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PROOF OF INSURANCE (2015) CLOSED Agreement No. 4576 Hensley Law Group HENSL-1 OP ID: MG CERTIFICATE OF LIABILITY INSURANCE DATE/15120Y 04115/204 14 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 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). 'CONTACT Summer J Corsica !Ahern PRODUCER NAME:kera PH ONE F,AQ; UJ ............. Ar -571-9010 8655 Granite Rid� Dr. /C No ,,:858-571-9030 N858 San Diego,CA 923 E-MAIL s orsica aherninsurance.com Summer J.Gor ica rp s ... qo. rs!ca _ INSURER(S)AFFORDING COVERAGE NAIC p INSURER A::Sentinel Insurance Company _ 11000 .............._.... ...................................................................................................,.....___.,.._.... ..........._,_.........._............................. . INSURED Mark Hensley dba INSURER B: Hensley Law Group . ...................................................... 2600 W.Olive Avenue,#500 INSURER C Burbank,CA 91505 INSURER D: INSURER E: INSURER F! 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. .O SCS POLICY EFF I .............................. .......INSR PE iuco min POLCYNUMBER L TY tL Itpf,pp DONYYYI LIMITS GENERAL LIABILITY `, EACH OCCURRENCE $ 2,000,00 A X COMMERCIAL GENERAL LIABILITY X 72SBWAP7031 05/01/2014 05/0112015 DAM S-0 1,000,00 N OCCUR M� I Ea�r )arreP,r�- _ _OO ..........mmmm�CLAIMS-MADE [XI WED EXP(Any,one person, , ONAL&ADV INJURY $ 2,000,00( ....._ ,_......_.........................................................................__._..��_. PERSGENERAL AGGREGATE $ 4,000.,....... .... .... GEN'LAGGREGATE LIMIT APPLIES P._E R: PRODUCTS-COMP/O.PA GG $$ 4,000,_00 OX : ................... ... POLICY LOC AUTOMOBILE LIABILITY COMBINEOSINGLIE IIMIf .. 2,000,00 Ea accudest _.......................... .. A ANY AUTO 72SBWAP7031 05/01/2014 0510112015 BODILY INJURY(Perperson) $ ALL OWNED SCHEDULED BODILY INJURY(P AUTOS AUTOS eraccident) '$ NON-OWNED KIIAMAV X HIREDAUTOS X AUTOS Idw"AC:RIEfiCf ,„ $ _..... ..... $ UMBRELLALIAB OCCUR EACHOCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ f)FD RFTFNTIC)N$ .....................................�_ $ __ _„ WORKERS COMPENSATION WCSTATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY.LIMIT$ ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L..EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ NIA •••• (Mandatory in NH) E..L..DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below I E,L DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) The certificate holder is named as additional insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City f Se THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ty El Segundo City Hall ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street AUTHORIZED REPRESENTATIVE El Segundo, CA 9024 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 72SBWAP7031 It THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Additional Insured - Person/Organization City of El Segundo, City Hall, 350 Main Street, El Segundo, CA 90245 are named as an Additional Insured as per written contract. Form IH 12 00 11 85 T SEQ. NO. Printed in U.S.A. Page Process Date: 04/15/2014 Expiration Date: 05/01/2015 HENSL-1 OP ID: HS CERTIFICATE OF LIABILITY INSURANCE DATE 04/141201 Y) 04/14/2014 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 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). CONTACT 9666 anit Ridgor�r�X5(70 PHONE 9666 ... ...... . ... X PRODUCER NAME Rand T Gust cam,858 571 9010 -San Dlo o CA 92123 Randy dust INSURERS)AFFORDING COVERAGE mmNAIC 0 INSURER A:W @SC o Insurance Company INSURED Marts Hensley+d'ba INSURER B: m... Hensley Low Group INSURERC 2600 W.Olive Avenue,#500 � .... .. __ Burbank,CA 91505 INSURER D: _ INSURER E: _ INSURERF: ..._................................................................................. ,. 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. ---- ....._...TYPE OF...-_ 1NSR PO fV"� II�JI _....... LTR INSURANCE use •n,n POLICY NUMBER MMMD'YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ _..COMMERCIAL GENERAL LIABILITY aR.FM OE rp ye CLAIMS-MADE OCCUR MED (A one person) ._$ _�.�---- ..............._ .. PERSONAL&ADV INJURY $ GENERALAGGREGATE $ GEN'L AGGREG _ ATE LIMIT APPLIES PER: PRODUCTS. AGG $ POLICY PR LOC $ AUTOMOBILE LIABILITY COMBINED I _tl �ddnt) ......_ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per AUTOS AUTOS accident) $ AUTOS NON-OWNED PRRwAm AC _W$ HIRED AUTO (,r,;, $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ .......... EXCESS LIAR CLAIMS-MADE AGGREGATE.................... $ RETE I$ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN 0? L "T "" _E _�..° ANY PROPRIETOR/PARTNER/EXECUTIVE El N NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? - (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If DKS. ON describe under OPERATIONS he14W E.L.DI--•-- .... .... SEASE-POLICY LIMIT $ A Claims Made WPP1117973-00 05/01/2014 05/01/2015 2,000,000 Per Claim Lawyers'Prof Llab 2,000,000 Aggregate DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Deductible: $15,000 per claim CERTIFICATE HOLDER CANCELLATION FOR REF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE FOR REFERENCE ONLY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. / AUTHORIZED REPRESENTATIVE ED R � ... 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010105) The ACORD name and logo are registered marks of ACORD MARKHEN-02 KSKA DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 4/17/2014 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 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 NAME '. Automatic Data Processing Insurance Agency,Inc PHONE VAX 1 ADP Boulevard N. a!.. Fm (A/C.No): AJL Roseland,NJ 07068 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER.,,,.,,Employers o ._.._...- _......__ ........ ,,,, A: Compensation Ins Co 41394 ,.INSURED Mark Hensley INSURER a: ,. m __ Mark Hensley INSURER C.... _._.. ------— ....... ..,, . ,,.'.. 2600 W Olive Ave Ste 500 INSURER D: ......... Burbank, CA 91505- INSURER E INSURER F: 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„ tNTp ........ POLICY EF POLICY E,XP TYPE OF INSURANCE INSR wvn POLICY NUMBER Mkr/U'OL".+YYY MPdRI'CIDJYYNY' LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 5AMAGETOkENTI=rb -- COMMERCIAL GENERAL LIABILITY PRFMIRFR(Fa nrrurrenra) $ _ ___ CLAIMS-MADE OCCUR MED EXP(Any one person) PERSONAL&ADV INJURY $ - GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $ POLICY - PR LOC $ AUTOMOBILE LIABILITY COMBOIED SWGLE'LIMIT ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY --- AUTOS AUTOS BODILY INJURY(Per accident) $ '....NON-OWNED PRoPER'IY DAMa4CrE;. $ HIRED AUTOS AUTOS (Per accident) , UMBRELLA LIAB OCCUR EACH OCCURRENCE $ .... ...... CLAIMS-MADE AG _................. ...... . EXCESS LIAB GREGATE $ —DED 71 RETENTION$ I$ WORKERS COMPENSATION WCSTATU OfH AND EMPLOYERS'LIABILITY X T Rv I,),nnlrc FR n A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N IEIG209275200 5/1/2014 5/1/2015 1 EL,EACH ACCIDENT $ $1,000,000.00 (Mandatary in NH) E,L.DISEASE-EA EMPLOYEE $ $1,000,000.0 describe under DYSCRIPTI N OF OPERATIONS below E.L p .DISEASE POLICY LIMIT $ $1,000,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) "PROOF OF COVERAGE" CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN INSURED COPY ACCORDANCE WITH THE POLICY PROVISIONS. ~ AUTHORIZED REPRESENTATIVE t C 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD MARKHEN-02 CACA DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 4/2212014 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 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 C NTA T NAME: Automatic Data Processing Insurance Agency,Inc PHONE �°ir No .............................................................. ako,'..... 1 ADP Boulevard E.MAIa_ _...................... ........ Roseland,NJ 07068 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Employers Compensation Ins Co 41394 Mark Hens... ........... ........ ......... - __ ...INSURED.... ley INSURER,B, ........ ......... ........... .......................... Mark Hensley INSURER C,., 2600 W Olive Ave Ste 500 INSURER D,. Burbank,CA 91505- INSURER E, INSURER F: 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 VVITH 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 ...._ ... UI1 ., ---._ ......_.. . .. ... POLIaCY EFF' POLICY EXP LTR TYPE OF INSURANCE IN SR WV. POLICY NUMBER 'MMfC7DIYYY"r MMiDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ ___ DAmAG 'MoRENfEC COMMERCIAL GENERAL LIABILITY PREMISES�,E;a ;ct.alparrpe) $ ............... CLAIMS-MADE L N OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ ....... ......... _............ --....--- GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $ PRO• NN _.___ .....__-_ .....__,. POLICY LOC $ AUTOMOBILE LIABILITY COMBgfJLD SINGLE LIMIT A !Ery aRjden.kl.... $ .. .. ........ .....-................, ANY AUTO BODILY INJURY(Per person) $ _... ALL OWNED ..._ SCHEDULED ... AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED P'AOPER1rY DAMAGE $ ... HIRED AUTOS AUTOS (P±Jraaccident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ QED RETENTIONS ... $ WO QED .. AND EMPLOYERS'LIABILITY YIN ATU OTH A ANY PROPRIETOR/PARTNER/EXECUTIVE IEIG209275200 5/1/2014 5/1/2015 E.L EACH ACCIDENT rq WORKERS COMPENSATION X WC ST AT — ❑ NIA CCIDENT 5 $1,000,000.00 OFFICER/MEMBER EXCLUDED? — - --- ..... .....-................................ (Mandatory in NH) E.L-DISEASE-EA EMPLOYE $ $1,000,000 0 f yes,descrbeunder .... .................-- ---- ........ ......... DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ $1,000,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) """A waiver of subrogation applies to this certificate holder`— CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Chino HIIIS ACCORDANCE WITH THE POLICY PROVISIONS. City Hall 14000 City Center Drive AUTHORIZED REPRESENTATIVE Chino Hills, CA 91709- ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed.4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy.We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2 % of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description ANY PERSON OR ORGANIZATION FOR WHOM BUILDING OPERATINOS THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER. This policy Is subject to a minimum charge of$250 for the Issuance of waivers of subrogation This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated, (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective 05/01/2014 at 12;01 AM standard time, forms a part of Policy No. EIG 2092752 00 Of the EMPLOYERS COMPENSATION INS.CO Carrier Code 00441 Issued to HENSLEY, MARK(INDIVIDUAL) Endorsement No. Premium $8,621 �g &,.- Countersigned at on By; Authorized Representative WC 04 03 06 (Ed.4-84) 0 1998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved.