PROOF OF INSURANCE (2016) CLOSEDDATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
L_ _ � 6/15/2016
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 Staci Thistlewhite
NAME!,
Insurance Solutions (949)348-7400 FAX (949)346 -2373
PHONE
C(A , No, Ext)w ) ®,A.,, .........t I ..N .
License #0746539 E-MAIL stacit @ins- solutions.com
ADDRESS:
33302 Valle Rd, Suite 200 INSURE
R(S) AFFORDING COVERAGE NAIC #
surance Compa "ny
__Inc. 10200
San Juan Capistrano CA 675 n
� ---- ,..... ......... ............... INSURER A :HisCOX I. .... .........,...... .. �..
INSURED INSURER B:
Emergency Management Consulting Solutions Inc. INSURER C:
21520 Yorba Linda Blvd. Ste. G560 INSURER D:
INSURER E:
Yorba Linda CA 92887 1 INSURER F,
COVERAGES CERTIFICATE NUMBER :15 -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.
., _. - TYPE OF INSURANCE........ a �_ _ .. POLtCY NUMBER �. M ,IY ........ .. ....... .. ...... .... ... .......
INSR.....,. ,.... AoItYL �"US`R " POI. ICY 1w.FF PO' ;L11CY E.XPI LIMITS
LTR ''. YYY MM/DDlYYYY'
R
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 3 , 000, 000
--• .�
DAMA� E To, RENTED—
',PIF.9;.dE,aa�o<Imgmoal
100, 000
A
ro.....
CLAIMS -MADE R OCCUR
$
--------
1487197
8/28/2015
8/28/2016
MED EXP (Any one person)
$ 5, 000
._._.....
PERSONAL &ADVINJURY
$ 3,000,000
GEN'L
AGGREGATE LIMIT APPLIES PER.
GENERAL AGGREGATE
$ 3,000,000
R
O
POLICY PRO �LOC
PRODUCTS COMPIOPAGG
$ 3,000,000
- ----- -.
O'rrltR
I
$
AUTOMOBILE LIABILITY
C MBINkG1 IN LE. LIMIT
$
'.. ANY AUTO
BODILY INJURY (Per person)
$
ALL OWNED ( SCHEDULED
BODILY INJURY (Per accident)
$
AUTOS (,.,....,,.., AUTOS
NON -OWNED
m
PROPERTY DAMAGE
.. ... ..... ......... ....
$
HIRED AUTOS AUTOS
er .
.( a�,ddgnl), ...
....... ....
UMBRELLA LIAB OCCUR
EACH OCCURRENCE III $ .,.�,
EXCESS LIAR .
. ,,,...... � CLAIMS MADE
I
AGGREGATE $.. ................
jj
DEL) RETENTION $
$
WORKERS COMPENSATION
I H
STATIJTE ll, ER
AND EMPLOYERS' LIABILITY Y' / N'-
ANY PROPRIETOR /PARTNER /EXECUTIVE
E L EACH ACCIDENT $
/MEMBER EXCLUDED? 1
� a
N/A
(OFFICER
(Mandatory in NH)
E L DISEASE EA EMPLO YEE ...,.
If s desc.ri under
.,.. ,$ ..... . ®.
0 9CRIPTION OF OPERATIONS Aelrtrvr
E L DISEASE POLICY LIMIT $
A
Errors & Omissions
1487197
8/28/2015
8/28/2016
Limit: $ 1,000,000 Dad: $ 500
Aggregate: $ 1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
RE: Management Consulting @ City of E1 Segundo
Certificate Holder is included as additional insured.
CANCELLATION
cdonovan @elsegundo.org
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Attn: Fire Chief Chris Donovan ACCORDANCE WITH THE POLICY PROVISIONS.
314 Main St, E1 Segundo
El Segundo, CA 90245 f AUTHORIZED REPRESENTATIVE
T AleSSandra /PETERS
@ 1988 -2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INSn25 t9nfanll
4
ISO Hiscox Insurance Company Inc.
Policy Number: UDC - 1487197 - CGL -16
Named Insured: Emergency Management Consulting Solutions Inc.
Endorsement Number: 9
Endorsement Effective: August 28, 2016
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INS AUTOMATIC STATUS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A. Section II — Who Is An Insured is amended
to include as an additional insured any per-
sons) or organization(s) for whom you are
performing operations or leasing a premises
when you and such person(s) or organiza-
tion(s) have agreed in writing in a contract or
agreement that such person(s) or organiza-
tions) be added as an additional insured on
your policy. Such person or organization is
an additional insured only with respect to lia-
bility 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:
1. In the performance of your ongoing opera-
tions; or
2. In connection with your premises owned by or
rented to you.
A person's or organization's status as an addi-
tional insured under this endorsement ends
when your operations or lease agreement for
that additional insured are completed.
CGL E5421 CW (02/14) Includes copyrighted material of Insurance Services Office, Inc., with its Page 1 of 1
permission.
a
In erinsurance Exchange of the Automobile Club A
Automobile Insurance Policy Coverages and Limits
Policy Change Declarations
C'&jFjAEArr1 HL - rmPglerA-,,0—i
Insurance is in effect only for the vehicles, coverages, and limits of liability shown on this declarations page and as set forth in the insurance
policy and endorsements. These declarations, together with the contract and the endorsements in effect, complete your policy.
NAMED INSURED titem 1,I
AUTO POLICY NUMBER: CAA 087654017
BIRRELL, JAMES AND BIRRELL,
17568 CLOVERDALE WAY
YORBA LINDA CA 92886 -1948
SUBJECT OF POLICY CHANGE
AUTO - CORRECTION
ANNUAL - MILEAGE -CHG -
POLICY PERIOD (PACIFIC STANDARD TIME)
POLICY EFFECTIVE DATE: 01 -25 -16 12:01 A.M.
POLICY EXPIRATION DATE: 01 -25 -17 12:01 A.M.
POLICY CHANGE EFFECTIVE DATE: 06 -18 -16 12:01 A.M.
THIS IS NOT A BILL
This policy change will increase your premium by
VEHICLES
VEH' YEAR MAKE MODEL
IDENTIFICATION
VEHICLE GARAGE ANNUAL VERIFIED
NO•
NUMBER
USE ZIP CODE MILES MILEAGE
SALVAGE
4 2009 FLEE DISCOVERY
4UZACWDT38CZ04420
PLEASURE 92886 1 - 5D0 VERIFIED
6 2015 LINC NAVIGATOR
5LMJJ2HT2FEJ13710
PLEASURE 92888 15,001-17,500 VERIFIED
NO
7 2010 JEEP WRANGLER 4D 4X4 UNL
1J4BA5H12AL169317
PLEASURE 92886 7,501-10,000 VERIFIED
NO
8 2016 FORD F15D CREW C SUPER
1 FTFW1 EFOGFB44134
PLEASURE 928M 12,501 - 15,000 VERIFIED
NO
COVERAGES AND LIMITS
Coverage Is not In effect unless a premium or the word "Included" Is shown.
ANNUAL PREMIUMS
COVERAGES LWATS OF LIABILITY
Vehicle 4 Vehide 6 Vehicle 7 Vehide 8
Vehide
Liability
I
Bodily Injury $1,000,000 each person/ $1,000,000 each occumerrce
E i 5 X
Property Damage $1,000,000 each occurrence
i 9
Medical
r
A
f
i No Coverage No Coverage N No Coverage g No Coverage tl
PhyS/Cal Damage (/kdral Aun Value union oftrwiw silted, lees ded_ uadble)
«
Vehicle 4 Vehicle 8 Vehicle 7
Vehicle 8 Vehicle
: I
Comprehensive $125000 ACV ACV
ACV
I
(Less Deductible) $250 $500 $500
$500
Collision $125000 ACV ACV
ACV'
I i e
, w
(Less Deductible) $250 $500 $600
$500
Car Rental
r
Per De No Crave a No Craw No Cover
a No Cora a
No Covexa, e
# I No Coverage No Coverage, i No Coverage i
Uninsured Motudst
x
Bodily Injury - $1,000,000 each person/ $1,000,000 each accident
i, s
Uninsured & Underinsured Vehicles
I i
Uninsured Deductible Waterer
s
i Included j Included 1 Included Included
Uninsured Collision
'No Coverage Coverage'' No Coverage No Coverage
Total Premium
I
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.
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.
U 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 Policy Number Expiration Date
Name of Agent Phone #
(/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 I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must
g p r the agreement will automatically become void.
immediately comply with those provisions
Signature of Appfica ns o Date
Agreement for: ��"M MAyJkMv+ CmAns� S1 Ai�51 Ine- —ft*33
Dated: v8, I -� ' I I,°
J'
Reviewed by.` ..