PROOF OF INSURANCE (2018) CLOSED CERTIFICATE OF LIABILITY INSURANCE DA 01/15/20118)
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 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
r this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER 4�ONTACT Alyssa Wilkinson
NAME:
L.A.Bowen Insurance Inc PHONE (801)225-2442 gg FAX (801)225-2428
Al No.Eatl; 111C.No);
1345 West 1600 North AD�olaEss: alyssa.w@laboweninsurance.00m
PO Box 67 I INSURER(S)AFFORDING COVERAGE NAIC t
Orem UT 84059 I INSURERA: Hartford Casualty Ins.Co. 29424
INSURED INSURER B: Hartford Fire Ins.CO. 19682
Decisionwise,LLC V INSURER C: United States Liability Ins Co 25895
815 W 450 S INSURER 0:
INSURER E:
Springville UT 84663 INSURER F:
COVERAGES CERTIFICATE NUMBER: 111542018 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.
MW 'AUUL 51JUH POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSO WVD POLICY NUMBER l'M'M/DDIY'YYY) (MMIDDIYYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE I$ 2,000,000
CLAIMS-MADE �OCCUR I PREMISES(Essoccurrance) I s 300,000
"O'EX (/ny one person) $ 10,000
A Y 34SBARU1392 12/27/2017 12/27/2018L&ADV INJURY I s 2,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ 4,000,000
POLICY =JEST LOC I I PRODUCTS-COMP/OP AGG g 4,000,000
OTHER; I Non-owned $ 2,000,000
AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT $
d"£®ercIdentY
ANY AUTO I BODILY INJURY(Per person) $
A OWNED SCHEDULED 34SBARU1392 12/27/2017 12/27/2018 BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
.� HIRED NON-OWNED PROPERTY DAMAGE $
,,. ......, AUTOS ONLY AUTOS ONLY War awdcrM
$
X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 1,000,000
A EXCESS LIAR CLAIMS-MADE 34SBARU1392 12/27/2017 12/27/2018 AGGREGATE $ 1,000,000
DED I xI RETENTION$ D yp$
WORKERS COMPENSATION PER I STATUTE I I ETH E
AND EMPLOYERS'LIABILITY Y/N
B ANY PROPRIETOR/PARTNER/EXECUTIVE F_� NIA 34WECIC5120 12/27/2017 12/27/2018 E.L.EACH ACCIDENT IS 1,000,000
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) F DISEASE-EA EMPLOYEE I s 1,000,000 _
Ifyes,describe under
DESCRIPTION OF OPERATIONS below E,L,DISEASE-POLICY LIMIT I$ 1-000,000 _
ERRORS&OMISSIONS GENERAL AGGREGATE 1,000,000
C I SP1010305J/34KDGIQ0553 12/27/2017 12/27/2018 DEDUCTIBLE 1,000
I _
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
CYBER LIABILITY Pol#:106759980 08/21/2017-08/21/2018 GENERAL AGGREGATE 1,000,000 PER CLAIM 10,000
The City of EI Segundo,CA has been added as additional insured In regards to the general liability.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
City of EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
AUTHORIZED REPRESENTATIVE
EI Segundo CA 90245 �, �yr/.Li��
®1988.2015 ACORD CORPORATION, All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
THE
HARTFORD
Select Customer Insurance Center
3600 WISEMAN BLVD.
SAN ANTONIO TX 78251
Policyholder, please call us at: (866) 467-8730
Agent, please callus at: (866) 467-8730
SERVICE.TX@THEHARTFORD.COM
INSURANCE ENDORSEMENT
ATTACHED
*** PLEASE REVIEW THE CHANGE***
Enclosed is an endorsement for your business insurance policy. Please review it at your convenience. If you have
questions or need to make further changes:
Policyholder, please call us at: (866) 467-8730
Agent, please call us at: (866) 467-8730 between 7 A.M. and 7 P.M. CST .
The premium billing will be mailed to you separately. You can expect to receive it soon.
Thank you for allowing us to service your business needs.
L A BOWEN INSURANCE AGENCY INC/PHS
THE HARTFORD SELECT CUSTOMER INSURANCE CENTER
The Hartford
Hartford Fire Insurance Company and its Affiliates
One Hartford Plaza,Hartford,Connecticut 06155
it
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
POLICY CHANGE
This endorsement changes the policy effective on the Inception Date of the policy unless another date is indicated
below:
Policy Number: 34 SBA RU1392 DX
Named Insured and Mailing Address; DECISIONWISE, LLC
815 W 450 S
SPRINGVILLE UT 84663
Policy Change Effective Date: 12/27/17 Effective hour is the same as stated in the
Declarations Page of the Policy.
Policy Change Number: 003
Agent Name: L A BOWEN INSURANCE AGENCY INC/PHS
Code: 470386
POLICY CHANGES:
HARTFORD CASUALTY INSURANCE COMPANY
ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING
STATEMENT.IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BANK
ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS.
THIS IS NOT A BILL.
NO PREMIUM DUE AS OF POLICY CHANGE EFFECTIVE DATE
FORM NUMBERS OF ENDORSEMENTS REVISED AT ENDORSEMENT ISSUE:
IH12001185 ADDITIONAL INSURED - PERSON-ORGANIZATION
PRO RATA FACTOR: 1.000
THIS ENDORSEMENT DOES NOT CHANGE THE POLICY EXCEPT AS SHOWN.
Form SS 12 11 04 05 T Page on
Process Date: 12/05/17 Policy Effective Date: 12/27/17
Policy Expiration Date: 12/27/18
POLICY NUMBER: 34 SBA RU1392 it
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED w PERSON-ORGANIZATION
ARAPAHOE COUNTY
5334 S PRINCE STREET
LITTLETON, CO 80120
SOCIETY FOR HUMAN RESOURCE MANAGEMENT (SHRM)
1800 DUKE STREET
ALEXANDRIA, VA 22314
FARMER BROS CO
ITS SUBSIDIARIES, AFFILIATES, AND DIVISIONS
PO BOX 77057
FORT WORTH TX 76177
BANK OF THE WEST, ISAOA
C/O INSURANCE CENTER
SME SBA LENDING DIVISION
PO BOX 4260
NAPA, CA 94558
GLOBAL SPECTRUM, LP
3601 SOUTH BROAD STREET
PHILADELPHIA, PA 19148
COUNTY OF BOULDER, STATE OF COLORADO, A BODY CORPORATE AND POLITIC
PO BOX 471
BOULDER, CO 80306
Form IH 12 00 1185 T SEQ. NO. 002 Printed In U.S.A. Page 001 (CONTINUED ON NEXT PAGE)
Process Date: 12/05/17 Expiration Date: 12/27/18
POLICY NUMBER: 34 SBA RU1392
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - PERSON-ORGANIZATION
CITY OF EL SEGUNDO
350 MAIN STREET
EL SEGUNDO, CA 90245
Form IH 12 00 1186 T SEQ.NO. 002 Printed in U.S.A. Page 002 (CONTINUED ON NEXT PAGE)
Process Date: 12/05/17 Expiration Date: 12/27/18