PROOF OF INSURANCE (2027).. CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDD/YYYY)
05/18/2026
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
Hiscox Inc. d/b/a/ Hiscox Insurance Agency in CA PHON y ExtL (' ."".. FAx
5 Concourse Parkway EMAIL 888) 202-3007 tA/c Not:
Suite 2150 ntact o hiscox.com
At RESS
Atlanta GA, 30328 Hiscox Insurance Company Inc
10200^ ^~
INSURER A: p y _ .....
INSURED
INSURER B
Metro-Tec, LLC
INSUR ER C
402 Virginia Street
El Segundo, CA 90245
Inls•
UR
INSURER E
rnvGoer_Gc r_FRTIFIrATF NIIMRFR• 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.
LTR ., — ._..-......... _
INSR TYPE OF INSURANCE ADDL SUBR POLICY
LTR NUMBER MM/DD/YYYY MM YY LIMITS
i�pydYYm
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000.000
X .
CLAIMS MADE mmmmm OCCUR
DPR SES Ea occy,,r„rence�
(
.. . ,.,.. m.
$ 100,000
�. ..�-..
person)
MED EXP (Any one.Pe......
$ 5 000
_ - ... .
A�
Y
P106.607.661.1
05/13/2026
05/13/2027 PERSONAL a ADV INJURY... ...$
1,000,000 .... _
GEN'L
__
AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,000 .... .. ,.
X.
PRO-
POR.ICY' � LOC
JECT
PRODUCTS COMP/OP AGG
$ S/T Gen Agg�mmmm
$
OTHER
AUTOMOBILE LIABILITY
COMBINED SINGLE .LIMIT
E a ac-
$
-
ANY AUTO
BODILY INJURY (Per person)
I $
-- ALL OWNED SCHEDULED
BODILY INJURY (Per accident)
$
AUTOS AUTOS
PROPERTYIDAMAGE
—.
HIRED AUTOS AUTOSWNED
(Perq„Ideral)
UMBRELLA LIAB OCCUR
EACH OCCURRENCE ...
$
EXCESS LIAB CLAIMS -MADE
AGGREGATE
$
DED RETENTION $
WORKERS COMPENSATION
I$
POTH-
ER UTE, ER....
AND YIN
E?ECUTIVE
ONFICERMEMN R ANYPROPRIETOR/PRBNE
❑NIA
...E.....DISEASECEAENT
.............rvnmm^,....___�-w„L.,,,,.....
atory in
EM_PLOYEE...$
If yes, describe under
$
DESCRIPTION OF OPERATIONS below
E„L. DISEASE- POLICY LIMIT
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
City of El Segundo, its elected and appointed officials, employees, and volunteers.lts officers directors, agents, board members, affiliates , subsidiaries, officials,
rustees , employees and volunteers are additionally insured on this policy per its terms and conditions.
Gt.RIII- I+GAII HU,LUtK LArNUCLLAI'.IVIII
City of EI Segundo, its elected and appointed officials, employees, and volunte
err SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
350 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
EI Segundo, California 90245
AUTHORIZED REPRESENTATIVE
9 1988-2015 ACORD GURPUKA I IUN. All rignts reservea.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
Metro-Tec, LLC
402 Virginia St
El Segundo, CA 90245
POLICY CHANGES
POLICY NUMBER POLICY CHANGES EFFECTIVE COMPANY
N8PL508135 05/22/2026 Berkshire Hathaway Direct Insurance
Company
NAMED INSURED PREMIUM CHANGE
Metro-Tec, LLC $0.00
CHANGES
Additional Insureds
Added Name of Person or Organization: The City of El Segundo, its elected and
appointed officials, employees, and volunteers
Address: 210 S Academy Ave
City: Sanger
State: CA
Zip: 93657
city search:
Policy Forms
Added Additional Insureds (MPL 00 24 11 15)
MPL MTC 1218 Page 1 of 1
MISCELLANEOUS PROFESSIONAL LIABILITY
MPL 00 24 11 15
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY..
This endorsement modifies insurance provided under the following:
Miscellaneous Professional Liability Insurance Policy
SECTION V — DEFINITIONS, Section M. "Insured"
of the policy is amended to add the following:
The Additional Insured stated below, but only for
liability arising solely out of Wrongful Acts in the
performance of Insured Services by the Named
Insured or the Individual Insureds:
The City of El Segundo, its elected and appointed
officials, employees, and volunteers
It is also agreed the policy does not apply to any
Claim which includes allegations or facts indicating
actual or alleged independent or direct liability on the
part of an Additional Insured.
All other terms and conditions of this policy
remain unchanged.
MPL 00 24 11 15 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:
L_) 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 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
Signature ly compAppliant ose pr visions or the agreement will automatically become void..
immediate) comply with th 05 / 13 / 2026
Date
Print Name arc Cava polo
Agreement for:
Dated
Reviewed by: