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PROOF OF INSURANCE (2017) CLOSEDCERTIFICATE OF LIABILITY INSURANCE 09/13/2006 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 License# 0751768 NAiiE� BOB HADZOR Robert Hadzor Insurance Services PHONE (925) 372 -9000 (925) 372 -9003 3755 Alhambra Ave. Suite 7 „bob @hadzorinsurance.com INSURFR(Sl AFFORDING COVERAGE NAIC Y Martinez, CA 94553 - INSURED El Segundo Nursery School P.O. Box 73 300 E. Pine Street is El Segundo CA 90245- 1 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. IIN,TR TYPE OF INSURANCE POLICY NUMBER P LI Y �FF /,N /OOPY'YYY P l P M � D YY LIMITS A GENERAL LIABILITY 016- 20766 -NPO 4/01/2016 4 01/2017 EACH OCCURRENCE $ 1,000,000' X COMMERCIAL GENEERAL MAHMlY / / / / PREMtl E; Eo rr $ 100, 000 FAI / / / / CLAIMSWADE OCCUR MED EXP (Any one person) $ 10,000, PERSONAL& ADV INJURY $ 1,000,000' GENERAL AGGREGATE S 3,000,000 G'EN't AGGREGATE LIMIT APPLIES PER: / / / / PRODUCTS - COMP /OP AGG $ 3,000,000 X POL6CY '.., P"O. LOC / / / / 1 1000R I IAB S 1, 000, 000 A AUTOMOBILE UABILITY 016- 20766 -NPO 4/01/2016 4/01/2017 AINED I I 1 000 000 ANY AUTO / / / / L BODILY INJURY (Per person) S .. ALL OWNED SCHEDULED AUTOS AUTOS / / / / BODILY INJURY (Per accident) S X HIRED AUTOS X NOTOSWNED / / / / PROPERid nl DAMAGE $ UMBRELLA LIAB OCCUR / / / / EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE', E' ­T / / / / AGGREGATE $ DED RETENT ION$ C WORKERS COMPENSATION C0023768 -05 2/01/2016 02 '0172017 X STATU- OTH- AND EMPLOYERS' LIABILITY YIN �1 ANY PROPRIETOILPARTNER/EXECUTIVE i NIA E.L EACH ACCIDENT $ 000 000 OFFICER/MEMBER EXCLUDED? In / / / / (Mandatory NH) E.L DISEASE - EA EMPLOYE S 14000,000 If yes, describe under DESCRIPTION OF OPERATIONS below _ E.L DISEASE - POLICY LIMIT $ B PERSONAL PROPERTY CWB0006763-07 4/01/2016 4/01/2017 SPECIAL FORM RC 5,000 A D&O INSURANCE 016- 20766 -DO 4/01/2016 4/01/2017 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space Is required) City of E1 Segundo its Officers, Officials, Employees and Voluteers to be named as additional insured and Also attached is the Waiver of Subrogation for Work Comp policy through Markel Insurance company. Re: Landlord of E1 Segundo Nursery School CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of El Segundo its Official and Employees c/o City Cllerk AUTHORIZED REPRESEIITAYN 350 Main Street RM 5 E1 Segundo CA 90245 -3813 ACORD 25 (2010105) ©1& I)2010 ACOR CO ORATION. All rights reserved. INS025 (201005).01 The ACORD name and logo are registered marks of ACORD COMMERCIAL !Qrl�"i LIABMITY CG 20 110196 sal: 1 1 r THIS ENDORSENOT CHMORS THE POLICY. Pii.EASR READ IT CAPJWULLY. 1 1 Ir I ! • IY it This endorsement modifies insurance provided under the following: City of El Segundo its Official and Employees C/O City Clerk 350 Main Street. Rm S El Segundo, CA 90245 -3813 WSVBD TO: City of El Segundo its Officers, Official, Employe" and Volunteers RE: Landlord of El Segundo Nursery School :F vi _. (If no entry appears above, the information required to complete this endorsement will be shown in the Declarations as applicable to this end ent.) WHO IS AN INSURED (Section H) is amended to include as an insured the person or organization shown in the Schedule but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to: 1. Any `occurrene which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the person or organization shown in the Schedule. CO 20 11 01 96 Copyright, Insurance Services Office, Inc., 1994 Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) 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 5 % of the California workers' compensation premium otherwise due on such remuneration. Work performed by EL SEGUNDO CO -OP NURSERY SCHOOL(NONPROFIT) at: PO Box 73 El Segundo, CA 90245 -0073 Schedule Subrogant Information Class Code Description City of El Segundo its officers, officials, empoloyees, agents & 8868 Day Care Center. professional Employees Volunteers 350 Main Street Roon #5, El Segundo, CA 90245 -3813 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 02/01/2016 Insured: EL SEGUNDO CO -OP NURSERY SCHOOL(NONPROFIT) Policy No. MWC0023768 -05 Endorsement No. Insurance Company: Markel Insurance Company Countersigned WC040306 (Ed. 04-84) m 1998 by the Workers Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's Califomia Workers' Compensation Insurance Forms Manual 0 2001 17 of 29 Payroll $0.00