPLOYEE..°..-, wwwww„ If yes, describe under DESCRIPTION OF OPERATIONS below E.Lr DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES AG ENTS AND VOLUNTEERS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 MAIN ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. EL SEGUNDO, CA 90245 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) 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 Califomia one of the following declarations: (J 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. (J 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 withe prr " Ions olrthe agreement will automatically become void. Signature of Applicant � �"- Date Print Name Agreement for: Dated:' c I /S Reviewed by: