PROOF OF INSURANCE (2026 - 2026)qSr AC COR`O CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY)
. 12/19/2025
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(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terns 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 Lin D Diaz
NAMES ....... .... ........._..
PHONE 888.457.4426 Fq N�,323.576.4552
D&C Insurance Solutions r t��.EzttJ:
E-M'5 conlact0dcn-insurance,com
300 S. Atlantic Blvd., Ste 201-8 INSURER(S)AFFORDINGCOVERAGE ,NAIC#
Monterey Park CA 91754 INSURERA: Western World Insurance Company 13196
........ ............... _. .
INSURED INSURER B
g ER C t
Tillmann Forensic Invests atlons, wSU .... .................
INSURER D
PO Box 4373 INSURER E : _
Covina CA 91723 IN�� SURER F
rnvcoAncc CERTIFICATE 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.
INSR OOL SUER POLICY EFF OLICY EXP
LTR TYPE OF INSURANCE POLICY NUMBER MNI/DDIYYXX MMIDOIYYYY
LIMITS
....
X COMMERCIALGENERAL LIABILITY A NPP6232586 12/17/2025 12/17/2026
EACHOCCURRENCE $ 1,000,000
�I
.....
_159M_AZi��T�U� l.
$ 100,000
X �
CLAIMS -MADE OCCUR
IX
PR MI SF r Rgnr,P.
MED EXP Any are .Person) $ .............. 5,000
..._.
............ ..._._.
PERSONAL B ADV INJURY $ 1,000.000
AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $ 2,000 000
rX POLICY❑ PRO- ❑ LOC
ODUCTS-COMP/OPAGG $ Included
PR ........�
Errors & Omissions $ Included
OTHER,
COMBINED SWGLLE LIMIT $
AUTOMOBILE LIABILITY
......_ .........
ANY AUTO
BODILY INJURY (Prperson) $
OWNED SCHEDULED
BODILY INJURY (Per accident)
„ AUTOS ONLY AUTOS
HIRED NON -OWNED
----
PROPFR'IY DAMAGE $ ..
AUTOS ONLY .,„,_,_m, AUTOS ONLY
,(?er ucxu n¢nll _... .....
....
$
Wes .
— .. ......... ....
UMBRELLA LIAB OCCUR
. EACH OCCURRENCE $
EXCESS LIAB CLAIMS -MADE
_.. .....
AGGREGATE $ .. .
...._... ....._
..
pED RETENTION
$
WORKERS COMPENSATION
PER OTH
TATUTE
'AND EMPLOYERS' LIABILITY YIN
_ .l�.I?
ANYPROPRIETOR/PARTNER/EXECUTIVE
E,L EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? ❑ NIA
(Mandatory in NH)
E.L. DISEASE EA EMPLOYEE $
.
M. —
If yes describe under
DESCRIPTIONOF OPERATIONS below
'E,L,DISEASE - POLICY LIMIT $ _
WDESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Regarding the above referenced General Liability Insurance policy, the certificate holder is included asadditional insured,
but only with respect to the negligent acts, errors or omissions of the named insured.
CERTIFICATE HOLDER t ANUr_LLA I Ivn
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
V l9tStf-LUIb AI.VFCU I.VF(F'VrW I IVIY. MII ngnLs rGaervUU.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: NPP6232586
COMMERCIAL GENERAL LIABILITY
CG20100413
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 Organization(s):
City of El Segundo Various 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
state, Pdrm CALIFORNIA
INSURANCE CARD
Farm Mutual Automobile Insurance Company
W 2358 Bloomin toll II. tI1702 2 98
IED TILLMANI Won & VUL
POLICY NUMBER � -74G EFFECTIVE
m 21i19 W E JEEP sVa OR -96M TO UAR 29 2020
MODEL WRAN aLF-Ft VIN 789
A r-SMP61-r 1317-AED
NA;IC 2017f
6 ty
oETHE POU Y M E7$ '"HE MIMMUM I IAHIUN LIMITS
I gb Cx1000 }i U U1
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.
C_) I have and will maintain workers'compensation insurance as required by Labor Cade § 3700farthe 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 $6 as to become subject to the workers' compensation laws of California, and
agree that, if I should become s bract to the workers' compensation provisions of Labor Code § 3700 1must
immediately comply with those pr signs o e agreement will autoratically become void.
Signature of Applicant
Date fifgSltl5
Agreement for:
Dated:
Reviewed by: