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PROOF OF INSURANCE (2017 - 2017) CLOSEDDATE (MMIDD /YYYY) '�6 "" CERTIFICATE OF LIABILITY INSURANCE 3/7/2016 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 certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Maile ;72 esen eNAME; O ti�^ FH1 ........ ... ---- ....... 7 7400 j�INC (510)547 -3159 Brennan and Associates Risk M t & Insurance Svc PHONE (510) 54 II &�'C,Na�h License # 0649629 E -MAIL. A .pFgss _ 2200 Powell St., Suite 1080 iNSURES(s)aw�zDlrawr�GE NAIC# Emeryville CA 94608 INSURER A Col.onv Insurance Comasanv INSURED INSURER B ReDUblic U/W Ins CO Krause ACT, Inc. �,S�Fsf,� Sentanel .. Insurance _ .. Coipp ... _... .... DBA: Air Cleaning Technology INSURER D: 411 Rowland Ave INSURER E . Santa Ana CA 92707 INSURER F. COVERAGES CERTIFICATE NUMBR2016 -2017 GL /XS Renewal 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. INSR ADCS -L.. 5� ra ......... ........ TYPE OF INSURANCE InnDR' ---- -- -- ----- --- L.•.... �^ ��^ POLICY NUMBER - -..... POLICY EFF POLICY IEXP... -.. ........ ......... ......... �MM0DIYYYY� MMIDWYYYY'. LIMITS ......... ....---- ........ X COMMERCIAL GENERAL LIABILITY FACH OCCURf4PNCE $ 1,000,000 A _ _� CLAIMS -MADE � X ,� OCCUR „ p.R.�MI� � ILa ��lrare �) .. � $ 300 , 000 X Deduc $2,500 tible X PACE303159 3/7/2016 3/7/2017 MED EXP,(Any one person) $ 5 00,0 -_ _ -- ­111 1 each occurence PERSONAL &ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ -- 2 , 000 , 000 GEN L AGGREGATE LIMIT APPLIES PER: PRO- POLICY X JECT � l LOC PRODUCTS - COMP /OP AGG - $ 2,000,000 - _ $ OTHER, AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT !Fa acridenFl $ BODILY INJURY (Per person) $ ANY AUTO ",...... ALL OWNED ..r. "" SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Perar.cdanh $ .. NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 AGGREGATE $ 4,000,000 A A X EXCESS LI B � CLAIMS -MADE $ DED RFTFNTIrKI E 3/7/2016 3/7/2017 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N X PER OTH- STATI ITF FR. _L _ ANY PROPRIETOR /PARTNER/EXECUTIVE " " "" OFFICER /MEMBER EXCL UDED (Mandatory in NH) NIA ATWO01779 -03 1/1/2016 1/1/2017 E L EACH ACCIDENT i . ................ mm........,. ....................,..B E L DISEASE - EA EMPLO 1 , 000. 000 r1FCr'RIPTI be Under ff eS deSCrnN r,)F r?PFRATI(1NS halnyy E DIASF POI I(FV I ! 1� m n0D.000 C Contractors Equip /Tools 72S 4796 2/1/2016 2/1/2017 Limits $10,000 /$1000 A Errors 6 Omissions PACE303159 3/7/2016 3/7/2017 Aggregate $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: E1 Segundo Fire Department, 314 Main Street, E1 Segundo, CA 90245. The City of E1 Segundo is included as Additional Insured with regard to General Liability per attached forms EPACE100 -0814 6 EPACE101 -0814. Waiver of Subrogation applies to Workers' Compensation per attached form WC 04 03 06. It m lt' CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of E1 Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn : City Clerk ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE Greg Havill /MJ ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD N S025 ran i em 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. KOK$] I ki � fit 11 1411*01Y.1"M K-01 N . 4�:1 19 R 6 " 4 0 This endorsement modifies insurance provided under the following: EnviroPACE Insurance Policy A. Section XX. WHO IS AN INSURED, Coverage Part 1 and Part 2 is amended to include as an additional insured the person(s) or organization(s) shown in the SCHEDULE above, but only with respect to liability for bodily injury, property damage, environmental damage, or cleanup costs caused, in whole or in part, by your work at the location designated and described in the SCHEDULE of this endorsement performed for that additional insured and included in the products - completed operations hazard. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to section XXI. LIMITS OF LIABILITY AND DEDUCTIBLE: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Liability shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Liability shown in the Declarations. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED, EPACE100 -0814 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1 with its permission. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. :101910 11 00740 010 r • • This endorsement modifies insurance provided under the following: EnviroPACE Insurance Policy SCHEDULE Name Of Additional Insured Person(s) Or Orqanization(s) Location(s) Of Covered Operations Where Required By Written Contract Where Required By Written Contract A. Section XX. WHO IS AN INSURED, Coverage Part 1 and Part 2 is amended to include as an additional insured the person(s) or organization(s) shown in the SCHEDULE above, but only with respect to liability for bodily injury, property damage, personal and advertising injury, environmental damage, or cleanup costs caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to bodily injury or property damage occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of your work out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. EPACE101 -0814 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 2 with its permission. C. With respect to the insurance afforded to these additional insureds, the following is added to section XXI. LIMITS OF LIABILITY AND DEDUCTIBLE: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Liability shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Liability shown in the Declarations. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. EPACE101 -0814 Includes copyrighted material of Insurance Services Office, Inc., Page 2 of 2 with its permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4 -84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA 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 225% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Blanket Waiver of Subrogation As respects to all CA jobs performed by the named insured during the policy period where by written contract a waiver of subrogation is required prior to the commencement of work. 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 01 -01 -2016 Policy No. ATW 001779 -03 Endorsement No, . Insured Insurance Company Krause ACT, Inc. (A Corp) Republic Underwriters Insurance Company Countersigned Icy ©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. StgeF&M STATE FARM@ PO Box 799 100 Dallas TX 75379 95A AT1 23 001397 0093 CITY OF EL SEGUNDO CITY CLEARK 350 MAIN ST EL SEGUNDO CA 90245-3895 Q? A DATE OF NOTICE: MAY 17 2016 CODE: 84686 NOTE: PLEASE NO'T'IFY STATE FARM AT THE ADDRESS LISTED AT THE TOP, LEFT CORNER OF THIS PAGE REGARDING ANY CHANGE OF ADDRESS INFORMATION. ADDITIONAL INSURED'S NOTICE OF COVERAGE State Farm Mutual Automobile Insurance Company 0598-FA64-A NAMED INSURED: POLICY NO: 379 1976-COI-75P COVERAGE: KRAUSE A C T YR/MAKE/MODEL: 2011 MERCEDES UTILITY BI AND PD LIABILITY DBA AIR CLEANING TENCHOLOGY VIN/CAMPER: WDAPF3CC4139478265 $1 MIL $100 DED. COMP. F- 411 ROWLAND AVE AGENT NAME: DAN RICKABUS $1000 DED. COLL. SANTA ANA CA 92707-3445 AGENT PHONE: (949)363-7100 ENDORSEMENT NO: 6028BU POLICY EFFECTIVE MAY 03 2016 UNTIL TERMINATED POLICY MESSAGES: J'tjjs policy sjiown atrove supetsedes policy# 3791976-750, st in fl m des(,rlbed car to fl'w extent of the insugance the policy inctttdes a lo�ss p<lyable clause protecting flie� additional irwreds irAer'0 o piovide('l rind subleclto egi policy provisions, The additjonaI insiAred will be given 20 days notice if ojtj� pol,4,,y is terrnim,,Ated. Until such notice d any change of intoresl or ownership coming to their attoifion. Failure to do so wlit render this, plaficy nkffl Wld void, FRT State&rm STATE FARM® 46. Old rqdvor° 1lmra'/ Bakerstiold CA 93,311 -9501 61A AT1 23 001049 0093 CITY OF EL SEGUNDO CITY CLEARK • y. 350 MAIN ST EL SEGUNDO CA 90245 -3895 0 0 s s s I "II "IIIIIIIIIIIIIIIIIII' Ill' III 'illllrlll'Illll'Ill'Illll "'I' A DATE OF NOTICE: APR 01 2016 CODE: 84686 NOTE: PLEASE NOTIFY STATE FARM AT THE ADDRESS LISTED AT THE TOP, LEFT CORNER OF THIS PAGE REGARDING ANY CHANGE OF ADDRESS INFORMATION. ADDITIONAL INSUREDS (NOT'I'CE OF COVERAGE State Farm Mutual Automobile Insurance Company 98- FA64 -A NAMED INSURED: POLICY NO: 309 0552- CO1 -75Y COVERAGE: KRAUSE A C'I' YR /MAKE /MODEL: 2013 TOYOTA SPORT WG BI AND PD LIABILITY v DBA AIR CLEANING TECHNOLOGY VIN /CAMPER: JTEBU4BF5DK167501 $ 1 MIL/$ 1 MIL P 1 MIL $100 DED. COMP. 411 ROWLAND AVE AGENT NAME: DAN RICKABUS $500 DED. COLL. SANTA ANA CA 92707 -3445 AGENT PHONE: (949)363 -7100 ENDORSEMENT NO: 6028BU POLICY EFFECTIVE MAR 08 2016 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy# 3090552 -75X. A The praiur.y Irx;ludos a loss payable clause, protecting the addihorural insureds 'interest in the clew ribed cai to the extent of the insurance Z provided and subject to all policy provisions. 1 h e radditr nzil insured gull be given 20 drys rrratNcam ut tYje policy is terrn"mined. Until such rrotiice is provided uI shall be prtas unred ltmt the realuirod renewal prorniuni ll�avaa braran paid, The e raddilronal irtraar'ed rnusIl nrratify us within 10 days of 8 any ch ai ige of inleresa or ownership oormuOr j to tf ucalr aatleralrcau Failure to do so will rendrar thus polucry null and void. N FRT StaftfWyll? STATE FARM@ PO Box 799 100 Dallas TX 75379 66A AT1 23 000623 0093 CITY OF EL SEGUNDO ATTN: CITY CLERK 350 MAIN ST EL SEGUNDO CA 90245-3895 0"I Jill A DATE OF NOTICE: MAR 15 2016 CODE: NOTE: PLEASE NOTIFY STATE FARM AT THE ADDRESS LISTED AT THE TOP, LEFT CORNER OF THIS PAGE REGARDING ANY CHANG&E OF ADDRESS INFORMATION. ADDITIONAL INSURED'S NOTICE OF COVERAGE State Farm Mutual Automobile Insurance Company 0598-FA64-A NAMED INSURED: POLICY NO: 391 3576-001 -75T COVERAGE: KRAUSE A C T YR/MAKE/MODEL: NONOWNED AUTO BI AND PD LIABILITY DB,A AIR CLEANING TECHNOLOGY VINICAM $1 MIL �PER, $250 DED. COMP/COLL. 411 ROWLAND AVE AGENT NAME: DAN RICKABUS SANTA ANA CA 92707-3445 AGENT PHONE: (949)363-7100 ENDORSEMENT NO: 6028BU POLICY EFFECTIVE 6164DP 6165CS MAR 04 2016 UNTIL TERMINATED N POLICY MESSAGES : pf)hcy .shown above� siiparsfzxles policy;l 391357(�-,75S, co 0M I'he poti(,,,y inchides as loss payabt e dause piroteclIng Wto adffifionW instjred's in erest in lhe desodbed cai tar tjj(r crxt(Lqjt of the insiwance o povided and sijbleel to all 1)04cy provisjons,"t'he addiHonal jrtskirefj will be given 20 days rpattce it th( jpolk,•y is Niraiinated. Until sudi nolice co is provided, i ORO be presurned flia [ 11 le required renewal pie n'flians have bow i pakl, 11,ie tTji,g;j 1°notify us within '10 days of Sany change of into'est or ownl,,trship conling''to theii, ajjetition, Pqfluire to do so wi0 rorjd(',w lhns poky ni,,M and void, FRT