PROOF OF INSURANCE (2017) CLOSED DATE(MM/DD(YYYY)
AC"" CERTIFICATE OF LIABILITY INSURANCE 1/18/2017
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
O T C ary StrO
hman
I Ressler Alair Insurance Services, Inc . (909)931-1500 �...LAA/CX..B )e („909)9aa 2133 W
License # OA 91387 mstrohman@kessleralair.co
12487 N. Mainstreet, Ste. 240 INSURER(S)AFFORDING COVERAGE NAIC#
Rancho Cucamonga CA 91739 INSURERA:Philadelphia Indemnity Ins Company
INSURED INSURER B:
.u..u.._.................................................
Revenue & Cost Specialists, LLC INSURER C:
1519 E. Chapman Ave., Suite C INSURER D:
..................
INSURER E:
Fullerton CA 92831-3623 INSURER F:
COVERAGES CERTIFICATE NUMBER:2016-2017 GL, Auto, EX, 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.
.i....SR...................................................-...m........................................... -__.__
N ADDDL i'SUBR'� POLICY EFF POLICY'M1DD(EXP LIMITS
LTR TYPE OF INSURANCEra POLICY NUMBER !MM/DD/YYYY1 (MM/DDF'P'YYMI
X COMMERCIAL GENERA H OCCURRENCE $ 1,000,000 00,000
I. ......� ..tX'�i�'1=”"I"�iS.�V"EiV"�Eb ............. ..�mmm................
A CLAIMS-MADE �N..^ LIOB UR PRE.AI,SE$...(Ecurrencel $
X PHSD1206454 12/31/2016 12/31/2017
MER...EX.Pm(Any one person) $ 10,000
PERSONAL&ADV INJURY $ 1,000,000
GE pN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X II POLICY F PRO-JECT ❑ LOC PRODUCTS-COMP/OP AGG $ 1,000,000
ON
OTHER $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
(Ea accldentl
ANY AUTO BODILY INJURY(Per person) $
p' ALL OWNED SCHEDULED
P1111206454 BODILY INJURY(Per accident) $
�_- AUTOSAUTOS �
12/31/2016 12/31/2017 B m^.L........N .._...._ mm..
X , HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS $
(Pe„ac5idRL
$
—
X UMBRELLA LIAB OCCUR E4CH OCCURRENCE $ 1,000,000
A ! EXCESS LIAB AGGREGATE $ p00,000
X CLAIMS MADE
DED II X RETENTION$ 10,000 PHUB567469 12/31/2016 12/31/2017 ... $ l
WORKERS COMPENSATION +
AND EMPLOYERS'LIABILITY _ STATUTE ., �RH
ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 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 I $
A I Professional Liability PHSD1206454 12/31/2016 12/31/2017 Liability Each Claim Incl.Exp $1,000,000
Retro Date 04/27/1990 Annual Aggregate-$2,500 Ded $1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Additional Insured is City of E1 Segundo, it's officers, officials, employees and volunteers as per
attached, PI-BP-001 (9-05) ,
CERTIFICATE HOLDER CANCELLATION
ntarnay@elsegundo.org J
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ATTN: Nina Tarnay ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE
Mary Strohman/MARY
���`� C--
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025(201401)
PI-BP-001 (9/05)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BUSINESSOWNERS POLICY-ELITE ENHANCEMENT
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS LIABILITY COVERAGE FORM
BUSINESSOWNERS SPECIAL PROPERTY COVERAGE FORM -
It is understood and agreed that the following extensions only apply in the event that no other specific
coverage for the indicated loss exposures are provided under this policy. If such specific coverage applies,
the terms, conditions and limits of that coverage are the sole and exclusive coverage applicable under this
policy.
Throughout this endorsement the words"you"and"your" refer to the Named Insured shown in the
Declarations. The words"we", "us" and "our" refer to the Company providing this insurance.
Part 1., Propertv Coverage Enhancements:
The following amendments are a part of the BUSINESSOWNERS SPECIAL PROPERTY
COVERAGE FORM:
1. Increased Glass Limits
Section A. Coverage, item 4.b. is replaced by:
b. With respect to glass(other than glass building blocks)that is part of the interior of a building
or structure, or part of an outdoor sign, we will not pay more than$3,000 for the total of all
loss or damage in any one occurrence.
This Limitation does not apply to loss or damage by the"specified causes of loss", except
vandalism.
2. Increased Fire Department Service Charge
Section A. Coverage, item 5.c. is replaced by:
c. Fire Department Service Charge
When the fire department is called to save or protect Covered Property from a Covered Cause
of Loss,we will pay up to$3,000 for your liability for fire department service charges:
(1)Assumed by contract or agreement prior to loss; or
(2)Required by local ordinance.
3. Reduced Waiting Period and Longer Duration for Civil Authority Coverage
Section A. Coverage, item 5.i. is replaced by:
I. Civil Authority
We will pay for the actual loss of Business Income you sustain and necessary Extra Expense
caused by action of civil authority that prohibits access to the described premises due to direct
physical loss of or damage to property, other than at the described premises, caused by or
resulting from any Covered Cause of Loss.
The coverage for Business Income will begin 48 hours after the time of that action and will
apply for a period of up to three consecutive weeks after coverage begins.
Page 1 of 5
Includes copyright material of the Insurance Services Office,Inc.used with its permission.
PI-BP-001 (9/05)
The coverage for necessary Extra Expense will begin immediately after the time of that action
and ends:
(1) 5 consecutive weeks after the time of that action; or
(2) When your Business Income coverage ends;whichever is later.
The definitions of Business Income and Extra Expense contained in the Business Income and
Extra Expense Additional Coverages also apply to this Civil Authority Additional Coverage.
The Civil Authority Additional Coverage is not subject to the Limits of Insurance.
4. Broadened Personal Property Coverage
Section A. Coverage, item 1.b.,the first paragraph is replaced by:
b. Personal Property located in or on the buildings at the described premises or in the open (or
in a vehicle)within 1,250 feet of the described premises, including:
5. Increased limits for Personal Property Off Premises
Section A. Coverage, item 6.b. is replaced by:
b. Personal Property Off Premises
You may extend the insurance that applies to Business Personal Property to apply to covered
Business Personal Property, other than "money" and "securities", "valuable papers and
records" or accounts receivable, while it is in the course of transit or temporarily at a premises
you do not own, lease or operate. The most we will pay for loss or damage under this
Extension is $10,000.
6. Increased limits for Outdoor Property
Section A. Coverage, item 6.c. is replaced by:
c. Outdoor Property
You may extend the insurance provided by this policy to apply to your outdoor fences, radio
and television antennas (including satellite dishes), signs (other than signs attached to
buildings), trees, shrubs and plants, including debris removal expense, caused by or resulting
from any of the following causes of loss:
(1) Fire;
(2) Lightning;
(3) Explosion;
(4) Riot or Civil Commotion; or
(5) Aircraft.
The most we will pay for loss or damage under this Extension is$5,000, but not more than
$1,000 for any one tree, shrub or plant.
7. Fire Extinguisher Recharge
Section A. Coverage, item 6. Coverage Extensions will also include:
You may extend the insurance provided by this coverage form to cover expenses you incur to
recharge portable fire extinguishers, dry chemical, carbon dioxide, or liquid automatic fire
extinguishing systems and the cost of resetting automatic fuel shut-off connections, if any of the
above are discharged to fight a fire or are discharged due to a mechanical malfunction.
The most we will pay for loss or damage under this extension is$3,000.
Page 2 of 5
Includes copyright material of the Insurance Services Office,Inc.used with its permission.
PI-BP-001 (9/05)
No deductible shall apply to this coverage.
8. Business Income Enhancement
Section A. Coverage, item 5.Additional Coverages, section f. Business Income is amended as
follows:
The reference to"60 days"as the limitation on payroll expenses is replaced by"365 days."
9. Lock Replacement
Section A. Coverage, item 6. Coverage Extensions will also include:
You may extend the insurance provided by this coverage form to cover necessary expense to repair
to replace exterior or interior door locks of a covered building:
a) If your door keys are stolen in a covered theft loss; or
b) When your property is damaged and your door keys are stolen by the burglars.
The most we will pay under this extension of$250 for any one occurrence.
10. Removal of Sewer Backup Exclusion
Section B. Exclusions, item g(3) is amended to include:
Backups of sewers will not be excluded, but the most we will pay for such losses is$500 in the policy
period.
Part 2: Liability Coveracle Enhancements:
The following amendments are a part of the BUSINESSOWNERS LIABILITY COVERAGE FORM:
1. Medical Payments
If Medical Payments Coverage(Coverage A.2.) is not otherwise excluded from this Coverage Part:
The Medical Expense Limit is changed subject to all the terms of Limits Of Insurance(Section D)to
the greater of:
a. $10,000; or
b. The Medical Expense Limit shown in the Declarations of this Coverage Part.
2. Supplementary Payments
In the Supplementary Payments—(Coverage AAA):
1. The limit for the cost of bail bonds (item (2)) is changed from $250 to$500; and
2. The limit for loss of earnings (item (a)) is changed from $250 a day to$500 a day..
3. Blanket Additional Insureds
Who is An Insured (Section C) is amended to include the following, but only for liability arising out of
the negligence of the Named Insured:
Each of the following is also an Insured:
a. any Contractor, including contracting governmental entities, who hires you as their
subcontractor;
b. any person or organization who has an ownership interest in you;
c. any lessor of leased equipment,who rents equipment to you, but only with respect to
liability arising out of the maintenance, operation, or use by you, provided-however that this
Page 3 of 5
Includes copyright material of the Insurance Services Office,Inc.used with its permission.
PI-BP-001 (9/05)
item c. will not apply to (1)any occurrence which takes place after the equipment lease
expires; nr(2) "Bodily Injury" or"Property Damage"arising out of the negligence of the
lessor or contractor engaged to operate the leased equipment; and
d. any owner, mortgagor, lessor, landlord, condominium association or manager of a
premises leased by you, but only for"occurrences"that take place while you occupy the
premises, provided however that this item d. will not apply to structural alterations, new
construction, or demolition operations; and
With regard to parties applicable under items a. through d. above, the Insurer and the Named
Insured agree to waive rights of recovery, as provided within the policy.
Nothing contained in this section C. shall serve to nullify matters excluded under section B. of the
policy.
4. Bodily Injury-Mental Anguish
The definition of"bodily injury" is changed to read:
"Bodily Injury":
a. Means bodily injury, sickness or disease sustained by a person, and includes mental anguish
resulting from any of these; and
b. Except for mental anguish, includes death resulting from the foregoing (item a. above)at any
time.
5. Liberalization
If we revise this endorsement to provide more coverage without additional premium charge,we will
automatically provide the additional coverage to all endorsement holders as of the day the revision is
effective in your state.
6. Employee Indemnification Defense Coverage
Under SUPPLEMENTARY PAYMENTS—COVERAGES A.1.d., the following is added:
(8) We will pay on your behalf defense costs incurred by an "employee" in a criminal proceeding,
provided, however that you must have a prior written agreement with such "employee"
whereby you agree to indemnify the"employee"for such defense costs, and the agreement
includes a provision for repayment of defense costs in the event of an adverse judgment. The
most we will pay for any"employee"who is alleged to be directly involved in a criminal
proceeding is$2,500 regardless of the number of employees, claims or"suits" brought or
persons or organizations making claims or bringing "suits."
7. Amendment of Aggregate Limit
SECTION D.4.—Aggregate Limits, item B is replaced by:
b. All other injury or damage, including medical expenses, arising from all 'occurrences"during
the policy period is three times the Liability and Medical Expenses limit. This limitation does
not apply to"property damage"to premises while rented to you or temporarily occupied by
you with permission of the owner, arising out of fire or explosion.
8. Amendment to Watercraft Exclusion
Part B-Exclusions, item g.(2)(a) is amended by the following:
The phrase"less than 26 feet" is replaced by"less than 51 feet."
Page 4 of 5
Incudes copyright material of the Insurance Services Office,Inc.used with its permission.
'
PI-BP-001 (9/05)
Part 3: Amendment of Conditions:
1. Other provisions of the policy notwithstanding, this policy will be primary for ail losses covered herein,
and the existence ofother insurance will not serve toreduce our obligation.
3.You will have the right towaive our rights ofrecovery prior boaloss with respect hoany part y.This must
bedone inwriting boaffect our rights.
Page 5of5
Includes copyright material ofthe Insurance Services Office,Inc.used vWt»its permission,
CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERS COMPENSATION 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 COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES.
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 EI Segundo.
Policy No.
(__)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 EI Segundo is executed. My workers' compensation insurance
carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone#
(� 1 certify that, in the performa ce f the work set forth in the agreement with the City of EI Segundo, I will not
mploy any person in any ma rye so s to become subject to the workers' compensation laws of California, and
agree that, if I should t 2 su jec to the workers' compensation provisions of Labor Code § 3700 1 must
immediately comply with t�se prov s'io s or the agreement will automatically become void.
Signature of Applicant Date l,
Agreement for:
Dated: "
Reviewed by:
1