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PROOF OF INSURANCE (2016) CLOSEDDATE (MM /DDIYYYY) - ACC►,w " CERTIFICATE OF LIABILITY INSURANCE i 07/14/2016 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). 99 PRODUCER PHONE JOHN EKNO la � NOI.... 14 11 JOHN L EKNO rta Xt), 714 257 2517 I 714 257 2522 I ,.Ii _ Vjekn9 farmera�l.. e . BR EA CA 9 82105 INSURE I i E EXCHANGE __ rtAlc a INSURI R S AF'' I.. — Ik TRUCK INSURANCE EXCHANGE 21709 INSURED ...... _ FARMERS IN � .. INSURED INSUReRB.. XCHANGE 21652 CROSSROADS SOFTWARE, INC INSURPRC MID CENTURY INSURANCE EXCHANGE 21687 .....r I. 210 W. BIRCH ST. #207 t SCURER D ., .. .................. _ BREA, CA 92821 INStFr^BEl'dE ..., .,.,. 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 BY PAID CLAIMS .. LIMITS SHOWN MAY HAVE BEEN REDUCED - IT — CE TYPE OF INSURANCE � POWµtC'Y NUMBER �. MMFDD� PYYYY MlDrBAY'YYY LIMITS COMMERCIAL GENERAL, 60439 -58-4 5 08/271201608/2712016 EACH OCCURRENCE 4 $ 2,000,000 � CLAIMS MADE �.x � occuR f a � acTa�rr-rWCrt1) ... PREMISES IEa .. E . B ..�YPvf"'lC,,NRPNTf`ia m _ MED EXP (AnT one porsan) $ S,000 . . _ ...... .... .....__ - -- Y & A URY PERSONAL DV INJURY $ 2,000,000.. - -- PER: •Nl AGGW�kGATE LIMIT APPLIES otr _.... GENERALACsORi'G?'iE, 4 000,000 $" q ffI� PIo'" Loc POLICY �. JCOT PROOUCrs d WJMPfOP Acc 2,000,000 $ OTHER IL AUTOMOBILE LIABILITY 60439 -58-45 0812712015 8127'12016 Cat riI) Ira L iufiJUT 0, ,,...., s._2,000.,m 00 B INJURY (Per person) L....,,„ $ ANY AUTO ALL OWNED SCHEDULED ...BODILY ... ...........__ BODILY INJURY (Per accident) .............. $ AUTOS AUTOS _- - -- NON -OWNED F'ROPFit1 DAMAG4 $ X,,,,, HIRED AUTOS AUTOS (#�dWx ¢Tud�inl) UMBRELLA LIAB OCCUR EACH OCCOURRFNCCEE.. mm..... E„ ,..., _....._...... ..__.] . EXCESS LIAR CI.AW!S, MADE. . AGO EGATL ...........IT .,....___ $ C �...----.. DED RETENTIONS, N WORKERS COMPENSATION A09465956 81"9 312015 8113/2016 I°rR _ � �H $ LIABILITY YIN AND EMPLOYERS LIABILITY mm In W. EACH4.ITF AC ID 1,000 0 00 ,XE . ANY PROP RIE'fORYPARTNL CUTIVE �� OPFIC EWddMEMBER EXCLUD�E.Dd NIA E L. DISEASE EA E., MP , .. , $ 1,000,000 (Mandatory In NH) If yetis describe under..:..._. _:.M.. w... ,. ..., L L.. DISEASE - POUC'Y LIMIT S 1,000,000.. . . . . . . . . . . . . . . . . . . . . . . . . . . . DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) CERTIFICATE HOLDER LISTED BELOW ALSO ADDED AS ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLA CITY OF EL SEGUNDO POLICE DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 348 MAIN ST ACCORDANCE WITH THE POLICY PROVISIONS. EL SEGUNDO CA 90245 AUTHORIZED REPRESENTATIVE John Ekno © 1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 60439 -58 -45 BUSINESSOWNERS THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED . DESIGNATED: PERSON ONE ORGANIZATION This endorsement modifles Insurance provided under the following: BUSINESSOWNERS POLICY SCHEDULE* Name Of Person Or Organization: CITY OF EL SEGUNDO POLICE DEPARTMENT :lid ""?-. * Information required to complete this Schedule, if not shown on this endorsement, will be shown In the Declarations. The following Is added to Paragraph C. Who Is An Insured In the Buslnessowners Liability Coverage Form: 4. Any person or organization shown In the Sched- ule Is also an Insured, but only with respect to liability arising out of your ongoing operations or premises owned by or rented to you. BP 04 48 01 97 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ R CAREFULLY. Policy Number: 60439 -58 -45 POLICY CHANGES Effective Date of Change: 08/27/16 Change Endorsement No.: 003 Named Insured: CROSSROADS SOFTWARE INC 210 W BIRCH ST STE 207 BRE CA 92821 -4504 The following item (s): Expiration Date: 08/27/17 Agent: 97 -55 -316 Insured's Name Insured's Mailing Address Policy Number Company Effective / Expiration Date Insured's Leval Status / Business of Insured Payment Plan Premium Determination X Additional Interested Parties Coverage Forms and Endorsements Limits / Exposures D(iltic tibles Covered Property / Location Description Classification / Class Cod(, -,, Ra::c";, Underlying Insurance is (are) changed to read {See Additional Page(s)}: The above amendments result in a change in the premium as follows: X No Changes To Be Adjusted At Audit j Additional Premium Return Premium E4277 1 it Edidon Authorizt,1 Representative Signature: 0;PhA FARMERS INSURANCE. 914211 1ST EDMON 742 Induda EaWghled Hakb Inwrano Ww Oft Ina, w1h Ih pamhdaa E4277101 PAGE 1 OF 2 E42774DI Policy Changes Endorsement Description Removal If Covered Property is removed to a new location that is described on this Policy Change, Permit you may extend this insurance to include that Covered Property at each location during the removal. Coycrage at e -aeh loe aadon will apply in the proportion that the value at cuch location beats to the value of all Covered Property being removed. This permit applies up to 10 drays after the ef'fec'tive date of this Policy Chang after that, this insurance d(,)( s not apply at the previous location, 914277 1ST EDITION 7 -02 I t IOhI®d MMAI, Imutanto Suft Oft Int, A h podalm, E4277102 PAGE 2 OF 2 E42774DI Shillin , Mona From: Shilling, Mona Sent: Monday, August 01, 2016 2:00 PM To: Evanski, Brian (Captain) Cc: Sandoval, Lili Subject: FW: Crossroads Software, Inc. - Serv. Agr. No. 5163 - Confirm Waiver not Required Brian, This email is to confirm the Waiver of Subrogation for the Workers Compensation is not required because the vender will not be on site or any other site on the City's behalf. If this is not the case, please advise. Thanks, Mona S From: Shilling, Mona Sent: Monday, August 01, 2016 1:55 PM To: Evanski, Brian (Captain) Cc: Lillio, Joseph; Cerritos, Maria; Sandoval, Lili; 'jcullen @corssroadssoftware.com' Subject: Crossroads Software, Inc. - Serv. Agr. No. 5163 Brian, The signature process for Service Agreement No. 5163 with Crossroads Software, Inc. is complete. The proof of insurance provided has been accepted. Attached is a PDF copy of the agreement for the department and the vender. PLEAE NOTE: The vender has been copied on this email. r Ltvuolo, Work-, " r , o s r 0 Work-, emclU Mfr