PROOF OF INSURANCE (2018) CLOSED ANR DATE(MMMD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE R054 11/6/2017
THIS CERTIFICATEIS 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(les)must have ADDITIONAL INSURED provisions 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 confer rights to the certificate holder In lieu of such endorsement(s).
PRODUCE)i CONTACT
tk wg
PAYCHEX INSURANCE AGENCY INC/PHS ((aCNN,E .Q: FAX
(888) 443-6112
210756 P: F: (888) 443-6112 ADDRESS:
PO BOX 33015 INSURER(S)AFFORDING COVERAGE NAICs
SAN ANTONIO TX 78265 INSURER A: Hartford Fire & Its P&C Affiliates V0091
INSURED INSURER B! f1)
INSURER C
HADRONEX INC DBA SMART COVER SYSTEMS ( INSURER D:
2067 WINERIDGE PL ST E ( INSURER E:
ESCONDIDO CA 92029 INSURER F: fI
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: RV
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 TTPEOFINSURANCE ADrDL SUBR POLICYNUMBER ���Eft POLICYEXP LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE g
R CLAIMS-MADE ❑OCCUR DAMAGETO S(RENTED
.-8 _ PREMISES R NTEDnce) S
MED EXP(Any one person) y;
PERSONAL&ADV INJURY ,
GEN'L AGGREGATE LIMIT APPLIES PER: fl GENERAL AGGREGATE
POLICY PRO- LOC PRODUCTS-COMPIOPAGG IS
JECT
OTHER: IS
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT IS
(Ee accident)
ANY AUTO I BODILY INJURY(Per person) Ig
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY(Per accident) $
........ HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY (Per accident) I,S
UMBRELLA LIAB OCCUR (EACH OCCURRENCE iS
EXCESS LIAB CLAIMS-MADE
AGGREGATE IiS
DED) RETENTI..5 u
I WORKERS 0AWYNTNTIONPER OTH-
ANDEMPLOYERS'LIABILITY X STATUTE IER
ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT 'I$1, 000, 000
OFFICERIMEMBER EXCLUDED?
A (Mandatory In NH) F1NIAX 76 WEG GH3220 10/01/2017 10/01/2018 V E.L,DISEASE-FA EMPLOYEE 'l, 000, 000
If yea,describe under E.L.DISEASE-POLICY LIMIT 11, 000, 000 J
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES ACORD 101,Additional Remarks Schedule,may be attached If mon apace Is required)
Those usual to the Insured' s Operations. Blanket Waiver of Subrogation applies
in favor of the Certificate Holder per the Waiver of Our Right to Recover from
Others Endorsement WC040306, attached to this policy. Notice of cancellation
will be provided in accordance with Form WC990394 attached to this policy.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
CITY OF EL SEGUNDO BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE
DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS,
ATTN: PW DEPT AUTHORIZED REPRESENTATIVE
350 MAIN ST
EL SEGUNDO, CA 90245
01'258.22015 ACORD CORPORATION,All rights reserved,
ACORD 25(2015103) The ACORD name and logo are registered marks of ACORD
it
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF OUR RIGHT TO RECOVER FROM
OTHERS ENDORSEMENT - CALIFORNIA
Policy Number: 76 WEG GH3220 Endorsement Number:
Effective Date: 10/01/17 Effective hour is the same as stated on the Information Page of the policy,
Named Insured and Address: HADRONEX INC
2067 WINERIDGE PL ST E
ESCONDIDO, CA 92029
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not
enforce our right against the person or organization named in the Schedule. (This agreement applies only to the
extent that you perform work under a written contract that requires you to obtain this agreement from us.)
You must maintain payroll records,accurately segregating the remuneration of your employees while engaged in
the work described in the Schedule.
The additional premium for this endorsement shall be 2 % of the California workers' compensation
premium otherwise due on such remuneration.
SCHEDULE
Person or Organization Job Description
ANY PERSON OR ORGANIZATION BLANKET OPERATIONS
FROM WHOM YOU ARE REQUIRED BY
WRITTEN CONTRACT OR AGREEMENT
TO OBTAIN THIS WAIVER OF
RIGHTS FROM US.
Countersigned by "Authorized representative
:a
Form WC 04 03 06 (1) Printed in U.S.A.
Process Date: 08/12/17 Pol Icy Expiration Date: 10/01/18