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PROOF OF INSURANCE (2017) CLOSED CERTIFICATE OF LIABILITY INSURANCE DAM(MMIDD/YYYY) 8/30/2017 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 Nicole Klink NAME: Merriwether & Williams Insurance Services PHONE Extys (213)258-3083 tA4FAX N0,),e(213)259-3099 License No. : 0001378 C-MAIL nicoleQimwis.com ADDRESS: 550 Montgomery St., Suite 550 INSURER(S')AFFORDING COVERAGE NAIC# San Francisco CA 94111 IN UR'ERA:Atain Specialty Insurance Company 17159 INSURED INSURER 8: Jeff Cason INSURER C: 531 Main Street #412 INSURER D; INSURER E: El Segundo CA 90245 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1783011855 REV'IS'ION 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 ADRAL„?'1,1Y"Y�I'' POLICY NUMBER IMMffa1UYYYYI (CY EFF MMCDDFYYYY) LIMITS I OLICY EXP LTR INSI7 1"J b'!"r - X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 2,000,000 DAMAGE TO RENTED 100,000 A CLAIMS-MADE X OCCUR PREMISES(Ea Occurrence) 5 X CIP305861 5/10/2017 10/9/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 3,000,000 Al CT LOC PRODUCTS-COMP/OP AGG $ POLICY PRD EXCLUDED ' OTI kE'R $ AUTOMOBILE LIABILITY 4",OMBI'NED SINGLE LTMIT $ (Ea:accident) ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERI YLAMA(' HIRED AUTOS AUTOS (rler accadeni) S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ • EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED 1 RETENTIONS 5 WORKERS COMPENSATION PtR OTH• AND EMPLOYERS'LIABILITY YIN STAT'I.II R FR ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ 0FriCr.WMEM0ER EXCLUDED? NKA (Mandalory In NHI E L DISEASE-EA EMPLOYEE $ It as,doscribe under' � D SSC M'ITION'OF OPERATIONS bcl'ow EL DISEASE-POLICY LIMIT S 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 officers, officials, employees, agents, and volunteers are hereby included as Additional Insured but with respects to our Insured's operations only. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of E1 Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. E1 Segundo, CA 90245 AUTHORIZED REPRESENTATIVE Nicole Klink/NICOLE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) GENERAL CHANGE ENDORSEMENT This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below: Name of Insurance Company(ics) Atain Specialty Insurance Company Potain Spec Insurance Company 100.0% GenLiab Inception Date Expiration Date 5/10/2017 10/912017 Endorsement Effective Policy Number Endorsement 8/28/2017 CIP305861 I Named Insured JEFF CASON,MARK CASPARY,MATT GLENN ONE TBD NAMED Harvey W Go(den6erg INSURED(SHOW CONTROL EXPERT-IT SPECIALIST) Countersigned By (Authorized Roprewntative) IN CONSIDERATION OF THE ADDITIONAL PREMIUM SHOWN BELOW,IT IS HEREBY UNDERSTOOD AND AGREED THAT THE POLICY IS AMENDED AS FOLLOWS: GENERAL LIABILITY LMTS ARE HEREBY AM TO THE FOLLOWING FOR THE ANNUAL ADDITIONAL PREMIUM OF$650,SHOWN PRO-RATED BELOW: GENERAL AGGREGATE:53,000,000 PRODUCTS/COMPLETED OPERATIONS: EXCLUDED PERSONAL AND ADVERTISING INJURY:$2,000,000 EACH OCCURRENCE:52,000,000 DAMAGE TO PREMISES RENTED TO YOU: $100,000 MEDICAL EXPENSE:$5,000 All other terms and conditions remain unchanged, PRXM3:M. . . . . . 152.04 TM. . . . . . . . . . 4.56 STANPXM r9s. .30 TOTAL. . . . . . . . 156.90 rchi 8/29/2017 POLICY NUMBER: CIP305861 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location(s)Of Covered Operations City of EI Segundo, its officers, officials, employees, agents, and volunteers 0 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional exclu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage" or "personal and advertising injury" "property damage"occurring after: caused, in whole or in part, by: 1. All work, including materials, parts or equip- 1. Your acts or omissions; or ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project (other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) desig- covered operations has been completed; or nated above. 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ S S'T'ATE: CO • 21st Century Insurance POLICY NO: 8259 27 06 COMPAW Na: EFFECTWE DATE, EXPIRATION DATE: 02/15/17 00/ x 17 VEHICLE IDENTIFICATION N 3U25 13 MAKE/MODEL: TOYOTA PRIUS INSURED,. i 531 MAIN JIL SZGU=Of CA 90245s t AGE,NCY/CONPANY ISSUING CARD: 21st CzxTunY jcjjsuRANc:M 21 : iAw 8T CZNTURY PLAZAP *O• BOX 15510WXLMIN(;Toxf DIC . THIS POLICY MEETS MINIMUM COVERAGES REQUIRED BY LABII IN' SECTION 14053. SEE IMPORTANT NOTICE ON REVERSE SIDE CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION ..........................................................---.............................. _..................................................................................._................_..........._................................................._...................._w...._w...................... rr.... 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. 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# () I 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 comply with t os rov ns or the agreement will automatically become void. Signature of Applicant Date 5-18-17 m C Agreement for: ��v 1�vti Dated: " Reviewed b � 1