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PROOF OF INSURANCE (2026)GOVEBUS-01 .......... CERTIFICATE OF LIABILITY INSURANCE DATE 5/22/2026 ) 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 .........._. µµµµWm WWW p ns 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 endorsements) COVERAGES CERTIFICATE NUMBER: REVISION NUMBED, ...... � ............ 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, ONS AND CONDITIONS OF SUCH BYO � CY EW PAID CLAIMS. tNSR I TYPE of INSURANCE DL sgJR LIMITS SHOWN MAY HAVE BEEN REDUCED A X . .... _ S P ,000 EXCLUSIONS . -t� POLICY NUMBER � ��...�- P17LICY EXP �.._ ... ... , _ LIMI �5...... ��.._,... 1,000.... - .... COMMERCIAL GENERAL LIABILITY EACH I: 47C C,URRENCE w DAMAGE 00,000 CLAIMS -MADE X X hGEC%kXP A �r gsaTO REN IEC escati. 110,000 L occuR C69865,27201 7113/2025 7/13/2026 P1fl PERSONALw&ADi+_uhl�q�RY ...,. 1,000,000 X PC799q;Y TELIMITAPPL❑IES ®C_PRCiCkkdC4MPt4P„O 5 2000r 00 GEN.L AGGREGATE 0 11 PRO- _ _ _ _.... 2 000......... JECT OOO OTHER: ..........._. � COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY _.lEMi IJtD ....... 111. 1 .. .. .. ANY AUTO BOfJtl M gF I BURY �cn acrtlrfei I BODILY I J (Per. p OWNED SCHEDULED I HIRED NON OWNED IPer rcnlsnN�. S„. AUTOS ONLY ,......... AUTOS �... R I „^ ....._„ ..„„„. . AUTOS ONLY .� AUTOS ONLY .„.mm.......mmIT....IT. __..... ._..... PROE 1"RY'YDAMAC.E _, CLPRREC4 S ........ UMBRELLA LIAB OCCUR EAF"@ 14OC,, ,mm ,_, , _. _. EXCESS LIAB r.............. CLAIMS -MADE AGiidEC,'A0'E..... ..........-- ....„ .... ..------......... .. COMPENSATION ' LIABILITY - WORKERSKERS COMPENSATION N $ ...... .............m.... .......... .._._....� PER OTH AND ' TAT.t7TC R .. .. Y/ ANFYtlCPROPMREIETOR/PARTNER/EXECUTIVE E L EAC ,tl ACCtlDFNT S - •„ MBER EXCLUDED......_.:......_.. .... ........_......., ,._. ...............�F.L. DBSstiSF EA EMPLOYEE ... addahary In NH) NIA E L DISEASE E E �.S .... Id eSS deSCr(be a r, D SCRI'PTIONC} OPL:,tl------ hcrlow FASF ,POIlOYn.IMtlG ... . ...... .. ..... ­­_..._.L . ........... ... .......... El Segundo Pollee A Department TIONS aEHICIT� iti __.. _ ...� DESCRIPTION OF OPERA"fiONS BILOCATIONS / VEHICLES. ACORD 101, Additional Remarks Schedule, maEyr be attached if more space is required) g p tonal insureds but only Wlth respect general liability. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE El Segundo Police Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 P ACCORDANCE WITH THE POLICY PROVISIONS. 348 Main Street El Segundo, CA 90245 ........ .�............................ . _ ....._ A�UTHAO'R.I.Z�ED REPRESENTATIVE ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CNA BEST CHOICE CONTRACTOR PROGRAM Blanket Additional Insured - Owners, Lessees or Contractors This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Policv Number: C6986527201 I Endorsement Effective: 07/13/2025 Named Insured: GOVERNMENT BUSINESS INTERIORS LLC DBA OFFICE DESIGN & FABRICATION at 12:01 a.m.. SCHEDULE Name of Additional Insured Person(s) or Organization(s): (Blanket) (Specific) Any person or organization that the Named Insured is obligated by virtue of a written contract or written agreement to make an additional insured on this Coverage Part, provided such contract or agreement: a Is currently in effect or becomes effective during the policy period; and and • Was executed prior to: a. the bodily injury, or property damage; or b. the offense that caused the personal and advertising injury; for which the additional insured seeks coverage. Location(s) of Covered Operations: Any location in the "coverage territory" that is subject and to the contract or agreement specified above. A. Section II — Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization shown in the Schedule is held liable for your acts or omissions arising out of your ongoing operations performed for that 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 part of the same project. C. With respect to the insurance afforded to these additional insureds, this insurance also does not apply to bodily injury, property damage or personal and advertising injury arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: 1. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or 2. Supervisory, inspection, architectural or engineering activities. D. Primary and Noncontributory Insurance Submission No:QCN07875699-1 Policy No: C6986527201 Page 1 of 2 Effective Date: 07/13/2025 Insured Name :GOVERNMENT BUSINESS INTERIORS LLC DBA OFFICE DESIGN & FABRICATION Copyright CNA All Rights Reserved. Includes copyrighted material of Insurance Services Office, Inc. used with permission. - BEST CHOICE CONTRACTOR PROGRAM CNA Blanket Additional Insured - Owners, Lessees or Contractors If so required by a written contract or written agreement, this insurance will be primary to, and will not seek contribution from, other insurance under which the additional insured is a named insured. But in all other instances, and notwithstanding anything to the contrary in the condition entitled Other Insurance, this insurance will be excess of any other insurance available to the additional insured. E. Solely with respect to the insurance granted by this endorsement, the section entitled COMMERCIAL GENERAL LIABILITY CONDITIONS is amended to add the following to the condition entitled Duties In The Event of Occurrence, Offense, Claim or Suit: Any additional insured pursuant to this Coverage Part will, as soon as possible: 1. Give us written notice of any claim, or of any occurrence or offense that may result in a claim; 2. Send us copies of all legal papers received and otherwise cooperate with us in the investigation, defense or settlement of the claim; and 3. Make available any other insurance and tender the defense and indemnity of any claim to any other insurer or self -insurer whose policy or program applies to a loss that we cover under this Coverage Part. However, if the written contract requires this insurance to be primary and non-contributory, this paragraph 3. does not apply to insurance on which the additional insured is a named insured. F. Solely with respect to the insurance granted by this endorsement: 1. The words "you" and "your" refer to the Named Insured shown in the Declarations. 2. Your work means work or operations performed by you or on your behalf, and materials parts or equipment furnished in connection with such work or operations. G. Blanket Waiver of Subrogation We waive any right of recovery we may have against an entity that is an additional insured under the terms of this endorsement with respect to payments we make for injury or damage arising out of your work done under a written contract or written agreement with that person or organization, provided such contract or agreement: 1. Requires such a waiver of our rights; 2. Is currently in effect or becomes effective during the policy period; and 3. Was executed prior the bodily injury, property damage or personal and advertising injury that gave rise to the claim. All other terms and conditions of the Policy remain unchanged. This endorsement, which forms a part of and is for attachment to the Policy issued by the designated Insurers, takes effect on the effective date of said Policy at the hour stated in said Policy, unless another effective date is shown below, and expires concurrently with said Policy. Submission No:QCN07875699-1 Policy No: C6986527201 Page 2 of 2 Effective Date: 07/13/2025 Insured Name :GOVERNMENT BUSINESS INTERIORS LLC DBA OFFICE DESIGN & FABRICATION Copyright CNA All Rights Reserved. Includes copyrighted material of Insurance Services Office, Inc. used with permission. 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; C_) 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 q�a.�e� a-� Date 5/21 /2026 Agreement for: Dated Reviewed by: