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PROOF OF INSURANCE (2013) CLOSEDYY) ACORD ,� CERTIFICATE OF LIABILITY INSURANCE DATE 09f25/2fN (MMIDD /YY 12 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(les) 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 CONTACT NAME. Brennan n # Associa Associates I iI ,fmm800.509.6452 5 hipbfi �Np^562.429.611 ADDRES�Sr. 5001 Airport Plaza Dr. #125 - p INSURERS) AFFORDING COVERAGE NAIC Long Beach, CA 90815 INSURER A: Everest Indemnity Insurance Co " " ._ INSURED Krause µACT, Inc. _ INSURER Preserver Insurance Company dba: Air Cleaning Technology _____.._ ................ __.._......._........ .........�...... ___ ._ ......................_..._ _.. gy INSURER C: Peerless Insurance Company 411 Rowland Ave INSURER D Santa Ana, CA 92707 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 2012 -2013 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. INSN.'.. ,""- " " " ° °.,.,...,_._...____ ..__ANSAtl WVO. ..- ....._.. POLICY NUMBER MMIDD YYV MM UD YYYY...._.._.._...�..." ..... ..... ........ _.�....m, ..._ LTR TYPE OF INSURANCE LIMITS GENERAL LIABILITY EF4ML01869 -12 03130/2012 03130/2013 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL -MADE GENERAL OCCUR MD EXP (Any one perso $ 5,000 (MISLS ! a oca4noen o $ 50 000 '... A - PERSONAL d ADV INJURY _ $ 1,000,000 _.�. ......._. ..._ _- _.._.. �..... � $ GENERALAGGREGATE 2 � , 00Q,000 GEN`L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 Pr POLICY I XGF LOG $ AUTOMOBILE LIABILITY CUMUI'NI ' ANY AUTO _ n) $ BODILY INJURY (Per perso I ALL OWNED SCHEDULED B NON -OWNED OILY INJURY (Per accid O snt) $ AUTOS AUTOS HIREDAUTOS AUTOS UMBRELLA LIAB X OCCUR EF4C000190-12 03/30/2012 03/30/2013 EACHOCCURRENcE $ 4,000,00 ._.. -,. -w.....,.. ...,,,,. - A X EXCESS LIAR AGGREGATE $ 4,000,000 _ CLAIMS -MADE LDED X J RF7I "ENIION$ 10,000 . $ WORKERS COMPENSATION WCCO01049501/01/2012 01/01/2013 X E.L. DISEASE ITSR ..__„ 0 AND EMPLOYERS' LIABILITY TQRY ACCIDENT $ 1 000 OO ANY PROPRIETOR /PARTNER /EXECUTIV NIA E.L. EACH A 1. B OFFICER/MEMBER EXCLUDE( (Mandatory in NH) - 00 EA EMPLOYEE $ a 7 If Yas, describe under "' DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT $ 1,000,000 Anployee DisDishonesty C13P811543 02/01/2012'02/01 /2013 $250,000 Limit C overage DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) 2E: El Segundo Fire Department, 314 Main Street, El Segundo, CA 90245. The City of E1 Segundo is included as Additional Insured with regard to General Liability per attached forms CG 20 10 07 04 and G 20 37 10 01. Waiver of Subrogation applies to Workers` Compensation per attached form WC 04 03 06. CERTIFICATE HOLDER CANCELLATION i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Cit y of El Segundo E �` a AUTHORIZED REPRESENTATIVE Attn: City Clerk Iy °r 350 Main Street E1 Segundo, CA 90245 Greg Havi11,NW _ m 1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: EF4ML01869 -121 COMMERCIAL GENERAL LIABILITY CG 20 37 10 01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS -- COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Blanket where required by written contract. Location And Descript €on of Completed Operations: Blanket where required by written contract, Additional Premium: Included (If no entry appears above, Information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) Section II — Who Is An Insured Is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" at the location designated and described In the schedule of this endorsement performed for that insured and included in the "products- completed operations ha- zard", CG 20 37 10 01 © ISO Properties, Inc., 2000 Page 1 of 1 13 POLICY NUMBER; EF4ML01869 -12 [ COMMERCIAL GENERAL LIABILITY „ CG 20 10 07 04: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY: ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS -- SCHEDULED PERSON OR ORGANIZATION This endorsement modlfles Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anlzatlon Blanket where required by written contract. to complete this Sohedul'e" if not shown above, will be A. Section It — Who Is An Insured Is amended to Include as an additional Insured the person(s) of organization(s) shown In the Schedule, but only with respect to liability for "bodily injury", "property damage " or "personal and advertising Injury" caused, in whole or In part, by. 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional Insured(s) at the location(s) desig- nated above. M CG 20 10 07 04 "' N"�` Of Covered Operation the Deci B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after; 1 � All work, Including materials, parts or equip- ment furnished in connection with such work, an the project (oufrer than service, maintenance or repairs;) to be performed by or on behalf` of the additional Insured(s) at the locatlon of the covered operations has been completed; or 2. That ,portion of "Your work " out of which tho Injury or darriage arises has been put to its In- tanded use by any person or orgarilation other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the sane project, © ISO Properties, Inc., 2004 Page 1 of 1 11 WORKERS COMPENSATION AND EMPLOYERS LIA131LiTY INSURANCE POLICY WC lkf• 03 06 04.84 WAIVER OF OUR RIGHT TO R (Ed, ) ECOVER FROM OTHERS ENDORSEMENT— CALIFORNIA ry 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 contiacl that requires you to obtain Ibis 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. Person or Organization All entities that you perform work for under a written contract that requires that you waive your right to recover from others. Job Description All work performed within the State of California 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 on[X.When this endorsement is issued Subsequent to preparation of the policy.} Endorsement Effective 01/01/2012 Policy No. WCC 0010485 Insured KRAUSE ACT, INC. Endorsement No, Insurance Company Preserver Insurance Company Countersigned By v WC 04 03 06 (Ed. 04 -84) „� �p ACORDTM CERTIFICATE OF LIABILITY INSURANCE °09/20/202' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION John Monson ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE State Farm Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR GENERAL LIABILITY ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, 30131 Town Center Dr, Ste 275 Laguna Niguel, CA 92677 EACH OCCURRENCE ...... ..............�......µ.... ...� INSURERS AFFORDING COVERAGE .INSURER... ..,.,,. ....— ....., , ,....,. , . .-_.. , . . NAIC # ...------ ............. INSURED . A, State Farm Mutual Automobile Insurance Company 25178 25178 Krause ACT DBA Air Cleaning Technology ........... �............. ................................... ............................... 11 Rowland Ave, INSURERS: COMMERCIAL GENERAL L CO Santa Ana, CA 92707 INSURER C: ..................W�W�W�_.�W� . ..........- ............ PR EM INSURER D: A INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR "Odd ^. ,. -- --- -- ---- ......... ...... ... POLICY EFFECTIVE... POLICY �� x..�......A _....... .............. ......... , ... ......... E PIRATI TYPE POLICY NUMBER I LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL L CO PR EM CLAIMS MADE OCCUR D EXP (Any one person) $ _ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ PRODU�C'H"S-COMPIOP.AGG.....' $ GEN L AGGREGATE LIMIT APP LIES PER: POLICY PRO• LOC X AUTOMOBILE LIABILITY 3090552- C01 -75G 09101/2012 09/01/2013 COMBINED SINGLE LIMIT $ 11000,000.00 ANY AUTO 3093182 -COI -75G (Ea accident) BODILY INJURY _ x L OWNED AUTOS AL O 1976-COI-75B 379976- -75 ..-, .... SCHEDULED AUTOS 3835032 -001 -75B (Per person) $ _ 391 3576 - COI -75C 'X- '�,,.„�"`� HIREDAUTOS BODILY INJURY $ .++ NON -OWNED AUTOS 401 0032- COl -75A (Per accident) 266 5524 - COI -75J _........ — 2843100- COI -75H PROPERTYDAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC L. AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR_ CLAIMS MADE AGGREGATE $ $ $ DEDUCTIBLE -- RETENTION $ $ WC STATU- OTH- WORKERS COMPENSATION AND _ TORX1JMlTS _ EMPLOYERS' LIABILITY E..L CAOH AOC¢OENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFFICER/MEMBEREXCLUDED7 E..L DtlSE.A'SE:- EAEMPL.OYBE $ under ^ ..,p .- . -. - - -- SPECIALscribe er below E.L DISEAS E - P LICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Comprehensive deductible: $100; Collision deductible: $500 City of El Segundo is named as additional insured Ur-Kt.l1- 1to/A It: . I1VI UCI% 1../1191,CLLNIIVIY City of El Segundo tI in SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION .rw* DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL SO DAYS WRITTEN Attn: City Clerk NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL 350 Main Street EI Segundo, CA 90245 -09$9 ,i IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Y REPRESENTATIVES. AUTHORIZED REPRESENTATIVE m John Monson by Katherine B Perry ACORD 25 (2001/08) © ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001108) STATE FARM INSURANCE COMPANIES® 900 Old River Road Bakersfield CA 93311 -9501 57A AT1 23 001147 0093 CITY OF EL SEGUNDO ATTN: CITY CLERK 350 MAIN ST EL SEGUNDO CA 90245 -3895 ADDITIONAL INSUREN NOTICE DATE OF NOTICE: NOV 06 2012 CODE: NOTE: PLEASE NOTIFY STATE FARM AT THE ADDRESS LISTED AT THE TOP, LEFT CORNER OF THIS PAGE REGARDING ANY CHANGE OF ADDRESS INFORMATION. State Farm Mutual Automobile Insurance Company 8186- F416 -M NAMED INSURED: POLICY NO: 391 3576 - 001 -75F COVERAGE: v BI AND PD LIABILITY CO, KRAUSE A C T YR /MAKEIMODEL: NONOWNED AUTO $ 1 MIL N DBA AIR CLEANING TECHNOLOGY VIN /CAMPER: $250 DED. COMP/COLL 411 ROWLAND AVE AGENT NAME: JOHN MONSON a SANTA ANA CA 92707 -3445 AGENT PHONE: (949)495 -2515 & ENDORSEMENT O: 602BAU POLICY EFFECTIVE m 6164RR 6165AA NOV 01 2012 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes polioy# 3913576 -75E. The policy includes a loss payable clause protecting the additional insured's interest in the described car to the extent of the Insurance n provided and subject to all policy provislons. The additional insured will be given 20 days notice lithe polioy is terminated. Until such notice i- -vided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of ange of interest or ownership coming to their attention. Failure to do so will render this policy null and void. FRT 8 0 T s s r 'm m iq 0 ro r r,n. ^• STATE FARM INSURANCE COMPANIES® 900 Old River Road Bakersfield CA 93311 -9501 56A AT1 23 001148 0093 CITY OF EL SEGUNDO ATTN: COUNTY CLERK 350 NAIN ST EL SEGUNDO CA 90245 -3895 A DATE OF NOTICE: NOV 06 2012 CODE: NOTE: PLEASE NOTIFY STATE FARM AT THE ADDRESS LISTED AT THE TOP, LEFT CORNER OF THIS PAGE REGARDING ANY CHANGE OF ADDRESS INFORMATION. FADDITIONAL INSUREDS NOTICE OF COVERAGE State Farm Mutual Automobile Insurance Company 8186- F416 -M NAMED INSURED: POLICY NO: 401 0032 - 001 -75D COVERAGE: KRAUSE A C T YR /MAKE /MODEL: 2004 DODGE UTILITY BI AND PD LIABILITY 0SA AIR CLEANING TECHNOLOGY VIN /CAMPER: WDi PD444X45684798 $ 1 MIL $100 DED. COMP. 411 ROWLAND AVE AGENT NAME: JOHN MONSON $500 DED. COLL. SANTA ANA CA 92707 -3445 AGENT PHONE: (949)495 -2515 ENDORSEMENT NO: 6028AU POLICY EFFECTIVE NOV 01 2012 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 4010032 -750. The policy inoludes a loss payable clause protecting the additional Insured's Interest in the desoribed oar to the extent of the insurance provided and subject to all policy provisions. The additional insured will be given 10 days notice if the policy is terminated. Until such notice iR ^rovided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of ange of Interest or ownership coming to their attention. Failure to do so will render this policy null and void. FRT