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PROOF OF INSURANCE (2018) CLOSED ^'� 0 DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 6/6/2017 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 CONTACT Ibrahim Peker NAME: Licensec#0746539ons ADDRESS IbrahimP @ins-solutions.com(A c'N°)' (9a9)Sae-z373 33302 Valle Rd, Suite 200 .NSUR I O ER S AFFORDING COVERAGE NAIC N San Juan Capistrano CA 92675 INSURERA H1s,OOX I nsurance Company Inc. 10200 INSURED INSURERB:California Automobile Insurance Co. 38342 Michael T Little INSURER C: 8504 Firestone Blvd #400 INSURER D: INSURER E: Downey CA 90241 INSURER F: COVERAGES CERTIFICATE NUMBER:17-18 GL/PL/AL 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 INSIR ---- AabtlL SUa POLICY NUMBER ��,,..Igag ,YYY. - -- POLICY YY TYPE OF INSURANCE POLICY EXP LIMITS w sM�1rDD/YYYYw COMMERCIAL GENERAL PLIABILITY EACH OCCURRENCE $ 1,000,000 A ----- CLAIMS-MADE f X C OCCUR PMEMISE_� aoccrramey $ 100,000 X UDC-1993098-CGL-17 6/6/2017 6/6/2018 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X PRO- POLICY JECT 1:1 LOC PRODUCTS-COMP/OP A29 $ 2,000,000 ,� $ AUTOMOBILE LIABILITY MIT $ 1,000,000 (a accpdent)SINGLE LI .........., „ ALL OWNED SCHEDULED 13A040000034276 6/6/2017 6/6/2018 BODILY INJURY(Peraccident) $ ANY AUTO INJURY(Per person) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Very',aC !)1 UMBRELLA LIAB OCCUR EACH OCCURRENCE U$ EXCESS L IAB m CLAIMS-MADE ,AGGREGATE $ ........ .DED RETENTION$ AND EMPLOYERS'LIABILITY j,PER '"ERH V ANY PROPRIETOR/PARTNER/EXECUTIVE YIN EL EACH ACCIDENT $ DESCRIPTION OF OPERATIONS below E L DISEASE-EA EMPLOYEI^V'$ OFFICER/MEMBER EXCLUDED'/ NIA If yes,describe under L DISEASE-POLICY LIMIT $ A Professional Liability X UDC-1993098-EO-17 6/6/2017 6/6/2018 Each Claim: 1,000,000 Aggregate: 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of El Segundo its officials, and employees as "additional insureds" under said insurance coverage and to state that such insurance will be deemed "primary" such that any other insurance that may be carried the City of E1 Segundo will be excess thereto. r CERTIFICATE HOLDER CANCELLATION canderson @elsegundo.org SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of E1 Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 314 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE Tony Alessandra/STACY ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 rgnunii Aew HI SCX Hiscox Insurance Company Inc. Policy Number: UDC-1993098-CGL-17 Named Insured: Michael Little Endorsement Number: 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED — AUTOMATIC STATUS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II —Who Is An Insured is amended to include as an additional insured any per- son(s) or organization(s) for whom you are performing operations or leasing a premises when you and such person(s) or organiza- tions) have agreed in writing in a contract or agreement that such person(s) or organiza- tion(s) be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to lia- bility 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: 1. In the performance of your ongoing opera- tions; or 2. In connection with your premises owned by or rented to you. A person's or organization's status as an addi- tional insured under this endorsement ends when your operations or lease agreement for that additional insured are completed. CGL E5421 CW(02/14) Includes copyrighted material of Insurance Services Office, Inc.,with its Page 1 of 1 permission. California Automobile Insurance Company P.O. Box 10730 E R C U 1"I Y Santa Ana, CA 92711-0730 INSURANCE Customer Service: (800) 503-3724 BUSINESS AUTO POLICY ADDITIONAL INSURED New Declarations Effective Date: 06/06/2017 NAMED INSURED: AGENT: MICHAEL LITTLE INSURANCE SOLUTIONS# 8504 Firestone Blvd#400 33302 VALLE ROAD SUITE 200 Downey,CA 90241-4926 SAN JUAN CAPISTRANO,CA 92675 (949)348-7400 SCHEDULE Insurance Company: California Automobile Insurance Company Policy Number: BA040000034276 Policy Period: From: 06/06/2017 to 06/06/2018 at 12:01 AM Standard Time at your mailing address Additional Insured: CITY OF EL SEGUNDO Address: 8504 Firestone Blvd #400, Downey CA 90241 Endorsements Attached: CA 20 48 02 99 - Designated Insured ---------. .......... ............. AUTOMOBILE LIABILITY PROVIDED Covered Autos: Symbol 1-Any "Auto" Limits of Insurance: $1,000,000 CSL MCADS910711 Page 1 of 1 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION I I WARNING: FAILURE TO SECURE S° C TI COVERAGE IS UNLAWFUL AND SUBJECTS EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND LL S ($100,000), IN ADDITION TO THE COST OF COMPENSATION, PROVIDED FOR IN LABOR CODE § 3706, INTEREST, TT EY° FEES. I I affirm under penalty of perjury under the laws of California one of the following declarations. ( ) I have and will maintain a certificate of consent of self-insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement with the City of El Segundo. PolicyNo _ .......... ... ,,.. .w..,.,....._.._....... _. (_) I have and will maintain workers'compensation insurance as required by Labor Code§3700 for the performance of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance carrier and policy number are: Policy Number Expiration Date Carrier m � _... A.. Name of Agent Phone # (tj I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not employ any person in any manner f�c� as to become subject to the workers' compensation laws of California, and agree that, if I should become w .ri Ic: ;t lci the workers' compensation provisions of Labor Code § 3700 1 must immediately comply w it fn sions c r the agreem_ent will automatically become void„ Signature of A pficzinf D ate 'rJ � w Agreement for; � It.....°...w Dated; Reviewed by; ,. „..:; °',"m...` :::............... .. ', P) 1