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PROOF OF INSURANCE (2026)
a DATE (MM/DDIYYYY) AC'C>R" CERTIFICATE OF LIABILITY INSURANCE 03/10/2026 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). NAME. ort.thimble.com/ PRODUCER CO ACT THIMBLE https l/supp Verifly Insurance Services, LLC DBA Thimble Insurance Services PHONE FAX 174 West 4th Street, Suite 204 Frst)'/ Nep ... New York, NY 10014 MAIL hlmble com �PpFESSs�°ppo�@t:........_ ....:.:...... �. p pp tS AFFORDING COVERAGE NAIC # htt s:llsu ort.thimble.coml INSURERA: tl f) I. �E:I? �: - ..... .------.. _ �� INSURE Morpheon Corporation dlb/a ACME 4IR)tN I9 �rp�ompanr -- 22608 3580 Greenhill Rd, Pasadena, CA, 91107 R B INSURE .. ...:.:. .. ... .... .-.. INSURED Time Machine INSURE:::::: C .. ---- .... .._ ............ .....- .,.,, purchasing@morpheon.com INSURER D . .. R ---- ....:. ........... ..... .: INSURE E . INSURER F : https://www.thimble.com/check-policy-status/ , COVERAGES 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. .:.:,,. ....... .,V ( ...... . .�..�.� .. ADDL S)I R� POLICY EFF POLI Y EXP .........._._ ..TYPE ILTR .... .... .......... LIMITS OF INSURANCE.. i. POLICY NUMBER... MMIDDIYYYY MMID X COMMERCIAL GENERAL LIABILITY 05/02/2026 05/02/2026 _EACH OCCURRENCE $ „ 2,0010 000 ( ..... CLAIMS -MADE I X....� OCCUR AM PM LAIWpihI'<')("59:N'rbM �a) $..,..:. ....... - 10Q,QQC?_ ..........� PDT PDT EDIEXP (Any one pers on) $ 5,000 A Y Y IBL-P3NM8YZ7YJ PERSONAL 8 ADV INJURY $ 2,000,000 GEN-L AGGREGATELIMITAPPLIES PER: GENERAL �$ 2,000,000 G AGGREGATE } '� I LOC-.-.-.. i X POLICY JEmC1`g - PRODUCT AGG $ 2,000,000 P .. S ........... ......1 ..l OTHER: COIutBVNtu StlNC9 E LIMIT AUTOMOBILE LIABILITY ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED �� BODILY INJURY (Per accident) $ AUTOS ONLY .l. AUTOS --� HIRED NON -OWNED PROPBRgYpAMAGE $ .....::: AUTOS ONLY :. AUTOS ONLY - I (([r Pcc.,tg9a?,nl) __ .................. , I,..... $ UMBRELLA LIAB EACH OCCURRENCE ... $ ,.,OCCUR EXCESS LIAR CIAIMS-MADE AGGREGATE $ .A DEp RETENTION$ $ O KERS COMPENSATIONI EPA El'TE EMPLOYERS'LIABILITY YIN `" "ERH OREXCLUDED?ECUTIVE EL EACHACCIDENT $ OFFICE Mandato m NH ( ry ) NIA E.L. DISEASE EA EMPLOYE PLOYEE:.:::.. $ _ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT $ .._-..-. $ .. .............. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space isrequired) Additional Insured: The City of El Segundo, its elected and appointed officials, employees, and volunteers Co : on form Acord 101 The City of El Segundo, its elected and appointed officials, employees, and volunteers 350 Main Street El Segundo, CA 90245 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 rr V IVUtf-ZUI*AGUKU I.UKt'VKAIIUIV. All ngnzs reserveu. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: purchasing@morpheon.com ABC AnnITIONAI RIPMARKS SCHEDULE Pnnc 1 of 1 AGENCY NAMED INSURED Verifly Insurance Services, LLC DBA Thimble Insurance Services Morpheon Corporation d/b/a ACME Time Machine 3580 Greenhill Rd, Pasadena, CA, 91107 ......................... POLICY NUMBER purchasing@morpheon.com I BL-P3 N M8YZ7YJ ER NAIC CODE National Specialty Insurance Company 22608 rrFE TdvE"DA"I'E. 65/02/2026" -0"A DT"u �� ------ AUVI I IUNAL KCMAKK5 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACOrd 25 FORM TITLE: ,Certificate Of Liability Insurance Description of Operations (con't) Episodic Coverage (THSN CG 02 03 02 21) for policy number IBL-P3NM8YZ7YJ until 05/02/2027 6:00 PM PDT ACORD 101 (2008/01) V ZUUtS AUUKU L UKYUKA I IVIY. Art rignis rebervea. The ACORD name and logo are registered marks of ACORD THSN IL 20 20 10 20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM PROFESSIONAL LIABILITY COVERAGE FORM SCHEDULE Name of Designated Person or Organization (including its departments and attached agencies, its directors, officers, officials, employees, representatives and agents): Any person(s) or organization(s) for whom you have agreed in writing in a contract or agreement that such person(s) or organization(s) be added as an additional insured on your policy. E-Mail Address: 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 above, but only with respect to liability for "bodily inju- ry", "property damage", "personal and advertising injury" or "wrongful acts" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. 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 insur- ance 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 is added to LIM- ITS OF INSURANCE section of the coverage form 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. C. If this policy is cancelled or nonrenewed for any reason, we will deliver notice of the cancellation or non -renewal to any Designated Person or Organization shown in the SCHEDULE above at the e- mail address shown above. D. This endorsement shall not increase the applicable limits of insurance shown in the Declaration All other terms and conditions remain unchanged. THSN IL 20 20 10 20 © Verifly Insurance Services, Inc. 2020 Page 1 of 1 Includes materials copyrighted by Insurance Services Office, Inc., used with its permission POLICY NUMBER: IBL-P3NM8YZ7YJ COMMERCIAL GENERAL LIABILITY CG24041219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF' RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person(s) Or Organization(s): Any person(s) or organization(s) for whom you have agreed in writing in a contract or agreement that such person(s) or organization(s) be added as an additional insured on your policy. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery 'Against Others To Us of Section IV — Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 04 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 THSN IL 20 20 10 20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED ADDITIONAL INSPIRED This endorsement modifies insurance provided under the following. COMMERCIAL GENERAL LIABILITY COVERAGE FORM PROFESSIONAL LIABILITY COVERAGE FORM SCHEDULE Name of Designated Person or Organization (including its departments and attached agencies, its directors, officers, officials, employees, representatives and agents): The City of El Segundo, its elected and appointed officials, employees, and volunteers E-Mail Address: bruszczyk@elsegundo.org 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 above, but only with respect to liability for "bodily inju- ry", "property damage", "personal and advertising injury" or "wrongful acts" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. THSN IL 20 20 10 20 © Verifly Insurance Services, Inc. 2020 Page 1 of 2 Includes materials copyrighted by Insurance Services Office, Inc., used with its permission THSN IL 20 20 10 20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 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 insur- ance 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 is added to LIM- ITS OF INSURANCE section of the coverage form 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. C. If this policy is cancelled or nonrenewed for any reason, we will deliver notice of the cancellation or non -renewal to any Designated Person or Organization shown in the SCHEDULE above at the e- mail address shown above. D. This endorsement shall not increase the applicable limits of insurance shown in the Declaration All other terms and conditions remain unchanged. THSN IL 20 20 10 20 © Verifly Insurance Services, Inc. 2020 Page 2 of 2 Includes materials copyrighted by Insurance Services Office, Inc., used with its permission COMMERCIAL GENERAL LIABILITY CG 20 01 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. oil 9 : 11:2 ""` 1 Aki I• ' IN • This endorsement modifies insurance provided under the following; COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the additional 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 CG 20 01 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 POLICY NUMBER: IBL-P3NM8YZ7YJ COMMERCIAL GENERAL LIABILITY CG24041219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE Name Of Person(s) Or Organization(s): The City of El Segundo, its elected and appointed officials, employees, and volunteers bruszczyk@elsegundo.org I information required to complete this Schedule, if not shown above, will be shown in the Declarations. I The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV —Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 04 12 19 © Insurance Services Office, Inc., 2018 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. 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 # J) 1 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 thos rovisirs he agreement will automatically become void. Signature of Applicant Date3/10/2026 Print Name Ronnie Po Agreement for: Dated: Reviewed by: