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PROOF OF INSURANCE (2015) CLOSED154987 Pro Forma Advisors LLC Certificate of Insurance (page 1 of 1) 01/30/2015 08:45:06 AM ACC >R0 CERTIFICATE OF LIABILITY INSURANCE DATE "Y'"' 1 /300 /201/2015 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 CONTACT NAME: BIN Insurance Holdings, LLC EDD AIL • (800) 668 -7020 (/uc.No) (877) 826 -9067 PHONE FAX BUSINESS 1301 Central Ex South, Suite 115 INSURANCE NOW Allen. TX 75013 PRODUCER INSURED Pro Forma Advisors LLC 326 S. Pacific Coast Highway, Suite 200 200 Redondo Beach. CA 90277 INSURER(S) AFFORDING COVERAGE NAIC # ACE .22667..... Sentinel Insurance Company, Limited 11000 COVERAGES CERTIFICATE NUMRER- REVISION NLIMRER7 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 A L POLICYEt°F POUCYEXP_. ............. LTR TYPE OF INSURANCE POLICY NUMBER (MMIDDIYYYY I (MMIDDfYYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 ✓ COMMERCIAL GENERAL LIABILITY 0. 0..... �Iperson�........�...$..1,0,, , S MA ✓( OCCUR .,MED EXPS (Any one 000. ..-........�.�.�.�.�.- _ B Yes 46SBMVE2409 9/15/2014 9/1512015 PERSONAL & ADV INJURY $ 2,000,000 ... ........... _. ............. ... .AGGREGATE........$..�4, GENERAL 000, 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 4,000,000 RilCk- ✓ Pu�LICY LOC [71 .........................$ .__..__...._... ............................... AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 2,000,000 - (Ea accident) ANY AUTO ........... ................ ... ........ ....._ ............ ...........____........__.._.- - - -- BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ B SCHEDULED AUTOS Yes 46SBMVE2409 9/15/2014 9/15/ 2015 .. �_ ... .. ........ .......... ����..__ ........ ........ ���� ............................ ✓ ............. HIRED AUTOS PROPERTY DAMAGE (Per accident) ...., ..... _..... ---- ---- - ----- - ----- ✓ NON -OWNED AUTOS $ $ u. ...... UMBRELLA LIAB ...,...,, OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DEDUCTIBLE $ RETENTION $ $��� WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N -TOR, . ... PROPRIETOR/PARTNER/EXECUTIVE BER EXCLUDED? ❑ OFFICat N/A E_L.��.. ...................... .........._................... (Mandatory in SEA'aEiCIEDA EM.PLC_YYEE...$ XLIMIT X DESCRIPTION OF OPERATIONS below E L M$E,A'$E POLICY $ A Professional Liability (Errors and Omissions) G24158093 005 9115/2014 911512015 Occurrence / Aggregate $3,000,000 / $3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) City of El Segundo, its officers, officials, employees, agents and volunteers are named as Additional Insured as their interests may appear in regards to general liability and automobile liability L City of El Segundo 350 Main Street El Segundo, CA 90245 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD r�' k y Select Customer Insurance Center 3600 WISEMAN BLVD. SAN ANTONIO TX 78251 Policyholder, please callus at: (866) 467 -8730 Agent, please call us at: (866) 467 -8730 SERVICE.TX @THEHARTFORD.COM INSURANCE ENDORSEMENT ATTACHED * ** PLEASE REVIEW THE CHANGE * ** Enclosed is an endorsement for your business insurance policy. Please review it at your convenience. If you have questions or need to make further changes: Policyholder, please call us at: (866) 467 -8730 Agent, please call us at: (866) 467 -8730 between 7 A. M. and 7 P.M. CENTRAL TIME The premium billing will be mailed to you separately. You can expect to receive it soon. Thank you for allowing us to service your business needs. BIN INSURANCE HOLDINGS LLC /PHS THE HARTFORD SELECT CUSTOMER INSURANCE CENTER The Hartford Hartford Fire Insurance Company and its Affiliates One Hartford Plaza, Hartford, Connecticut 06155 I r. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGE This endorsement changes the policy effective on the Inception Date of the policy unless another date is indicated below: Policy Number: 46 SBM VE2409 DX Named Insured and Mailing Address; PRO FORMA ADVISORS LLC �.. "A 326 S PACIFIC COAST HWY S"T;200� REDONDO BEACH CA 90277 Policy Change Effective Date: 01/30/15 Effective hour is the same as stated in the Declarations Page of the Policy. Policy Change Number: 004 Agent Name: BIN INSURANCE HOLDINGS LLC /PHS Code: 505500 POLICY CHANGES: SENTINEL INSURANCE COMPANY, LIMITED 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. NO PREMIUM DUE AS OF POLICY CHANGE EFFECTIVE DATE FORM NUMBERS OF ENDORSEMENTS REVISED AT ENDORSEMENT ISSUE: IH12001185 ADDITIONAL INSURED - PERSON - ORGANIZATION PRO RATA FACTOR: 0.704 THIS ENDORSEMENT DOES NOT CHANGE THE POLICY EXCEPT AS SHOWN. Form SS 12 11 04 05 T Page o o l Process Date: 02/02/15 Policy Effective Date: 09/15/14 Policy Expiration Date: 09/15/15 POLICY NUMBER: 46 SBM VE2409 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PERSON - ORGANIZATION LOCATION 002 BUILDING 001 CITY OF GARDEN GROVE IT'S OFFICERS, OFFICIALS, EMPLOYEES, AGENTS AND VOLUNTEERS. 11222 ACACIA PARKWAY GARDEN GROVE, CA 92840 LOCATION 002 BUILDING 001 THE CITY OF MOUNTAIN VIEW, IT'S OFFICERS, EMPLOYEES, AND VOLUNTEERS 201 S RENGSTORFF AVE MOUNTAIN VIEW, CA 94040 LOCATION 002 BUILDING 001 CITY OF GOLETA 130 CREMONA DR STE B GOLETA, CA 93117 LOCATION 002 BUILDING 001 CITY OF VALLEJO 555 SANTA CLARA ST VALLEJO, CA 94590 LOCATION 002 BUILDING 001 SOUTHERN CALIFORNIA ASSOCIATION OF GOVERNMENTS(SCAG) 818 W SEVENTH ST 12TH FL LOS ANGELES, CA 90017 -3435 LOCATION 002 BUILDING 001 ORANGE COUNTY PUBLIC WORKS 300 N FLOWER ST SANTA ANA, CA 92703 LOCATION 002 BUILDING 001 CITY OF LYNNWOOD PO BOX 5008 LYNNWOOD, WA 98046 Form IH 12 00 11 85 T SEQ. NO. 001 Printed in U.S.A. Page 001 (CONTINUED ON NEXT PAGE) Process Date: 02/02/15 Expiration Date: 09/15/15 POLICY NUMBER: 46 SBM VE2409 191'' THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PERSON - ORGANIZATION LOCATION 002 BUILDING 001 HERITAGE FIELDS EL TORO, LLC CONTRACT ADMINISTRATOR/ INSURANCE COORDINATOR 25 ENTERPRISE STE 400 ALISO VIEJO, CA 92656 -2712 LOCATION 002 BUILDING 001 THE CITY OF COSTA MESA 77 FAIR DRIVE COSTA MESA, CA 92626 LOCATION 002 BUILDING 001 CITY OF SANTA CLARA 1500 WAR BURTON AVE SANTA CLARA, CA 95050 LOCATION 002 BUILDING 001 LOS ANGELES HARBOR DEPARTMENT OFFICER, AGENTS AND EMPLOYEES PO BOX 151 SAN PEDRO, CA 90733 -0151 LOCATION 002 BUILDING 001 CITY OF SANTA BARBARA 735 ANACAPA STREET SANTA BARBARA, CA 93101 LOC 002 THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS, AND VOLUNTEERS 350 MAIN STREET EL SEGUNDO, CA 90245 Form IH 12 00 11 85 T SEQ. NO. 001 Printed in U.S.A. Page 002 (CONTINUED ON NEXT PAGE) Process Date: 02/02/15 Expiration Date: 09/15/15 POLICY NUMBER: 46 SBM VE2409 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PERSON - ORGANIZATION Form IH 12 00 11 85 T SEQ. NO. 001 Printed in U.S.A. Page 003 (CONTINUED ON NEXT PAGE) Process Date: 02/02/15 Expiration Date: 09/15/15 (r' rr Forma To: City of El Segundo From: Gene P. Krekorian (Pro Forma Advisors LLC) Date: January 30, 2015 Subject: Sole Proprietor /Partnership /Closely Held Corporation With No Employees Please let this memorandum notify the City of El Segunrd thAt Pro Forma Advisors LLC is a Partnership and does not have any employees where employn ts n�re+�,lkes us to carry Workers' Compensation Insur- ance. Therefore, we do not carry Workers' Comp than Insurance coverage. Contractor Signature: P Printed Name of Contractor: -gene P. Krekr rign.. Pr Forma Advisors) Date: 2015 Pro Forma Advisors LLC Los Angeles T 310.616.5079 New York Metro T 203 604.9007 F 888.696.9716