PROOF OF INSURANCE (2016) CLOSEDDATE (MMf)DrrrM
CERTIFICATE OF LIABILITY INSURANCE
1/20/2016
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
PRODUCER "I'll I Carrie Allen
NAME.
Robert c110216736 Insurance Agency, Inc. (L `E "arrie @reharris.
714) 619 -44$0 fA /m(ym (714)619 -4481
.. ...........
A.-OF ... Com
3150 Bristol St., Suite 200 INSURER(S)AFFORDINGCOVERAGE NAICq
_ INSURER A ; ._.__ .._ -- ................. ............................___
Costa Mesa CA 92626 � Travelers Cas Ins Co of America 19046
INSURED .... ___. _ ....__ _ _... .. _ .. ............................
INSURERB:Hartford Accident & Indemnity 22357
Complete Paperless Solutions LLC INSURERC Llovds of London
_._...__..._.._ .. ............................... ........................................................... ............... 1
4025 E. La Palma Ave #201 INSURERD:
.. . . . . . . . .......................
Anaheim, CA 92807 INSU RE:
INSURER F!
COVERAGES CERTIFICATE NUMBERc15 /16 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.
LTR TYPE OF INSURANCE ... .._ wen ......... Y ___.........
vwn POLICY NUMBER ImulmrVWVI IMMfM=JyI LIMITS
X COMMERCIAL GENERAL LIABILITY � $ 2,000, 000
EACH OCCURRENCE
A I CLAIMSAIADE X OCCUR PPv'EMI 300 000
E Gi4r„WM'pPX r9 $
X Y 68088847614 -15 6/2312015 6/23/2016 MIDI )CI> Y „Pnv one )Tarr nn1 $ 101000
PERSONAI.. & ADV INJURY $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE ''' $ 4,000,000
X_ POLICY PRO -
JECT LOG PRODUCTS- COMPIOPAGGmm 4 o
$ ,000,D00
OTHE'R'. I Is
AUTOMOBILE 0 0
OMOBILE LIABILIT' t4 �a7rrllr±lvk,l,” Ih. $... 1,000, 00.....
ANY AUTO IN (Per person) $
ALL 4VVNED SCHEDULED 68083847614 -15 6/23/2015 6/23/2016 BODILY INJURY Per accident) $
AUTOS AUTOS
PF�E`P+'+S +F+,s..`."
Noly- ou�aED .
HIREDAUTOS XW, AUTOS $,,,,,_,__
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAR HCILAIMS-INADE AGGREGATE $
I]ED RETENTION M $
WORKERS COMPENSATION 011,1111-
AND EMPLOYERS' LIABILITY X STATUTE _
ANY PROPRIETORfPARTNERtEXECUTIVE E E D EH ACCIDENT $ 1, 000, 000
(MandatovyinNH) Y, /wN 72WECZX9262 6/23/2015 6/23/2016 ry M .......
OFFICERIMEMEER EXCLUDED? Y N/A
B ASE- EAEMPLOYE $ 1,000,000
G)nCreIP ION 4rKl� ",uPtPATIONS twelra�ati E L DISEASE - POLICY LIMIT $ l ....0 , 000
,000 000
C Prof Liab; Claims Made ESE02166413 1/11/2016 1/11/2017. Each and everydaim $1,000,000
Deductible $10,000 ea claim Aggregate Limit ofLiablhty 01,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached 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 (see blanket policy form #CGD105 0494 attached). Coverage
provided is Primary over any other insurance maintained by the Additional Insured on all coverages,
except Professional Liability. All Members /Owners are excluded from Workers Compensation coverage. A
Waiver of Subrogation endorsement, issued on behalf of the Additional insured, as respects Workers
Compensation, is attached. Policies are subject to 10 -days Notice of Cancellation in the event of
non- vavment of premium.
CERTIFICATE HOLDER CANCELLATION
tomz@cps247.com
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
350 Main Street IQ ACCORDANCE WITH THE POLICY PROVISIONS.
El Segundo, CA 90245
AUTHORIZED REPRESENTATIVE
Carrie Allen /LIZ Q- •-° - --
O 1988 -2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INS025 (201401)
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
3�
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.
F1
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:
Effective Date: 06/23/15 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 & EMPLOYEES
350 MAIN ST
EL SEGUNDO, CA 90245
SCHEDULE
Countersigned by
Form WC 04 03 06 (1) Printed in U.S.A.
Process Date: 05/02/15
2 % of the California workers' compensation
Job Description
COMPUTER A C
D MAINTENANCE
Authorized Representative
Policy Expiration Date: 06/23/16