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PROOF OF INSURANCE (2017) CLOSEDGOVESTA -02 PPISANO CERTIFICATE OF LIABILITY INSURANCE DAT DIYYYY) 61/14/214 /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(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 NAME.: CTK North American Insurance Services, LLC I INSURICA P/NIa r E �,• (714) 779 -2000 FAX c No)• (714) 7791129 1240 North Lakeview Avenue, 0240 .MAIL Anaheim, CA 92807 ADDRES' INSURER(S) AFFORDING COVERAGE NAIC N INSURERA:Zurich American Insurance Co. of IL 27855 INSURED INSURER B: American Guarantee and Liability Ins. Co. 26247 Government Staffing Services INSURER C P.O. BOX 718 INSURER D : Imperial Beach, CA 91933 INSURER E ......... ......... ......... .... „,,,, INSURER F : COVERAGES CERTIFICATE NUMBER: 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 w3,.., an mpm,� WVn POLICY NUMBER po 1 L ICY EIfF POLII0ly I! O _ IT mmmITITITIT 0002,,!y+ Y, w� (�hp,MPgoyy . LIMITS A X I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X occuR X PRA969906304 RENTED 05/10/2016 DAMAGE TO 05/10/2017 PREMISES (Ea r�ccurrence) $ 1_00,000 „e,,,,,,,,,,,,,,,,,,,,,,,,,,, 4 $ 1 0,000 _ PERSONAL 8 ADV INJURY $ 1,000,000, GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE b 2,000,000 ', POLICY JEC LOC PRODUCTS - COMP /OP AGG $ 2,000,000 OTHER: 1 I S AUTOMOBILE LIABILITY MaCi S NOLLMIT $ 000,000; _. A ANY AUTO IPRA969906304 1 05/1012016 05/10/2017 BODILY INJURY (Per person) E ALL OWNED SCHEDULED AUTOS JAUTOS _ _ , _.., e,.__ ............................................ BODILY INJURY (Per accident) S X SWNED X PROPERTY DAMAGE $ ANON HIRED AUTOS _(Par accfderu1) ........ ,... l $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 1,000,000 B EXCESS LIAB CLAIMS -MADE UMB946734704 05/10/2016 05 /10/2017 AGGREGATE $ 1,000,000 11 111 11 1 DED X RETENTIONS 0� S WORKERS COMPENSATION �....,......- T)� - - -- --- - - - -- -- ---- --- - - - -- - _. -. - -- -.._ AND EMPLOYERS' LIABILITY Y� N ANY PROPRIETOR/PARTNER/EXECUTIVE E. L. EACH ACCIDENT $ BE EXCLUDED? C N /A (Mandatory In l rY ) E.L. DITEAUEE EA DISEASE EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT S A ;Crime PRA969906304 05/10/2016q 05/10/2017'$100,000 $2,500 Ded A Professional Llablll PRA969906304 05/10/2016 05/10/2017 !$1m /$2m $1000 Ded DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached K more apace Is required) Cyber Liability: BCS Ins. Co. / RPS -P- 0110241 / 10/23/15. 10/23/16 / $1,000,000 Schedule of Named Insured(s) Government Staffing Service dba: Herrera & Associates Staffing Services Government Staffing Service dba: Munlgroup,Government Staffing Service dba: Munitemps Government Staffing Service dba: Munistaff City of El Segundo named as and additional Insured as respects to general liability. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CI f El Se City o Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS, El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ®1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PRA 9699063 -04 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Any person or organization who you are required to add as an additional insured on this policy under a contract or agreement shall be an insured, but only with respect to that person's or organization's liability arising out of your operations as a "Staffing Service" or premises owned by or rented to you. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or 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 your acts or omissions or the acts or omissions of those acting on your behalf. A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 0 ISO Properties, Inc., 2004 Page 7 of 1 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION REP 04 9008463 -15 RENEWAL SP 7- 83 -77 -00 PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE FEBRUARY 12, 2016 AT 12.01 A.M. � ALL EFFECTIVE DATES ARE AND EXPIRING NOVEMBER 1, 2016 AT 12.01 A.M.��' "° AT 12:01 AM PACIFIC J"1 STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME MUNITEMPS PO BOX 718 IMPERIAL BEACH, CA 91933 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF EL SEGUNDO WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, MUNITEMPS IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03 %. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED, NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT, COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUtHOnIZED REPRrSENT IVE SCIF FORM 10217 (RIV,7 -20141 FEBRUARY 16, 2016 PRESIDENT ANN CrO 2570 • r CERTHOLDER COPY SP P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 05 -02 -2016 CITY OF EL SEGUNDO SP DEPT OF BUILDING a SAFETY 350 MAIN ST EL SEGUNDO CA 80245-3813 GROUP: POLICY NUMBER: 8008483 -2015 CERTIFICATE 0 23 CERTIFICATE EXPIRES: 11 -01 -2018 11 -01- 2015/11 -01 -2018 This is to certify that we have Issued a valid Workers' Compensation insurance policy In a form apprdved by the California Insurance Commissioner to the employer named below for the policy period Indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer, We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of Insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the poilcy listed hereln, Notwllhgtandlng any requirement, term or condition of any contract or other' document with respect to which This certificate of 'dnsurance tray be Issued or to which It may pertain. the insurance afforded by the policy described herein Is subject to all the terms, exclusions, and conditions, of such policy. Authorized Raptesertl',atrve President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #1600 - HERRERA, JOHN PRESIDENT - EXCLUDED. ENDORSEMENT #1600 - HERRERA, MARRISAL VICEPRES - EXCLUDED. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE, EFFECTIVE 11 -01 -2015 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2016 -02 -12 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO EMPLOYER GOVERNMENT STAFFING SERVICES INC SP PO BOX 718 IMPERIAL BEACH CA 81833 IJRC,CNJ IREV.7-2014) PRINTED : 05- 02-2010 WAIVER OF SUBROGATION NOTICE O ar - you must also agree to maintain accurately holder segregated payroll' records for employees engaged in work on job/s for thz certificate • has the waiver. The payroll records veri�,Ication by • . Example: Payroll for job: Sample Rate: Regular Premium equals: Surcharge: Additional Waiver charge: Total premium equals $5,000.00 13.3096 $ 665.00 3.0096 $ 19.95 $ 684.95 (665.00 + 19.95)