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PROOF OF INSURANCE (2017) CLOSED DATE(MMIDDIYYYY) ACCOR" CERTIFICATE OF LIABILITY INSURANCE �,. 6/12/2017 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(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 Mary POD'ar ISU - Dunlap Agency PHONE (714)838-3158 FAX (714)922-6157 lA/C,,No. xty: (AIC,Na),. 700 West 1st St. , Suite 8 ADDREssmary@dunlapins.com INSURERS)AFFORDING COVERAGE NAIC# Tustin CA 92780 INSURER INSURER Insurance 11000 INSURED ;Preferred Employers Ins. CO, .10900 INS .. Matrix Imaging Products, Inc. INSURERC:Gemini Ins. Co. (' 10833 8 Ranch Circle INSURER D; SURER E Lake Forest CA 92630 INSURER F: COVERAGES CERTIFICATE NUMBER:2016-2017 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 POLI,IES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR INV—WVn POLICY ...,�,�,�, ��.�� „ TYPE OF INSURANCE Y NUMBER I POLICY YlYEFF ((POLICY EXP) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE V$ 1,000,000 UAMAa`Of LNITEID A ( CLAIMS-MADE ( X ( OCCUR PREWSES iEp occurrenc'ep $, 1,000,000 DEDUCTIBLE: $0 72SBABD3913 DX 10/17/2016 10/17/2017 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X... POLICY ........ PE OT ( LOC PRODUCTS COMP/OP AGG $ 2,000,000 000,000 V.................... C �,,,,, OTHER: ...Employee..Benefits..................................$........................i..',00.0.;.00.0.... A AUTOMOBILE LIABILITY 72SBABD3913 DX 10/17/2016 10/17/2017 LOMBINI-D SINCaLE LIMIT $ 1,000,000 (9i4..n�Y;oe)i)......................................................................................................................... ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROF ER'r'DAMAGE X HIRED AUTOS R AUTOS (POT at.dont) $ DEDUCTIBLE $0 $ XII UMBRELLA LIAB OCCUR EACH OCCURRENCE _$ 4,000,000 A ` EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4,000,000 DED I X ( RETENTION$ 10,000 72 SBABD3913 10/17/2016 10/17/2017 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN X STATUTE. ERH ANY P'ROP'RIETDR9ARTNER/EXECUTIVEI E L EACH ACCIDENT $ 1,000,000 l;l'FFWER0AFM(9CR'�FXCL,UDED? ( N/A - B (Mandatory in NHI WKN157011-3 12/1/2016 12/1/2017 E L DISEASE-EA EMPLOYEE,$ 1,000,000 If r �yas„ Lina DI SCRIpyTIdes„robe ON OF OPERATIONS below I EL DISEASE-POLICY LIMIT $ 1,000,000 C Professional Liability VCPL064493 6/17/2016 6/17/2017 DEDUCTIBLE $2,500 $1,000,000 C Network Security VCPL064493 6/17/2016 6/17/2017 DEDUCTIBLE $2,500 $250,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The City of E1 Segundo, its officials. and employees are named as additonal insured. Insurance on the Certificate is Primary. Thirty (30) days notice of Cancellation required. CE'R'TIFICATE(MOLDER CANCELLATION rtoler@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: Russel Toler ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St. El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE c ; Dean Dunlap/MP __....�. ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 t9nunit MATRIX IMAGING PRODUCTS, INC POLICY NUMBER: 72ABABD3913DX COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. ADDITIONAL INSURED-OWNERS, LESSEES OR CONTRACTORS (Form B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART r� SCHEDULE Name of Person or Organization: CITY OF EL SEGUNDO, ITS OFFICIALS AND EMPLOYEES Primary Wording/Non-Contributory It is further agreed that such insurance as is afforded by the policy for the benefit of the above Additional Insured(s) shall be primary insurance but only as respects any claims, loss or liability arising out of the Named Insured(s) shall be excess and non-contributing. (If no entry appears above, information required to complete this endorsement will be shown in the Declaration as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the schedule, but only with respects to liability arising out of your work preformed for that insured. CG 20 10 07 04 Copyright, Insurance Services Office, Inc. 2004 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed.4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule City of El Segundo, its officials and employees a. 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: 12/1/2016 Policy No.:WKN157011-3 Endorsement No. 1 Insured:Matrix Imaging Products, Inc. Premium $ Insurance Company: Preferred Employers Insurance Company Countersigned by:Dean Dunlao WC 00 03 13 (Ed. 4-84) Copyright 1983 National Council on Compensation Insurance.