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PROOF OF INSURANCE (2016) CLOSEDCERTIFICATE OF LIABILITY INSURANCE °o3i3ai2o 6Y) 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 corlTACT DERRY MCLEAN, AGENT NAIeE DERRY IWIthAl _ STATE FARM INSURANCE PHONE �LE U`E'NY GI F1RYNICLEAN.C4M 9549 KENWOOD DRIVE SUITE A RESPRING VALLEY, CA 91977 IN rRIRER s AFFORDpNfaCOTPRAG Naca INSURED IZOR AND ASSOCIATES "NSYJRER B AN ARCHITECTURAL CORPORATION INSURERC: 2048 ALDERGROVE AVE STE A INSURERO -w ESCONDI DO, CA 92029 -1903 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. � 0D unm P ._........ w ............ ...........�...- ,.,.._.,. -..... . A17D SUB ..........-- .�.. - -- POYEF� M�lCPI E P' LIMITS TYPE OF INSURANCE OLICY NUMBER GENERAL LIABILITY 90- CV- F984 -5 1010112015 10101/201 EACH OCCURRENCE s 2,000,000 COMMERCIAL GENERAL LIABILITY PRE -MOCCUR MI Ea ocrxrn cam S CLAIMaADE ` EDEXP(An one Person) S 5,000 ` PERSONAL 8 ADV INJURY $ GENERAL _® ...... ......� � ATE s a,000,000 GEN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS -COMPIOPAGG S m..m - POLICY LOC $ AUTOMOBILE LIABILITY COMUINEoSINGLE Ft-m7 T _). S ANY AUTO BODILY INJURY (Per person) $ ALL ,�. - , AUTOS ED AUTOS�ED BODILY INJURY (Per aoddent) $ -__ -. AUTOS NON-OWNED rpROPE NFY 1MA4 $ HIRED AUTOS S UMBRELLA LIAB OCCUR DO EACH OCCURRENCE S EXCESS LIAR CLAIMS -MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY rnRV c IMITS Fa YIN E L EACHACCID ENT E ANY PROPRIETORIPARTNERIEXECUTIVE OFFICEIMEMBEREXCLUDED? t__-_J NIA CCID n (Mandatory In NH) E L DISEASE- EA EMPLOYEE S If yes, describe under .._ ncar•ci, r%mr%nocco. A.rr=a EL, DISEASE - POLICYLLIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS [VEHICLES (Attach ACORD 101. Addlllonal Remarks Schedule, If more space Is required) /"- I*TIVIe-. A"r' Will 11 12-0 PAKIP C t t A'w"fr°h►.t....... CITY OF EL SEGUNDO, Its officers, officials, employees, agents and volunteers 350 MAIN STREET EL SEGUNDO, CA 92045 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 0 ®19110.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 1001486 132849.7 03 -01 -2012 No 90— CV —F984— JL j� r �P —5 .� CMP- 4786.1 q„ RANGES Page � of 2 THIS ENDORSE�MEN76 THE POLICY. PLEASE READ IT CAREFULLY. CMP- 4786.1 ADDITIONAL INSURED — OWNERS, LESSEES, OR CONTRACTORS (Scheduled) This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM -SCHEDULE µms" Policy Number: 90- CV- F984 -5mM� -Na med Insured: ARCHITECTURAL CORPORATION � 2048 ALDERGROVE AVE STE A ESCONDIDO CA 92029 - -1903 , Name And Address Of Additional Insured Person Or Organization: CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, & EMPLOYEES 350 MAIN STREET EL SEGUNDO CA 92045 1. SECTION II — WHO IS AN INSURED of b. If coverage provided to the additional in- SECTION II — LIABILITY is amended to in- sured is required by a contract or agree - clude, as an additional insured, any person or ment, the insurance provided to the organization shown in the Schedule, but only additional insured will not be broader than with respect to liability for "bodily injury ", that which you are required by the contract property damage", or personal and advertis- ing injury" caused, in whole or in part, by: or agreement to provide for such addition - al insured; and a. Ongoing Operations c. If the contract or agreement between you (1) Your acts or omissions; or and the additional insured is governed by (2) The acts or omissions of those acting California Civil. Code Section 2782 or on your behalf; 2782.05, the insurance provided to the in the performance of your ongoing opera- additional insured is the lesser of that which: tions for that additional insured; or b. Products - Completed Operations (1) Is allowed for the satisfaction of a de- fense or indemnity obligation by Cali - "Your work" performed for that additional fornia Civil Code Section 2782 or insured and included in the "products- 2782.05 for your sole liability; or completed operations hazard ". (2) You are required by contract or However, Paragraph 1, above is subject to the agreement to provide for such addi- following: tional insured. a. The insurance afforded to the additional We have no duty to defend or indemnify the insured only applies to the extent permit- additional insured under this endorsement un- ted by law; til a claim or "suit" is tendered to us. ©, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission. CONTINUED CMP- 4786.1 Page 2 of 2 2. Any insurance provided to the additional in- (3) The nature and location of any injury sured shall only apply with respect to a claim or damage arising out of the "occur - made or a "suit' brought for damages for rence" or offense; which you are provided coverage. b. Tender the defense and indemnity of any 3. With respect to the insurance afforded to the claim or "suit' to us and to all other insur- additional insured, the following is added to ers who may have insurance potentially SECTION II — LIMITS OF INSURANCE: available to the additional insured; and If coverage provided to the additional insured c. Agree to make available any other insur- is required by contract or agreement, the most ance the additional insured has for de- we will pay on behalf of the additional insured fense or damages for which we would will be the lesser of the amount of insurance: provide coverage under SECTION II — a. Required by the contract or agreement; or LIABILITY. b. Available under the applicable Limits Of 5. With respect to the insurance afforded the ad- Insurance shown in the Declarations. ditional insured, the following replaces SEC- TION II — LIABILITY of Paragraph 7. Other This endorsement shall not increase the ap- Insurance of SECTION I AND SECTION II — plicable Limits Of Insurance shown in the COMMON POLICY CONDITIONS: Declarations. a. This insurance is primary to and will not 4. With respect to the insurance afforded to the seek contribution from any other insurance additional insured, the following is added to available to the additional insured, provided Paragraph 3. Duties In The Event Of Occur- that the additional insured is a named in- rence, Offense, Claim Or Suit of SECTION sured under such other insurance. II — GENERAL CONDITIONS: b. Regardless of any agreement between The additional insured must: you and the additional insured, this insur- ance is excess over any other insurance a. See to it that we are notified as soon as whether primary, excess, contingent or on practicable of an "occurrence" or an of- any other basis for which the additional in- fense which may result in a claim. To the sured has been added as an additional in- extent possible, notice should include: sured on other policies. (1) How, when and where the `occur- There will be no refund of premium in the event rence" or offense took place; this endorsement is cancelled. (2) The names and addresses of any in- jured persons and witnesses; and All other policy provisions apply. CMP - 4786.1 1007033 148011 08 -21 -2014 (t), Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission. � 0 DATE CERTIFICATE OF LIABILITY INSURANCE °2°' 6' 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$, C DANA CLARK HARTLEY CYLKE PACIFIC- 1#0574253 PHONE (619)295 -5155 FA)C „ c.n�., , (619) 291 -0912 INSURANCE SERVICES, INC. E.MAtL AOD ES S: 2747 UNIVERSITY AVENUE INSURERISI AFFORDING COVERAGE NA(C0 SAN DIEGO CA 92104 -4068 INSURERA:SCOTTSDALE INDEMNITY CO. INSURED Izor 6 Associates, Inc. 2048 AIdergrove Ave, Suite A Escondido CA 92029 1 INSURER COVERAGES CERTIFICATE NUMBER:CL1632841760 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, ADDL TYPE OF INSURANCE �ucn COMMERCIAL GENERAL LIABILITY POLICY NUMBER unm , __„_, w�_, BER PLIC LICY EXP i,. LIMITS EACH OCCURRENCE $ CLAIMS-MADE 0 OCCUR INAM LIMUEM 2m mninae) _ $ MED EXP (Anv am person) S PERSONAL 8 ADV INJURY S GENERAL .AGGREGATE S G'EN'E. AGGRE"T'E LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG S POLICY � JECT EI LOC S OTHER AUTOMOBILE LIABILITY CCIMS $ ANY AUTO BODILY INJURY (Per parson) $ ALL UTOS OWNED SCHEDULED AUTOS NON -OWNED HIREDAUTOS AUTOS H- BODILY INJURY (Per accident) S PR P DAMAGE PargM 5 S I UMBRELLA LIAB OCCUR EACH OCCURRENCE is 'EXCESS LIAB CLAIMS -MADE AGGREGATE S NS O'ED RETENTION RETENTION _ i $ VYORtlrE1iS COMPENSATION WORKERS ANO EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE PER E.L. EACH ACCIDENT 5...� -- OTFI'CERIMCMBER EXCLUDED? NIA IMyypIaodalory Im NH) PL E.L. DISEASE EA EMPLOYEE S DESCRIPTION OF OP • 'RATIONS belcner � '� WIL , DISEASE - POLICY' LtlMR" rS A PROFESSIONAL LIABILITY EK13104466 3/21/2016 3/21/2017! CCURRENCE $1,000,000 *CLAIMS MADE — DED: $2,500 Lw�REGATE $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addlllonal Remarks Schedule, may be attached If more space Is requl d) *PROOF OF INSURANCE * *10 DAY NOTICE OF CANCELLATION FOR NONPAYMENT OF PREt+tIOM SHALL APPLY. PROOF OF INSURANCE 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 JANA CLARK /DANA _ .j`„ t✓a_E1:�'``_'._ ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 (201401) * 11 n 1 1 Interinsurance Exchange of the Automobile Club Automobile Insurance Policy Coverages and Limits Renewal Declarations We are pleased to offer you a renewal for your automobile insurance policy. To renew your policy, send at least the minimum payment on or s before the due date. Insurance is in effect only for the vehicles, coverages, and limits of liability shown on this declarations page and as set g forth in the insurance policy and endorsements. These declarations, together with the contract and the endorsements in effect, complete your policy. If any change to your policy or to the information we have on file results in a premium decrease during the policy period, the Interinsurance Exchange reserves the right to apply any refund due to your outstanding balance. g NAMED INSURED (Itern 1.) AUTO POLICY NUMBER: CAA 064973213 IZOR, GREGORY K AND GENEICE G 3066 HILL VALLEY DR ESCONDIDO CA 92029 -1522 VEHICLES VEH, YEAR MAKE MODEL NO. 2 2010 HYUN VERACRUZ GLS /LTD 3 2008 COUG VVH292QBS 4 2016 FORD F250 CREW C CREW POLICY PERIOD (PACIFIC STANDARD TIME) POLICY EFFECTIVE DATE: 03 -24 -16 12:01 A.M. POLICY EXPIRATION DATE: 03 -24 -17 12:01 A.M. IDENTIFICATION VEHICLE GARAGE ANNUAL" VERIFIED NUMBER USE ZIP CODE MILES MILEAGE SALVAGE KMBNL14CCXAU136083 COMMUTE 92029 15,001 - 17,500 VERIFIED NO 4YDF2922X82500266 PLEASURE 92029 $500 1 FT7W2BT9GEA14525 PLEASURE 92029 10,001 - 12,500 VERIFIED NO COVERAGES AND LIMITS ANNUAL PREMIUMS Coverage is not in effect unless a premium or the word "included" is shown. COVERAGES LIMITS OF LIABILITY Vehicle 2 Vehicle 3 Vehicle 4 Vehicle Vehicle Liability Bodily Injury $100,000 each person/ $300,000 each occurrence $ 228 No Coverage; $ 198 Property Damage $100,000 each occurrence $ 200 No Coverages', $ 164 Medical Payments $5,000 each person $ 33 No Coverage,' $ 29 Physical Damage (Actual Cash Value unless otherwise stated, less deductible) Vehicle 2 Vehicle 3 Vehicle 4 Vehicle Vehicle Comprehensive ACV $30000 ACV $ 26 $ 117 $ 40 (Less Deductible) $500 $500 $500 Collision ACV $30000 ACV $ 303 $ 112 $ 417 (Less Deductible) $500 $500 $500 Car Rental Expense Per Da) $35 No Coverage $35 $ 37 No Coverage' $ 34 Uninsured Motorist Bodily Injury - $100,000 each person/ $300,000 each accident s $ 40 No Coverage $ 32 Uninsured & Underinsured Vehicles s Uninsured Deductible Waiver Included No Coverage Included Uninsured Collision No Coverage E No Coverage; No Coverage' Total Premium $ 867 $ 229 $ 934 PREMIUM DISCOUNTS "No Coverage" indicates coverage not purchased, Please refer to the enclosed document entitled "Premium Discounts Applied to Your Automobile Policy "' Total Annual Premium * If at any time you choose to pay less than the full balance outstanding, finance charges of up to 1.5% per month of the balance outstanding will apply as explained in your billing statements, which are part of these declarations. ** To see the annual mileage for your expiring policy, please refer to the "Notice of Annual Mileage" page contained in your renewal package. (Includes all applicable discounts.) $ 2030 Less Policyholder Savings Dividend $ 201 Net Premium* $ 1829 E20141014 PROCESS DATE 02 -12 -16 PLEASE ATTACH TO YOUR POLICY (SEE REVERSE) 021316 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: (_) I have and will maintain a certificate of consent of self- insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement with the City of El Segundo. Policy No. (_) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Name of Agent Policy Number Expiration Date Phone # (A I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if l should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those prov ns or the agree �vyill auto ,tically become void. Signature of Applicant Agreement for: 2 AeE�V"A Dated: D�� ,a 14a Reviewed by:' Date 3 -� 6,