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PROOF OF INSURANCE (2018) CLOSED DATE / Y)AC CERTIFICATE OF LIABILITY INSURA CE 03/02/2017 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 NAMEACT' Gabriel Oh _ Western Pacific Insurance Group i °N! . I _ivc. 7.Ez :425.361.7454..... . ._ C,Not.425.9993053 ........ 16300 Mill Creek Blvd.Suite 208 EMAIL Mill Creek,WA 98012 -°'-lap ��s.°--gam stetDpaclg.dDl�+ INSURER($)AFFORDING COVERAGE NAIC N ..............................._.,.,...-....,.,.,... INSURER A: Sentinel Insurance ViOn"tl7afY..N..................................................................... Toyer Strategic Consulting,LLC INSURED 3705 Colby Ave Suite 3 INSURER C Everett,WA 98201 INSURER E INSURER F: COVERAGES CERTIFICATE NUM'BE'R: REVISION NUMBER.. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. � TYPE OF INSURANCE ADS&SU�,rl'„........�.- POLICY NUMBER 4'156U0dY_0Y0"A�..i......--._. .........................�-�,...,-. INSR I PO CY E.XP� �.��..m.... I IMMdODfYY'YY) LJMITS GENERAL LIABILITY AEACH OCC7`REY31E'f7�`�1$ 1 .00 mop .wwwwww...WWW �° r 1 I 5 000 x COMMERCIAL CLAIMS-MADE OCCUR LIABILITY PREMISES �OCCUR MED EXP )(AnY one person 15„1 1,,,,,,,,,X000 ..,m,,,,,,, . 52SBAIX1115 03103/2017 03103/2018 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE I$ 2,000,000 GEN AGGREGATE MI APPLIES PER: �PRODUCTSOMP OPAGG.. ,S ZQQ,( �Q„ POLO LOC I CUMBNEO SYNEMI AUTOMOBILE LIABRXTY I� (Ea accident) ANY AUTO BODILY INJURY(Per person) S ALL OWNED ..........i SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) S w_ NON-OVINED -P�9CiPECt1' ,XSEm._.m..........�........ HIRED AUTOS „ AUTOS Per arwenl UMBRELLA LiAS OCCUR F EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS I $ N!A �.. .....I WC STATU- OTH- AND ERF/PART ER/EXECUTIVE YIN EL ACH Ir•CCIDENT EAR_._.____...............................................�, WO-HERS COMPENSATION EACH ACCIDENT $ (Mandatory in NH) I E.L.DISEASE-EA EMPLOYEE $ If yes,describe under ETA Rdlfitil0e E,L..DISEASE-POLICY LIMIT S $1,000,000 Professional Liability 1_ F_ 52SBAIX1115 03/03/2017 03/03/2018 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) City of El Segundo,its affiliates and subsidiaries are listed and additional insured CERTIFICATE HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo,CA 90245-3813 AUTHORIZED REPRESENTATIVE Gabriel Oh ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 52SBAIX1115 COMMERCIAL GENERAL LIABILITY CG 20 18 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MORTGAGEE, ASSIGNEE OR RECEIVER This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Person(s) Or Organizations) Designation Of Premises City of El Segundo and any affiliates All projects of the Named Insured per written contract Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to C. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III—Limits Of Insurance: with respect to their liability as mortgagee, If coverage provided to the additional insured is assignee, or receiver and arising out of the required by a contract or agreement, the most we ownership, maintenance, or use of the premises will pay on behalf of the additional insured is the by you and shown in the Schedule. amount of insurance: However: 1. Required by the contract or agreement; or 1. The insurance afforded to such additional 2. Available under the applicable Limits of insured only applies to the extent permitted by Insurance shown in the Declarations; law; and whichever is less. 2. If coverage provided to the additional insured is required by a contract or agreement, the This endorsement shall not increase the insurance afforded to such additional insured applicable Limits of Insurance shown in the will not be broader than that which you are Declarations. required by the contract or agreement to provide for such additional insured. B. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. CG 20 18 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 1 ��01 CERTIFICATE OF LIABILITY INSURANCE I DATEIMMIDDIYYYY) _ 03/17/2017 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 pollcy(les)must have ADDITIONAL INSURED Provisions or 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 Jerry Goebel StateFarm Slate Farm Insurance � 1d°Ep.kx1'l" 515 832 4066 1 � 515 832 4067 1209 Superior St E PMAILSS. jeny.goebel.t2lg@sta'lefarn),com Webster City IA 50595 INSURER(SI AFFORDING COVERAGE NAIL A INSURER A: Stale Farm 25143 INSURED _INSURER 6 David&Heather Toyer INSURER C: 1807 Navajo St INSURER D: 1 Burlington IA 52601-3492 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. NNSR ADDLISUSRX POLIOY EX,P '-- L,TTI, TYPE OF INSURANCE POLICY NUMBER POd 'tM li LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS MAD£ -UAMA IU HLNIEU OCCUR P EMI ES To occurrancq)„-, S MED EXP(Any one person) S PE'R'SONAL 0 AOV INJURY S GEN'tAGGREGATE LIMIT APPLIES PER: yf GENERAL AGGREGATE $ POLICY 17 ECT LOC 1 PRODUCTS-COMPIOP AGG S OTHER. S AUTOMOBILE LIABILITY Y 1256247AO715E 01/07/2017 07/07/2017 a MBINEO SINGLE LIMIT S �-ANY ALTO BODILY INJURY(Per person) S 1.000.000 A OWNED SCHEDULED BODILY INJURY(Per S 1,000,000 AUTOS ONLY AUTOS ( l HIRED NON-OWNED PROPERTY DAMAGE S 1.000.000 AUTOS ONLY AUTOS ONLY pP Rperddrr7'1 S UMBRELLA LIAO OCCUR EACH OCCURRENCE S EXCESS LAB HCLAIMS-MADE AGGREGATE S D I RETENTIQNS $ WORKERS COMPENSATION PEH O'pH- AND EMPLOYERS'LABILrrY YIN �ST----7UT.E L-1„„0 ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED'! NIA EL.EACH ACCIDENT S ., (Mrrrldatory In NH) E.L.DISEASE-EA EMPLOYEE S Ues dosoibe under S4IRIP+TION OF OPERATIONS below a E.L.DISEASE•POLICY LIMIT $ DESCRIPTION OFOPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Rcmarts Schedule,may be attached N morn space Is required) CERTIFICATE H'O'LDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Et Segundo ACCORDANCE WITH THE POLICY PROVISIONS. City Hall 350 Main S t AUTHOR E ESria EI Segundo CA 90245-3813 r' pilACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849.12 03.16-2016 IOWA INSURANCE CARD Bible FaimMiaual Automobile I,Co. 25143 F--j Slate Fafm File IL—i and CmAualiy Go, INSURED TOYER,DAVID 8,HEATHER MUTL POUCY NUMBER 125 6247-AO7.15E EFFECTIVE VOL YR 2007 MAKE FORD JAN 07 2D17 'ro JUL 07 2017 MODEL F$50 VIN IFTpW110671(c91693 AGr,NT JERFIYGOEBFI. 2076-02E WE 8$T E A C Y,IA 60695 EIAERQNCY PHONE (615)832.4066 NAIL 25178 A C 0260 GSOO III R1 U w THE COVERAGE PROVIDED BYTHE POLICY MEETS THE MINIMUM LIABILITY LIMITS PREStnISED By LAWL SEEREVERSESIDE FOR A1301TIONAL COVERAGE INFORMATION li CITY OF EL SEGUNDO OS' COMPENSATION DECLARATION WARNiNG: FAILURE TO SECURE E S' C PSTI 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 COT OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE§3706, INTEREST•, AND ATTORNEY'S FEES. I Wfkrm under ponalty of perjury under the lawn of Calliornoe one of the foliowirg declarations, I_ }I halve And wll maintain a certificate of con sent of self•in.3uro for workers'compensation,issued by the Llirrjcttx of Indo.mirial Refatio is as provided fox by L abtx Cude§3700 for Ott parfcaxouv=of the work,act forth the egrcsamwtl with the City of El Segundo Policy No µ,.. _., .u... { )I have and will maintain workers'oxw"nsation ineura iwvr as faquired by Labor QxJM Q 3700 for tint pnrfum i ice 0 the work for which the agreement with the City of C-1 Segundo is executed.My workers'eomponsoon inr;urmnrw carrier and poriicy number are: o;imrmiem , ­. ...,,. .. �, ., . .- ", Pink:y Niiirnber f°xpiraCion Ilr'',h ie NNaiiirma i I ra t Phone ,...... I certify thKt, ITT the pnripr1tWC0 of thM WLVk stA mmi on oie sarimmeot wltlh me Uty of Ell Segaendu, I will not pl®y any pemon in any manner so as to bacome subject to the wc*ers' eompensattiosn laws of California, anti 4 agrees Chet, 9 1 should becomes sut.>leo3 to the workers' q npansatiort provialon® of Labor Code § 3700 1 must d t Imnedlate h Cam Icy wit w,..„l. hos e x o s r wi . uuimatically b® nt;void, 3)h Signature of Applicant fate t>Ao Agreetnellt for: e �,- Hated 3 Reviewed by' 1