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PROOF OF INSURANCE (2018) CLOSED GOVESTA-02 CIVIARK AM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/15/2017 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 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 NAME: CTK North American Insurance Services,LLC/INSURICA PHO,Nau,Ext):(714)779-2000 FAX,No):(714)77911129 1240 North Lakeview Avenue,#240 EMAIL Anaheim,CA 92807 ADDRESS: INSURER(S,),AFFORDING COVERAGE NAIC# INSURERA:Zurich American Insurance Co.of IL 27855 INSURED INSURER B:American Guarantee and Liability Ins.Co. ,26247 Government Staffing Services INSURER C: P.O.Box 718 INSURER D: Imperial Beach,CA 91933 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 INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD _._„(MJl)J) �'�'J_.JMMLPD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PRA9699'06305' 05/10/2017 05/10/2018 DAMAGE S i DENTED 100,000 X PROP+�IF+[5(Fs�aar,;;c�rrre/r„e) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 1 JET $ 2,000,000 X POLICY LOC PRODUCTS-COMP/OP AGG f}1'IIt;R __ rr_.._w_..... ABUSIVE ACTS 1,000,000 �.................. _ ....... .... ....... .... ... ....... ................ ............................................... ...... $ �.. A AUTOMOBILE LIABILITY COMBINED SINGLE:LIMIT 1,000,000 (Fa agcidan0 $ ANY AUTO PRA969906305 05/10/2017 05/10/2018 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ X �j1�yy NA PROPERTY DAMAGE AUTOS ONLY X A70�C�M1YFty (Per accident) $ B X UM13RELLALW3 X OCCUR EAV„ OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE UMB946734705 05/10/2017 05/10/2018 AGG'REGA1"F $ 11000,000 ?ED X RETENTION$ 0 $ PER 0['7��51.1•. AND EMPLOYERS'LI COMPENSATION $'p',A'I U'l"( Eel AND EMPLOYERS"LIABILITY i, /i„ ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E L DISEASE-EA.EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE.POLICY'LIMIT $ A Professional Liabili PRA969906305 05/10/2017 05/10/2018 $1/$2M Ded $1000 DESCRIPTION OF OPERATIONS d LOCATIONS P VEHICLES I;ACORD 101,Additional Remaalcs Schedule,may be attached if more space is required) Cyber Liability:BCS Ins.Co./RPS-P-0'110241/10'/23/15-10123/16/$1,000„000 Schedule of Named Insured(s) Government Staffing Service dba:Herrera&Associates Staffing Services Government Staffing Service dba:Munigroup,Government Staffing Service dba:Munitemps Government Staffing Service dba:Munistaff City of El Segundo named as and additional insured as respects to general liability. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN tY 9 ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo,CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PRA 9699063-05 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED DESIGNATED PERSON OIL ORGANIZATION IZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s)Or Organization(s) Any person or organization who you are required to add as an additional Insured on this policy under a contract or agreement shall be an Insured,but only with respect to that person's or organization's liability arising out of your operations as a"Staffing Service"or premises owned by or rented to you. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability 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: A. In the performance of your ongoing operations;or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 0 ISO Properties, Inc.,2004 Page 1 of 1 CERTHOLDER COPY SP STATEE COMPEN5ATiON P.O. BOX 8192, PLEASANTON, CA 94588 INSURANCE ■ CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 05-16-2017 GROUP: POLICY NUMBER: 9008463-2016 CERTIFICATE ID: 31 CERTIFICATE EXPIRES: 11-01-2017 11-01-2016/11-01-2017 CITY OF EL SEGUNDO SP DEPT OF BUILDING & SAFETY 350 MAIN ST EL SEGUNDO CA 90245-3813 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #1600 - HERRERA, JOHN PRESIDENT - EXCLUDED. ENDORSEMENT #1600 - HERRERA, MARRISAL VICEPRES - EXCLUDED, ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 11-01-2015 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2017-05-16 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO EMPLOYER GOVERNMENT STAFFING SERVICES INC DBA: SP MUNITEMPS PO BOX 718 IMPERIAL BEACH CA 91933 [JRC,CN] (REV.7-2014) PRINTED : 05-16-2017 POLICYHOLDER COPY SP STATE COMPEN5ATION P.O. BOX 8192, PLEASANTON, CA 94588 FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 05-16-2017 GROUP: POLICY NUMBER: 9008483-2016 CERTIFICATE ID: 31 CERTIFICATE EXPIRES: 11-01-2017 11-01-2016/11-01-2017 CITY OF EL SEGUNDO SP DEPT OF BUILDING & SAFETY 350 MAIN ST EL SEGUNDO CA 90245-3813 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer, We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1;000,000 PER OCCURRENCE. ENDORSEMENT #1600 - HERRERA, JOHN PRESIDENT - EXCLUDED. ENDORSEMENT #1600 - HERRERA, MARRISAL VICEPRES - EXCLUDED. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 11-01-2015 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2017-05-16 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO EMPLOYER GOVERNMENT STAFFING SERVICES INC DBA: SP MUNITEMPS PO BOX 718 IMPERIAL BEACH CA 91933 [JRC,CN] (REV. -2014) PRINTED : 05-16-2017 WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation: 1. Please be advised that a waiver of subrogation requires that a 3% surcharge will be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certificate holder who requested the waiver. (Note: if you have no employee payroll on that job, then there is no charge.) 2. To apply the 3% surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work on job/s for the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. Example: Payroll for job: $5, 000 . 00 Sample Rate : 13 . 300 Regular Premium equals : $ 665 . 00 Surcharge : 3 . 00% Additional Waiver charge : $ 19 . 95 Total premium equals $ 684 . 95 (665 . 00 + 19 . 95)