PROOF OF INSURANCE (2027 - 2027)ACCORD® CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYY)
4/23/2026
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).
PRODUCER
CONTACT
NAME: Chavon Hurtado
Balsiger Insurance - Centurion
PHONE FAX
3481 E Sunset Dr # 100
A/C No Ext : 7028521165 A/C, No):
E-MSUITE
ADDRESS: chavon@balsigerinsurance.com
600
INSURER(S) AFFORDING COVERAGE
NAIC#
Las Vegas NV 89120
INSURERA: The Burlington Insurance Company
23620
INSURED CODE5GR-01
INSURERB: Spinnaker Specialty Insurance Company
17045
Code 5 Group, LLC
2505 ANTHEM VILLAGE DR
INSURERC:
INSURERD:
Suite E459
Henderson NV 89052
INSURERE:
INSURER F :
COVERAGES CERTIFICATE NUMBER:351942550 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
LTR
TYPE OF INSURANCE
ADDL
INSD
SUBR
WVD
POLICYNUMBER
POLICY EFF
MM/DD
POLICY EXP
MM/DD
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
482B0088273
4/20/2026
4/20/2027
EACH OCCURRENCE
$ 1,000,000
CLAIMS -MADE OCCUR
DAMAGE TO RENTED
PREMISES Ea occurrence
$ 100,000
MED EXP (Any one person)
$ 5,000
PERSONAL & ADV INJURY
$EXC
GEN'L
AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,000
POLICY ❑PRO ❑
JECT LOC
X
PRODUCTS - COMP/OP AGG
$ EXC
$
OTHER:
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
Ea accident
$
BODILY INJURY (Per person)
$
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
UMBRELLALIAB
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LAB
CLAIMS -MADE
DED RETENTION $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
PER OTH-
STATUTE ER
ANYPROPRIETOR/PARTNER/EXECUTIVE
E.L. EACH ACCIDENT
$
OFFICER/MEMBER EXCLUDED? ❑
N/A
E.L. DISEASE - EA EMPLOYEE
$
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$
B
Commercial Cyber
FLY-RBC-XK4396002
3/3/2026
3/3/2027
Cyber Liability 1
$1,000,000
Privacy Liability
Social Enginerring
$250,000
Breach Costs Outside
$500,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of El Segundo Police Department
348 Main St
AUTHORIZED REPRESENTATIVE
El Segundo CA 90245
@ 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 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 #
(X) 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 Applicanty' /(/�azsu.� Date 05/08/25
Agreement for:
Dated:
Reviewed by: