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PROOF OF INSURANCE (2013) CLOSED0, DATE (MMIDDIYYYY) . CERTIFICATE OF LIABILITY INSURANCE 1/15/2013 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 N 6. CT Michelle Vandervoort Robert Harris Insurance Agency, Inc. PHONE (714) 619 -4480 OC Na: (714)619 -4481 Lic. #0216736 michelle @reharris.com 3150 Bristol St., Suite 200 INSURERS AFFORDING COVERAGE NAIC! Costa Mesa CA 92626 INSURERA:Travelers Cas Ins Co of America 19046 INSURED INSURER B-Hartford Ins. Co. of the Midwe 37478 Complete Paperless Solutions LLC INSURER CAdmiral Insurance Company 4856 4025 E. La Palma Ave #201 INSURER D: INSURER : Anaheim CA 92807 INSURERF: COVERAGES CERTIFICATE NUMBER* 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. IN TYPE OF INSURANCE POLICY NUMBER &iA1�7L"IPCDJYYYY fA 1DOIyEXY ''. LIMITS LT'R GENERAL LIABILITY EACH OCCURRENCE $ 2, 000, 000 X COMMERCIAL G11:1 +1ERAI. LIAB11_11 Y Jk' IPV t iY t FrF?UJvvaU R �,, PU�w nrr iirrEnrtre $ 300, 000 A CLAIMS' MA /r:: OCCi,.IR 808BB47612 -12 6/23/2012 6/23/2013 MFD Eft, vAjny one person) $ 10,000 PERSONAL & ADV INJURY Is 2, 000, 000 cF.IV RA aa:�( lal (,ATE $ 4, 000, 000 PRODUCTS .. COMP /0P AGG $ 4, 000, 000 -,ENT. AGGREGA 1 E L..IMIT APPI DID SAY PER D a.Il.I(A L� pL &;.kl. X $ AUTOMOBILE LIABILITY (::Oh fV .:L S'I1N�,u :: Llfvfif A ANY AU f D FOD1It.Y INJURY (Per per son $ BODI_YIN,A)HY (Per & denll) $ Al OWNED CHEDU ED 6808BS47612 -12 6/23/2012 6/23/2013 I AU1'0 AIRDS X NON ED RC,17 a.l n CiAIdtA:; . $ I -I REDJ AA.1. f O AI $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MA.I:)E; AG( REGA f E $ $ DED REIDNiON J WORKERS COMPENSATION X TOVCR.'X..IAtdT�' OI�R- AND EMPLOYERS' LIABILITY YIN "'-"' E L EACH ACCIDENT $ 1 000 000 ECUIIVE ANY PROMEMBEF B OFFICFOPRIEQERPARINERIL NIA E>rLUDEW � (Mandatory in NH) 72WECZX9262 6/23/2012 6/23/2013 E L D I E /' <SE. E/'tEMPI...OYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E I. DI: Ef `,i)F POI -ii L..ICtAI f $ 1 000 000 C Prof Liab; Claims Made 0000021609 -01 .1/11/2013 /11/2014 'Eiiact(Rx,.uarron,. $1,000,000 Ded: $10,000 ea occur A,nualAggrotpik� $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The City, its officials and employees are added as Additional Insured as their interest may appear as respects operations of the Named Insured as per the blanket Additional Insured policy form attached. Coverage provided is Primary over any other insurance maintained by the Additional Insured. All Owners /Officers are excluded from Workers Compensation coverage. A Waiver of Subrogation endorsement, as respects Workers Compensation, is attached. Policies are subject to 10 -days Notice of Cancellation in the event of non - payment of premium. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo, CA 9024 AUTHORIZED REPRESENTATIVE M Vandervoort /MICHEL rYi e --ve 11[9 0 tai ACORD 25 (2010105) © 1988 -2010 ACORD CORPORATION. All rights reserved. INS025 (201005) 01 The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PROVISIONS: 1. WHO IS AN INSURED (SECTION II) is amended to include as an insured any person or organiza- tion (called hereafter "additional insured ") whom you have agreed in a written contract, executed prior to loss, to name as additional insured, but only with respect to liability arising out of "your work" or your ongoing operations for that addi- tional insured performed by you or for you. 2. With respect to the insurance afforded to Addi- tional Insureds the following conditions apply: a. Limits of Insurance — The following limits of liability apply: 1. The limits which you agreed to provide; or 2. The limits shown on the declarations, whichever is less. b. This insurance is excess over any valid and collectible insurance unless you have agreed in a written contract for this insurance to apply on a primary or contributory basis. 3. This insurance does not apply: a. on any basis to any person or organization for whom you have purchased an Owners and Contractors Protective policy. b. to "bodily injury," "property damage," "per- sonal injury," or "advertising injury" arising out of the rendering of or the failure to render any professional services by or for you, in- cluding: 1. The preparing, approving or failing to prepare or approve maps, drawings, opinions, reports, surveys, change or- ders, designs or specifications; and 2. Supervisory, inspection or engineering services. CG D1 05 04 94 Copyright, The Travelers Indemnity Company, 1994. Page 1 of 1 Includes Copyrighted Material from Insurance Services Office, Inc,. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number: 72 WEC zx9262 < Endorsement Number: 02 Effective Date: 12/13/12 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: COMPLETE PAPERLESS SOLUTIONS LLC 4025 E LA PALMA AVE STE 201 ANAHEIM, CA 92807 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 premium otherwise due on such remuneration. Person or Organization CITY OF EL SEGUNDO ITS OFFICIALS & EMPLOYEi" 350 MAIN ST EL SEGUNDO, CA 90245 SCHEDULE Countersigned by 2 % of the California workers' compensation Job Description COMPUTER INSTALLATION AND MAINTENANCE Authorized Representative Form WC 04 03 06 (1) Printed in U.S.A. Process Date: 01/11/13 Policy Expiration Date: 06/23/13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CHANGE IN INFORMATION PAG INSURER: HARTFORD INSURANCE COMPANY OF THE MIDWEST t" NCCI Company Number: 20605 AUDIT PERIOD: ANNUAL POLICY EFFECTIVE DATE: 06/23/12 POLICY EXPIRATION DATE: 06/23/13 Policy Number: 72 WEC ZX9262 Endorsement Number: 02 HOUSING CODE: SC Effective Date: 12/13/12 Effective hour is the same as stated in the Information Page of the policy. Named Insured and Address: COMPLETE PAPERLESS SOLUTIONS LLC 4025 E LA PALMA AVE STE 201 ANAHEIM, CA 92807 FEIN Number: 270926551 PRO RATA FACTOR: .526 PRODUCER NAME: ROBERT E HARRIS INSURANCE AGCY INC PRODUCER CODE: 180361 It is agreed that the policy is amended as follows: ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING STATEMENT. IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BANK ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A BILL. IN CONSIDERATION OF AN ADDITIONAL PREMIUM OF $34 IT IS AGREED THAT: (A) POLICY IS AMENDED TO ADD LOCATION 02 FOR INSD 01 ST 04 LOC READS: 350 MAIN ST (WOS) EL SEGUNDO, CA 90245 FORM NUMBERS OF ENDORSEMENTS ADDED TO THIS POLICY AT ENDORSEMENT ISSUE: WC040306 WC040306 Countersigned by Form WC 99 00 06 A (1) Printed in U.S.A. Process Date: 01/11/13 Authorized Representative Pagel (CONTINUED ON NEXT PAGE) Policy Expiration Date: 06/23/13 CHANGE IN INFORMATION PAGE (Continued) Policy Number: 72 WEC ZX9262 SCHEDULE IT IS AGREED THAT THE POLICY IS AMENDED AS FOLLOWS! CLASS CODE NUMBER AND DESCRIPTION (A) ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER 100 OF ANNUAL REMUNERATION REMUNERATION PREMIUMS 8859 6,000 .21 13 COMPUTER PROGRAMMING OR SOFTWARE DEVELOPMENT - ALL EMPLOYEES - INCLUDING CLERICAL OFFICE EMPLOYEES AND OUTSIDE SALESPERSONS WAIVER OF SUBROGATION (0930) 2.00 PERCENT OF PREMIUM 50 ALL OTHER STATE CLASS PREMIUM 1,338 TOTAL CLASS PREMIUM 1,401 CA SMALL POLICY CREDIT 5.00 PERCENT (9701) -70 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 1,331 CA SURCHARGE - 2.285 PERCENT 37 USER FUNDING ASSESSMENT 0.9669 PERCENT 16 FRAUD ASSESSMENT 0.2648 PERCENT 4 CA UNINSD EMPL BENEFIT TRUST FUND 0.1362 PERCENT 2 CA SUBSEQ INJ BENEFITS TRUST FUND 0.1255 PERCENT 2 CA OCCUP SAFETY AND HEALTH FUND 0.2350 PERCENT 4 CA LABOR ENFORCE AND COMPL FUND 0.2380 PERCENT 4 EXPENSE CONSTANT (0900) 150 TERRORISM (9740) 643,000 .020 129 TOTAL ESTIMATED ANNUAL PREMIUM - CA 1,679 CA SMALL POLICY CREDIT 5.00 PERCENT (9701) -70 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 1,331 EXPENSE CONSTANT 0900 150 TOTAL ESTIMATED STATE SURCHARGE 69 TERRORISM (9740) 129 TOTAL ESTIMATED ANNUAL PREMIUM 1,679 ESTIMATED ANNUAL ADDITIONAL ENDORSEMENT PREMIUM 65 Form WC 99 00 06 A (1) Printed in U.S.A. Page 2 Process Date: 01/11/13 Policy Expiration Date: 06/23/13 ADMIRAL INSURANCE COMPANY A BerNley Company A.M. Best Ratinq: A+ (Superior) + Financial Size Category; Xlll + To: SWETT & CRAWFORD Attn: Amy loane Policy: Subject: STEVE HINES NO. 1, LLC DBA: COMPLETE PAPERLESS SOLUTIONS Coverage Policy Term: BINDER CONFIRMATION Technology Professional Liability 01/11/2013 to 01/1112014 Integration of Hardware and Software Technologies for Others for a Fee, including Related Training and Support Item I: Professional Services: Date: 01/11/2013 E0000021609 -01 Item II: Limits of Insurance: A. Third Party Liability Coverage Limit of Insurance $1,000,000 1. Professional Services Wrongful Acts $1,000,000 2. Electronic Media Wrongful Acts $1,000,000 3. Network Security Wrongful Acts $1,000,000 4. Privacy Wrongful Acts $1,000,000 B. Regulatory Coverage Limit of Insurance $250,000 C. First Party Privacy Coverage Limit of Insurance $250,000 1. Crisis Management Expense Sub Limit $25,000 2. First Party Privacy Coverage Aggregate Limit $250,000 D. Policy Aggregate Limit of Insurance $1,000,000 Item III: Deductible: A. Per Claim or Regulatory Proceeding $10,000 B. Per Privacy Breach Event $10,000 Item IV: Retroactive Date: 01/11/2013 As respects Third Party Liability Coverage and Regulatory Coverage 01/112013 As respects First Party Privacy Coverage Item V: Premium: $2,500 Flat Rate Minimum Retained Premium: 25% Minimum Retained at Inception TERMS & CONDITIONS Schedule of Forms & Endorsements View View All Forms DE23161110 PROFESSIONAL LIABILITY POLICY DECLARATIONS CLAIMS MADE FORM ET00011010 TECHNOLOGY COVERAGE FORM E012391112 PROFESSIONAL SERVICES WRONGFUL ACT AMENDATORY ENDORSEMENT E012360912 AMENDED DEFINITION OF CLAIMS EXPENSES REGULATORY PROCEEDING FINES AND PENALTIES SUB LIMIT A107100207 SERVICE OF SUIT STATE OF CALIFORNIA A107340111 CALIFORNIA DISCLOSURE NOTICE COMMENTS Thanks for the order Ross Boozikee Underwriter E &O Acceptable Certificates of Insurance —Unaltered ACORD form only Certificates of Insurance should not be forwarded to Admiral. Page 1 of 1 FM5210 (3109) ADMIA*,r=..uP)R,,AmNwFE As an adjunct of your policy with Admiral Insurance, your company now has access to the eRisk Hub®, powered by NetDiligence . The eRisk Hub is a private web -based portal containing information and technical resources that can assist you in the prevention of network, cyber and privacy losses and support you in the timely reporting and recovery of losses if an incident occurs. The eRisk Hub portal is an intemet -based service that features news, content and services from leading practitioners in risk management, computer forensics, forensic accounting, crisis communications, legal counsel, and other highly- specialized segments of cyber risk. Please note the following: 1, The eRisk Hub portal is a private site for customers of Admiral Insurance only. Do not share portal access instructions with anyone outside your organization. You are responsible for maintaining the confidentiality of the Access Code provided to you 2, Up to three individuals from your organization may register and use the portal. Ideal candidates include your company's Risk Manager, Compliance Manager, Privacy Officer, IT Operations Manager or Legal Counsel. This portal contains a directory of experienced providers of cyber risk management and breach recovery services. Admiral Insurance does not endorse these companies or their respective services. Before you engage any of these companies, we urge you to conduct your own due diligence to ensure the companies and their services meet your needs. Unless otherwise indicated or approved, payment for services provided by these companies is your responsibility. 4. Should you experience a data breach event, you may choose to call the Breach Coach® listed in the portal for immediate triage assistance. Your initial consultation of up to one half -hour is free of charge. Please be aware that the Breach Coach service is provided by a third -party law firm. Therefore, contacting the Breach Coach does NOT satisfy the claim notification requirements of your policy.. To register for the Admiral eRisk Hub: Go to http_ N w_eriskhub con1h diniral._php. 2. Complete the registration form. Your Access Code is 10152. 1 Once registered, you can access the portal immediately Risk NetDiligence® is a leading cyber security and a -risk assessment services company. For more information, visit w,Avv.NetDiligence.com.