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PROOF OF INSURANCE (2016) CLOSEDMAGEL -1 OP ID: DL DATE (MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 0 412 912 01 5 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 endorsements , PRODUCER CONTACT Diane Larson Bruce Gendelman Co., Inc. NAME: _ Suite 101 Wt%11 ._slshy._262�78 -1000 dAl i 262-478-1001 PHONE FAX 500 W Brown Deer Rd E-MAIL. Milwaukee, WI 53217 ADDlztrs dlarsonendelman com Kathryn OroSZ INSURERS AFFORDING COVERAGE NAIC # .. INSURED Magellan Advisors, LLC Mr. John Honker 1000 South Pointe Drive, #703 Miami Beach, FL 33139 COVERAGES CERTIFIC INSURERA: Mount Vernon Fire Insurance Co 26522 INSURERS Transportation In _ _..... _ __ s .. 20494 INSURER C: US Liability Insurance Company 2.. _.. ........ 5895_ INSURER D INSURER E INSURER F: ISION 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,. R TYPE OF INSURANCE...... NUMBER w , . ......._........ ._.. _ ..._..__.,.., -AD sU0 .... PDUCY EFF PoLlc EX1' ...— --- -._ .................... .. wsn wvn POLICY UMBER IMM /DD /YYYYI IMM /DD/YYYYI LIMITS X ],COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000 001 X DAMACL."I .0 RE "w riEl 30000. CLAIMS -MADE OCCUR X MTK2001204E 04/12/2015 04112/2016 PRrMI E_s {Ea zcwnrrrsnr( $ 300,001 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY F] JE � El LOC AUTOMOBILE LIABILITY A ANY AUTO MTK2001204E X ALL OWNED Xm SCHEDULED AUTOS AUTOS NON -OWNED HIF AUTOS AUTOS DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) The Cert'if'icate Holder is included as an Additional! Insured under eneral liability coverage as required by written contract and er form BP'1 4(06.09) attached. A Waiver of Subrogation applies under the Mrkers Compensation coverage. "'1 City of El Segundo 350 Main Street El Segundo, CA 90245 CITEL01 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 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD UMBRELLA LIAB X OCCUR MED EXP (Any one person) $ 10.001 C X EXCESS LIAB CLAIMS MADE $ 1,000,0 XL1561356 GENERAL AGGREGATE DED X RETENTION $ 0 PRODUCTS COMP IOP AGG $ --- - - -�.. 001 . . WORKERS COMPENSATION - AND EMPLOYERS' LIABILITY YL OOMBINED -SINGLE ELIMIT 1,000,00( 04/12/2015 B ANY PROPRIETOR /PARTNER /EXECUTIVE X WC585214092 BODILY INJURY (Per accident) OFFICERIMEMBER EXCLUDED? N / A P'ROP'ER "IYIJAMAaI $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below . mm .. S 1,000,001 09/06/2014 09106/2015 A TECH PROFESSIONAL —7 MTK2001204E LIABILITY X STATUTE ER H _ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) The Cert'if'icate Holder is included as an Additional! Insured under eneral liability coverage as required by written contract and er form BP'1 4(06.09) attached. A Waiver of Subrogation applies under the Mrkers Compensation coverage. "'1 City of El Segundo 350 Main Street El Segundo, CA 90245 CITEL01 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 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD MED EXP (Any one person) $ 10.001 PERSONAL & ADV INJURY $ 1,000,0 GENERAL AGGREGATE 2.000,00 1 PRODUCTS COMP IOP AGG $ --- - - -�.. 001 . . - OOMBINED -SINGLE ELIMIT 1,000,00( 04/12/2015 04/12/2016 BODILY INJURY (Per person) BODILY INJURY (Per accident) P'ROP'ER "IYIJAMAaI $ ......... -.___ EACH OCCURRENCE . mm .. S 1,000,001 09/06/2014 09106/2015 AGGREG ATE $ 1,000,00I X STATUTE ER H _ 07101/2014 07/01/2015 1 ACCIDENT - E.L. DISEASE - EA EMPLOYEE $ 500 „001 E L DISEASE POLICY LIMIT 0 1 � 500, OQ 04/12/2015 04/1212016 EA CLAIM 3,000,001 ANNL AGGR 3,000,001 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) The Cert'if'icate Holder is included as an Additional! Insured under eneral liability coverage as required by written contract and er form BP'1 4(06.09) attached. A Waiver of Subrogation applies under the Mrkers Compensation coverage. "'1 City of El Segundo 350 Main Street El Segundo, CA 90245 CITEL01 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 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD UNITED STATES LIABILITY INSURANCE' GROUP WAYNE, PENNSYLVANIA �.��..This endorsement rnodifies insurance .�.�.���...��. .�..��.. mmminurance provided under the following: BTJSINESSOWNERS CO'V'ERAGE, FORM BLANKET ADDITIONAL INSURED SECTION R -- LIABILITY; C. Who Is An Insured is amended to include as an additional insured any person(s) or organization(s)' for whom you are performing "your work" under a written contract or agreement, that requires such person(s) or organization(s) to be added as an additional insured on your policy. Such person(s) or organization(s) is an additional insured only with respect to liability for "bodily injury ", "property damage" or "personal and advertising injury" occurring after the effective date of such contract or agreement that is caused, in whole or in part by: a. Your acts or omissions; or b. The acts or omissions of those acting on your behalf; in the performance of "Your work" for the additional insured. Coverage for an additional insured under this endorsement ends when "your work" for that additional insured ends or is put to its intended use by any person or organization. SECTION It — LIABILITY; B. EXCLUSIONS, 3. Applicable To Loth Business Liability Coverage And Medical Expenses Coverage, is amended to add the Following with respect to this endorsement only: There is no coverage. under this endorsement for loss or expense, including but not limited to the cost of defense for "bodily injury" or "property damage" or "personal and advertising injury" occurring: a. After all of "your work ", including materials, parts or equipment furnished In connection with "your work" and performed under the above referenced written contract(s) or agreement(s) has ended; or b. 'When that portion of "your work" out of which the "bodily injury ", "property damage" or "personal and advertising injury" arises and performed under the above referenced written contracts) or agreements) has been put to its intended use by any person or organization; whichever occurs first. All other terms and conditions of this policy remain unchanged. This endorsement is a part of your policy and takes effect on the effective date of your policy unless another effective date is shown. BP 134 (06 -09) Page 1 of 1 CNA 333 S Wabash Chicago, Illinois 60604 STANDARD WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CHANGE ENDORSEMENT - EFFECTIVE 04/29/15 DATE PROCESSED= 051215,REASON= ADDED WAIVER OF SUBROGATION Policy Number From Policy Period To Coverage Is Provided By Agency WC 5 85214092 07/01/14 07/01/15 TRANSPORTATION INSURANCE CO. 018394090 Named Insured And Address Agent ITEM MAGELLAN ADVISORS, LLC BRUCE GENDELMAN CO., INC. 1. 450 ALTON ROAD ##1402 MIAMI BEACH, FL 500 W. BROWN DEER ROAD, ##101 ILWAUKEE WI 53217 33139 FEIN NUMBER: 651218484 NCCI CARRIER CODE NO: 12408 =_ ACCOUNT NUMBER: 3022386688 DATE OF ISSUE: 05/12/15 POLICY ISSUING OFFICE: MILWAUKEE Chw— of U. Bova INSURED (WC000001) P- 39543 -A ** S C H E D U L E OF O P E R A T I O N S ** SCHEDULE PAGE 1 4. LOC CLASS CLASSIFICATION OF OPERATIONS EST TOTAL RATE PER PREMIUM NO. CODE ANN REMUN $100 REMUN DIFFERENCE * * * * * * * ** STATE: FLORIDA 001 CLASS 8742 ADDED EFF 04/29/15 - 07/01/15 8742 SALESPERSONS, COLLECTORS OR MESSENGERS 1 .52 0 - OUTSIDE 002 9848 INC. LIM. BALANCE TO MINIMUM PREMIUM 0 0930 WAIVER OF SUBROGATION 0 9740 TERRORISM PREMIUM 110,001 .0200 0 THE FOREGOING AMENDMENT RESULTS IN AN ADDITIONAL PREMIUM OF $0 * * * ** REVISED POLICY TOTALS * * * ** ESTIMATED CLASS PREMIUM $494 ESTIMATED STANDARD PREMIUM $569 PREMIUM DISCOUNT $0 . EXPENSE CONSTANT $200 TERRORISM PREMIUM $22 ESTIMATED PREMIUM $791 STATE TAXES /ASSESSMENTS /SURCHARGES $0 ESTIMATED COST $791 =_ ACCOUNT NUMBER: 3022386688 DATE OF ISSUE: 05/12/15 POLICY ISSUING OFFICE: MILWAUKEE Chw— of U. Bova INSURED (WC000001) P- 39543 -A CNA 333 S Wabash Chicago, Illinois 60604 STANDARD WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY CHANGE ENDORSEMENT - EFFECTIVE 04/29/15 DATE PROCESSED= 051215,REASON= ADDED WAIVER OF SUBROGATION Policy Number From Policy Period To Coverage Is Provided By Agency WC 5 85214092 07/01/14 07/01/15 TRANSPORTATION INSURANCE CO. 018394090 Named Insured And Address Agent MAGELLAN ADVISORS, LLC 1UCE GENDELMAN CO., INC. 450 ALTON ROAD #1402 MIAMI BEACH, FL 500 W. BROWN DEER ROAD, #101 �ILWAUKEE WI 53217 33139 ** E N D O R S E M E N T S C H E D U L E ** SCHEDULE PAGE 1 NUMBER DESCRIPTION EDITION DATE WC000313 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDT. 04/84 * * * ** ADDED * * * ** DATE OF ISSUE: 05/12/15 POLICY ISSUING OFFICE: MILWAUKEE INSURED (WC000001) P- 39543 -A WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 4 -84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. CITY OF EL SEGUNDO 350 MAIN STREET EL SEGUNDO, CA 90245 Schedule 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.) Endorsement Effective Policy No. Endorsement No. Insured Insurance Company WC 00 0313 (Ed. 4 -84) Premium $ Countersigned by Copyright 1983 National Council on Compensation Insurance. rr �, _ '� Sandoval, Lili From: Klingaman, Larry J. Sent: Monday, July 20, 2015 9:43 AM To: Shilling, Mona; Sandoval, Lili Cc: Nguyen, Trang Subject: FW: Assistance with Review of Proof of Workers' Compensation Waiver a' Segundo Larry Klingaman City of El From: Diane Larson [mailto:dlarson @gendelman.com] Sent: Friday, July 17, 2015 6:30 AM To: 'Courtney Violette'; Klingaman, Larry J. Subject: RE: Assistance with Review of Proof of Workers' Compensation Waiver Courtney and Larry, My sincere apology for the delay in responding to Mona's email. Yes, any employee of Magellan- Advisors, or person deemed to legally be an employee under workers compensation law, while traveling out of state and working within the scope of their employment will be covered by Magellan's workers compensation policy and waiver of subrogation. Please let me know if you need any additional information. Thank you, D _!.1 Diane L. Larson Bruce Gendelman Insurance Services 500 W. Brown Deer Road, #101 Milwaukee, WI 53217 414.409.7614 direct 262.478.1000 ext. 32 800.845.4145 ext. 32 262.478.1001 fax dlarson endelman.com From: Courtney Violette [i)�Uinlett.,-�, @�l�la ellan -Advi; rte] Sent: Thursday, July 16, 2015 6:47 PM To: Klingaman, Larry J. Cc: Diane Larson Subject: RE: Assistance with Review of Proof of Workers' Compensation Waiver Diane, see Larry's email below. He is also copied on this message. The City believes the ball is in your court. Thanks, Courtney From: Klingaman, Larry J. [imailto:lklin aman el jn .or ] Sent: Thursday, July 16, 2015 7:45 PM To: Courtney Violette Subject: FW: Assistance with Review of Proof of Workers' Compensation Waiver Hi Courtney, Neither the Clerk's Office or I have heard from Diane. Larry Klingaman Information Systems Manager City of El Segundo 310.524.2392 From: Shilling, Mona Sent: Wednesday, June 24, 2015 12:02 PM To: 'dlarson @gendelman.com' Cc: 'J Honker@ Magellan-Advisors.com'; Klingaman, Larry J.; Nguyen, Trang; Sandoval, Lili Subject: FW: Assistance with Review of Proof of Workers' Compensation Waiver Diane, Hello, my name is Mona Shilling, I work with Larry Klingaman, with the City of El Segundo but in the City Clerk's Office, Our City has entered into an agreement with your customer Magellan Advisors, LLC. I have a question regarding the proof of insurance provided to us and the email correspondence, both attached for reference, specific to the Workers Compensation and Waiver. Can you please confirm that any employee and /or person working on Magellan - Adviosrs behalf while traveling out of state and working in any capacity, based on the scope of the agreement between the City and Magellan- Advisors, will be covered by Magellan - Advisors proof of Workers Compensation and Waiver, provided to the City of El Segundo? Thank you, Mona F. Shilling AeputU CitU CLerle II (Anti, e) cite of EL seguwdo C i tU CLerlpz's o f face sso mci v%. street EL seguvLdo, CA90245