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PROOF OF INSURANCE (2026)HOPEFOR-02 .,,.,. �j�i Al RO DATE (MM2026YY) CERTIFICATE OF LIABILITY INSURANCE zizm3i.. 26 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)mmITmmm�IT PRODUCER C TACT Alex Garcia ' _... American Tri-Star Insurance Services Inc. PHONE 16162 BEACH BLVD STE 100 (Arc,tly El„?� 919-0326 al i Huntington Beach, CA 92647° .co amt m INSURED Hope For Homeless Youth 9700 La Tuna Canyon Rd Sun Valley, CA 91352 r:1I" COVERAGES CERTIFICATE NQMBER: _ _ VI ION NL!99I 1t mm 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. _ ., ,. �ADDLJSUB POLICY NUMBER �POl � 1 LIMITS INSR .. }NSD �.'.W.ViE RI CMMf.^J..�.LICY EXP TYPE OF INSURANCE I A X COMMERCIAL GENERAL LIABILITY ... EACH OCCURRENCE ..1 �I'tll �QtIM 1 CLAIMS -MADE X OCCUR �( 1 �( 96B00848'1 gfiA MADE Tab ReNTEO 100,000 5/29/2025 f 5/29/2026 J �IFM� I IGr„ryPP,/ rla e) , ..1, ME D FXP �,. .... (AnyAne p rsop) 1 000 000 �, PFRRSONAL 8 ADV INJURY � 5 " -.. , '^ PER: f GENL AGC RECAlE LIMIT APPLIES P P I I C EPViti9T6LAt`afl"aREJ1TP,. ... 2„000,000 POLICY JPERCOT LOC 0,000d 2 00 CCOMP ,, � ,m �....,,�'lV%',I . ................ AUTOMOBILE LIABILITY D SINGLE COMBINE I IMIT . ANY AUTO { 9�OOIft Y pNUURY IPar,pf"gr!1 .,.� ....�OWNED I SCHEDULED AUTOS ONLY ; AUTOS ; { d ,,S _ I { BOY.7ILY IN.IMRY IPecaca.id�rnap , S ., PROPERTY DAMAGE Ni,"aN•O�WNECb HIRED ,,,, AUTOS ONLY AUTOS ONLY �, (Perae.cwrdenl) ,� .. mm_ _ ........� .......1 .. UMBRELLA LIAB OCCUR 1 RR E S {EA9"hV O U OJT, ,,. EXCESS LIAB CLAIMS MADE ACGR)- I TE mm DED RETENTION $ WOR........, IRS AND EMPLOYERS' LIABILITY YIN ....... ..r,.�-------PIER I I ANY PROPRIETOR/PARTNER/EXECUTIVE A CEA E111R aRo�M 'n NH EXCLUDED? ;NIA ry ) E h. I7aS AS EMPLO?",E, ;„ 5ae .. II�p ens, describe under DESCRIPTION OF'OPERATiONSbelmv _. -- i EL MSEASE flaOtl.gGYL@MRd ....._ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) 30 day cancellation notice applies. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St El Segundo, CA 90245 ._......_....... ...._... .......... .,,, ...... AUTHORIZED REPRESENTATIVE 1. ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 796BOO8481 COMMERCIAL GENERAL LIABILITY CG 20 12 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OFF GOVERNMENTAL AGENCY OR SUBDIVISION OR POLITICAL SUBDIVISION - PERMITS OR AUTHORIZATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: City of E1 Segundo, its elected and appointed officials, employees, and volunteers 350 Main St El Segundo CA 90245 I 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 any state or governmental agency or subdivision or political subdivision shown in the Schedule, subject to the following provisions: 1. This insurance applies only with respect to operations performed by you or on your behalf for which the state or governmental agency or subdivision or political subdivision has issued a permit or authorization. However: a. The insurance afforded to such additional insured only applies to the extent permitted by law; and b. 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. 2. This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the federal government, state or municipality; or b. "Bodily injury" or "property damage" included within the "products -completed operations hazard". B. 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; whichever is less. This endorsement shall not increase the applicable limits of insurance. CG 20 12 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Reg 10 ffa This endorsement modifies insurance provided under the following:. COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is, added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance 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 (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 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 Name of Agent Policy Number Expiration Date 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 Applicant ly w e gree , ent will automatically become void. Si nauecomply with th prov�sron r t Date 9 Print Name Agreement for: Dated:. Reviewed by: