PROOF OF INSURANCE (2018 - 2018) CLOSED ATE
CERTIFICATE OF LIABILITY INSURANCE I D08109122D'0011YY)
081097
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(los)must have ADDITIONAL INSURED provtstons 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 confor rights to the certificate holster In Flou of such Dndorsoment(s). yy
PRODUCER ., PE
1No 400 E HONJERRY IIPtAIC.IA°.,s' +M1?
(Cooley Dr.Ste.202-A ,mos FAt). ($88)440-4094„1lBerTohasslalnnet I 909' 83
o
Colton, CA 92324
License#: OE74924 IN9lfRERA: t11�11T.EM�^ER(sIAFFDRDINOCl1dER <iG tanictR _
INsD-STATES IA 111 A
'INSURED INSURER B
Christpher Heppell _.__.__.. ...�_.................................... .........
DBA:Precision Reef Systems INSURER C
77y1'2-Goddard°A've. wsur�ERo. .. ,. .....,�..
Los Angeles,CA 90045 INSURERS:
,INSURER F
COVERAGES CERTIFICATE NUMBER, 00000000-18094 REVISION NUMBER: 4
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR 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 aOLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
LTR A
TYPE OF INSURANCE .^ WL SU9D POLICY NUMBER....._
COMMERCIAL GENERALUABILITY IPO111201F t�A1111 R1 t1'ralalHOCCtD ENNEO LIMITS r.0
16!11!2017 Os111/2018 ...F E16f_T _t C, IL h_...m .........................�
.
CLAIMS-MADE ❑X OCCUR Y Y CL1757885 0 M1DD _. t�pr�rYYYYI e
A
..... _ - MED E....X...P(... ..
AoV one uerson) $ 61„0„00
PERSONAL 8 ADV INJURY $ _1,90,00
GEN'LPOOR OZATFMTT APPLIES ._..... a.
�.,._.I RO° LOC PRODUCTSCCOMPlOPAGG $ 20 00,000
OTHER': $
AUTOMOBILE LIABILITY COMBINED SINGLE L,IMn $
ANY AUTO BODILYINJURY(Per person) $
OMED SCHEDULED
HIRED NON-OWNED PROEI
INJURY(Per accident) $
AUTOS ONLY AUTOS ONLY r..r..Z
AUTOS ONLY AUTOS BODILY
Pr'RTY DAh4P�»Ie $
.. adr� 17. .._....._•
q s
OCCUR MADE AGGROCCURRENCE $ ,
EXC SSLJAS �,. .. GATE $
U
IIII CLAIMS
-MADE
RETENTION'TION$ $ .......................
WORKERS COMPENSATION IPERI4P �H
AND EMPLOYERS'LIABILITY YIN "' TATt?TdL L,
ANY PROPRIETORIPARTNERIEXECUTIVE E ACCIDENT $
OFFICERIMEMBER EXCLUDFD7
N
(Mandator,In NH SE-EAEfdPLOYEF
lfg,RIIsTI be Linder
OF OPfwf�ATK)NS below ..L.DISEASE ..... .
'
dei
.POLICY LIMIT $
$................................................ ......
v
DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Sohedule,may be attsohed If more space Is required)
CERTIFICATE HOLDER LSITED AS ADDITIONAL INSURED
I
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE T'HEREOFMOTICE WILL BE DELIVERED IN
The City Of EI Segundo and its employeesACCORDANCE WITH THE POLNt,Y PROVISIONS_
350 Main Street
EI Segundo,CA 90245 U AUTHORIZED REPRESENTATIVE
/sofACORD
1JMAL
5 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered m
Printed by JMA on August 09,2017 at 12:22PM
POLICY NUMOER, CL1757885 COMMiRIMAL GENERAL LIABUTY
CQ 20 14 OT 04
`PHIS ENDORSEMENT QHANGES T"H5 POLICY, PLEASS RKAO IT CAREFU11 LY.
ADDITIONAL INSURED OWNERS, LESSEES OR
CONTRACTORS SC EDULE PERSON OR
ORGANIZATION
Tjrin oindorSorneril M0050n irioutFlNa praVlded under the following:
COMMERCIAL 01i*HAL LIABILITY COVSRAOE PAR'(
�C}I1;DllLf~
Name Of AcIdlilarial Insfurod Parson{s)
ar tAel tlantsy Loaattc nfe)Of Cov'ea"ed OPeratiOnct
whera mqui"by written conirert or r#yrao"nt, Ail 8perallnns ar the named Insured
The 0ty Of EI Segundo And ItS Ernpleyess 350 Main atraet,El Segundo,CA 90246
Ir f srlti ilatrs rnxeuUroJ to oomoteto Oils Wiedulu,If not sl'i M1t* b�s���rN_.. L.�slwt�uvrU l�a.tNte t��� s.
A. SaMion 11 W Who is An Insured Is.Artiondod 1* 8. wili respect to Vl it Inotirpnolr afforded to tI'ovb
molu do as tai vdil llon$al Insured tate porcou(irN or additional insured$. tho follaawitr9 r ddItlonsl exclu-
c'rrtn1l at°s'ocals;a sNisawn In It* 5pliodof4a, but only Morns lappfy:
warl l respect t to N71bllity tur`JvW 5y lPJJ ry',"pmfwsny Thli ln�ultrnsra does net apply tb"bodily In)aty"or
dumupfo"» Or "pgrsorsal Urict (ativerttsing liagtsryq'i "paropaatrly iir«mri90"orcuning after:
c atised,io wtrholia or In Poll.bY: 1. All War% Irttatudd'ng rt^ar kf0rats, phritr: or esl�rin
1. Your sots or omissions;or niont himished In oonnec;tk)n with rvoli work,
Z Tho nuts;or ornissiorm of tivotio acting ort Yuui on ilio pazalact(ota;or'than s arvkoe,rraMlleror;rV
60110; or lepaialria) to de p06or'rr3041 by or ora ta011u.41 of
In tho laerfearrnshca of your ongafng�apacaratluns rx 019 additional In ailrod(a) at'Ih Irsaailon of the
t$a+3 ocidillQ anal In�,ir4a(t:) ut tho locri tarns) detaig- tQverewl o'petlations lius t tian oompaloted,1 or
n ated obovia. 2. Thrat scorpion of "Vodr work" out of wMtrislw 1154
flijory or aantaVe anses has poen,paint to flu In-
.,. to oily patar'iron-c7't-4Ig'dht2gllpn.ratt� �.m._�� ��_.
or i'han -t—tdat er tant=lor or ffiitbcOntMolor
#%agad In paafloririing opef ailons for ra pdri,-
olpel as as ptartbft'ho 061no p101ctct.
Co Q 10 09 Od a)ISO Preat7ontee.Inc.,2004 Pago I of i l�
POLICY NUMBER:CL1757885 COMMERCIAL.GENERAL LIABILITY
CO 20370704
THIS PNOORSEMENI CHANGES THE POUCY. PI_EASIRE READ IT CAREFULLY.
ADDITIONAL INSURED -- OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
?4ti1�-er�dvrsament_modgfles_InA�ar�t�o0_pravlr5.u1ld'l�c Illt�.l'011tlt3'�;
COMMERCIAL GENERAL LIABILITY COVERA 13E PART
SCHWULK
r�dltl0nnl Ir�ared Pb>`n¢n(�)
Cr Lao tion ATIO I 4r1 Of
The City Of EI Segundo And Its EWIryees -350 Main Street, El Segundo, CA 00245
RIrtta rwx� Iq �k r�p�vct to t ors I I IhN B I�vd�plw
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laro tI"aw"p
ati It - hdfrra I Ao Ilitattrod is atrtended to
Ini as rn L)d0itionol ')nat tfort' the era rll' ) f
nrgnrw+�mt° n(S)SkVilh Irl ...a a-hbdtllb, ttt 0 MY WhIl.
rti to I10111tyr toil,"IDC4ty Irlit(v or" rar rty dom-
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ACC>R CERTIFICATE OF LIABILITY INSURANCE DATE ISrrvARtlorryYVI
OW21F2(317
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 INSURI=RIS), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the certHicate holder Is an ADDITIONAL INSURED,the policylles)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the berms and conditions of the policy.Certain policies may require an endorsement A Statement on
this certllicats does not confer rights to the!curriiflto holder In lieu of such andorsement(st
PRODUCHI CONTACTMahsa Sanders
S( 310-821-0064
.... . l ...NIRIaaaz
'('O T,I I' 97Inc 0 40 W Manchester Ave Ste 105 m Sssa xaarS,Isalr eNalefaf'+n,carrx
oNI 310-3
�LIL
Playa Del Rey,CA 90282 WW"R
N
NANCF
State Farm Mutual Automobile Insurance Coma 25178"'
.. _...
WSW= INWAVI e:
Christopher Heppell INSURER e:
DBA Precision Reef Systema IruI7rLER o
7712 Goddard Ave INSLfREIL a,
Los Angeles,Ca 90045 1>rSuR£1L F;
COVERAGES CERTIFICATE NUMBER. REVISION NUMBER-
THIS IS TO CERTIFY'THAT THE POLICIES OF INSURANCE LIST'E'D,BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOtI
INDICATED, NOTVATHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT'OR OTHER DOCUMENT Wv1xITH RESPECT TO VWIICIN Till$
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY 'THE POLICIES DESCRIBED HEREIN IS SUBJECT TQ ALL THE TE'RM'S,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS'SHOWN,MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Ifw TYPE OF INSLOAN001 tl 'C NUMIIT P..
. 6�1 OLIOY EI"P Y ESIP LtlhItlTS
P.ArRCN D
CO i CWM�SMACE�L!0=R ,..!L4AMQAtl �� IF '' s. ................ r�.
�
fJtlCCR Er IAn" n I f
PERSONAL& VV��
r E+LAG�YEtl3A'1E UMIT APPL.......... rrrr
A,71!INJURY >;
, f LOG PRODUCTS-COMPIOPAGO S
l£6 PER N TE I .. .
01 HER s
AUTOMOOLeUAMIJTV 75-1188485 47!2012017 0112012018 �L p;ptl^OI'x''IIMwx I
FDONLY r� s+rm6D PROPERTYODwAYsud
M wiqs'I i,O00,0 ._www_.......
A ....
AUTOS ONLY �, AUTOS(y ys � s 1,DDO,OOD
L'
UMBRELLA LL1a �OMUR
MAOF A OOCURRENCE L
EXCESS UAB ............_. __................. :
pr
tl#GTE°�INDIJ.t. PE CY.H..., S
WORKERS COMPENSATION Y�
AN OPRII Ela wId`NExI,� ICJ" NfA 1, T�� � ....
ANO EMPLOYER BLITY Yf __.__ ...
b° 'NzP N u N''d'E' EL EACH Ni S
Mss Ra�9 bop ur 1�aY ., �E q, NY�tiI-.A?;'1�.Pry.Btl:N d.I�RMd'f°'i
L�'�RAMEM 1 Fx(1 tlAd9�' 1#
I'WlmndptwyInNM ELI kAE-I MrfuMlN,LIII — I
6CN,af*'cK.Pl(0 f11 FBAT0*$L10t2w 9 1
01SCRRP7ION OF OPERATIONS I LOCATIONS f VEHICLES rACORD 101.AQdmonq Rwmru Schadde6 may be&U&W it mon•Paw Is ngWmd)
�I
CE'RTIFICAT'E HOLDER CA,NCELLATiON
SHOULD ANY OF THE ABOVE DESCRIED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
The City of El Segundo and eta employees ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
EI Segundo.CA 90245 A1JTNoraw n'EPENT E „
Q 1988.2016 ACORD CORPORATION All rights reserved.
ACORD 25(2018103) The ACORD name and logo are registered marks of ACORD
aom�ea Tsz>ela.tz pie-ima
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.
1 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.
(_)1 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#
(S/l certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not
employ any person in any manner so as to become subject to the workers' compensation laws of California, and
agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must
immediately
ympy with those provisions or the aJre �� en. t.�w.il_t aui'a""� i<RicalGy become
void-
Signatureof Applicant D
ate
Agreement for: C `
Dated:
Reviewed b
1