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PROOF OF INSURANCE (2017 - 2018) CLOSED 6124 Progressive Solutions Inc. Certificate of Insurance (page 1 of 1) 09/15/2017 01:39:30 PM ,4+1 CERTIFICATE OF LIABILITY INSURANCE DAT/15/2D/YYW) � 9/15/2017 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 po0c,y('ios) 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 endorsornent(s). PRODUCER 'CONTACT Tech 1101ICentral Ex South,Suite 250 (E, NV tl ^^800-668-7020 �^ A(��N91. (877)826-9067 ioi Tech Insurance Allen,TX 75013py AFFOROiNO COVERAGE NAIC# _.m.h�........................-......,. w.lqq... ____„ INSURER A: Sentinel InsuranC2,„Company.Limited ....................................... . 11000 INSURED INSURER B: BeaZleyl,n„sura„nc,e,Companv Inc. 37540 Progressive Solutions Inc. INSURER C: 850 Steele INSURER D: Brea,CA 92821 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 ._. ILTR TYPE OF INSURANCE I=WVn POLICY NUMBER...................................��, '+IY EFF POLICY EXP f�MdDODO1YYY'yEIMMIDD.II'YYYI( LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $2.000,000 ___.. CLAIMS-MADE flp ✓ �. ” "C R, IV'T __..._ 1000000 .._._: . ._..... .. OCCUR rl.Ala1FRCLm�;E, Ea0;.Lurt C-01..__ $ .' MED EXP(Any one person) $ 10,000 A � 46SBARI9399 4/10/2017 4/10/2018 PE11 RSONA11 L&ADV INJURY $2,000,000 GEN'LAGGREIS APP AGGREGATE 4.000,000 C PRODUCTS $4�IaC OTHER, $ (EamaYSINGLE LIMil' $ 2,000 000 AUTOMOBILE LIABILITY CC.YMBrJPNINEO) ANY AUTO BODILY INJURY(Per person) $ . ............ .................•.....er-____accent ................................... AOSCHEDULED 46SBARI9399 4/90/2097 ODIL.. Y NJURY Pid $ . AUTOS 4/10/2018 BAUTOS ( ) A ✓ AUTO WNED Ap'VROr k i I Y DA M E, $ HIRED AUTOS ✓ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB {CLAIMS-MADE AGGREGATE $ _—.. DED � RETENT ........$. .................................................____. ON $ OT. WORKERS COMPENSATION .. ......STATUTE �_EE_R ,,, .,.-................. ,.................,...... AND EMPLOYERS'LIABILITY Y'd N E L EACH ACCIDENT ANY PROPRIETOR/PARTNER/EXECUTIVE $ OFFICER/MEMBER EXCLUDED' N/A ..._- (Mandatory In NH) E L DISEASE-EA EMPLOYEE: $ Ifyes,describe under ..................__.. .................................................,,,,,,,.....,,,,... DESCRIPTION OF OPERATIONS below E DISEASE-POLICY LIMIT $ B Professional Liability(Errors and Omissions) V15UE5170901 7(7/2017 7!7/2018 $1,000,000/$1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) City of EI Segundo,its officers,officials,agents and employees are additional insureds as respects the above liability insurance. Note:General Liability Exclusion:Testing or consulting errors and omissions. Form SS0509 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo,CA 90245-3813 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD CERTHOLDER COPY SP STATE P.O. BOX 8192, PLEASANTON, CA 94588 lim ■ CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 09-15-2017 GROUP: POLICY NUMBER: 9033101-2016 CERTIFICATE ID: 28 CERTIFICATE EXPIRES: 12-31-2017 12-31-2016/12-31-2017 CITY OF EL SEGUNDO SP DEPT OF BUILDING & SAFETY 350 MAIN ST EL SEGUNDO CA 90245-3813 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representatov President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 12-31-2012 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2017-09-15 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO EMPLOYER PROGRESSIVE SOLUTIONS, INC. SP PO BOX 783 BREA CA 92822 [CWD,CN] (REV.7-2014) PRINTED : 09-15-2017 _w_ ................................... ..........w......... ..... WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation: 1. Please be advised that a waiver of subrogation requires that a 3% surcharge will be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certificate holder who requested the waiver. (Note: if you have no employee payroll on that job, then there is no charge.) 2. To apply the 3% surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work on job/s for the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. Example: Payroll for job : $5, 000 . 00 Sample Rate : 13 . 30% Regular Premium equals : $ 665 . 00 Surcharge : 3 . 00% Additional Waiver charge : $ 19 . 95 Total premium equals $ 684 . 95 (665 . 00 + 19 . 95)