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PROOF OF INSURANCE (2018 - 2018) CLOSED GOLFMAI-01 TDIEL CERTIFICATE OF LIABILITY INSURANCE I DATE 12712017Ir) II 1212712017 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(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, Subject to the terns 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 License#OF09643 gRgjAcT tona.delgado@des�ortempireins.com Desert Palm uite Dere Empire CA ub 1 ices,Inc. a Em):(760)360.4700 IN Ngy(Tg0)360.4799 77584 Country Club Drive .... @�? . ...... „ INSURER'ISIAFFORDING COVERAOE.... ..... NAIC-N ----- _ INsfuREatA; escea rrsurncp amp0Tay 2501,1 INSURED MSUR RD,StarStone National lnsuranc,P Ci! rrip19rly ...., „25486 Golf Maintenance Solutions,LLC IN4a1RERC Cgpltol 5,p_ca i_8ityr Irlslur n s,Corporation ..., 10328 P 0 Box 922 Carefree,AZ 85377 INSURER D .............,,.. INSURER E; INSURER F: COVERAGES CERTIFICATENUMBER: 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, EXCLUSPOLICY INN AR' X cl MMERcwL F INSURANCE A IiL s 'L„NMITS SHOWN MAY NUMB NUMBER BEEN REDUCED BY PAID S, OLICI T TYPE ;11�._ uMlrs GEN RAL COMMERCIAL X...I OCCUR X WPP114348103 0311512017 03115/2018 DAMAGE OCCURRENCE $ '1106 0O0 PF.MM15ES(.Fa o=rroncd) ... f --- - '0100 --- _ .............. MED EXP(Any one Penson) ,5, . 5,041 �� I L PERSONALaADVIN,IURY E,,,,,,,,,, 1,000,000 -. - J IMIT APPI S P ., GEN"L AGGREGATEPRa (� PER: GENE RAI,,AGGREG,ATE 5......... 2'000,000 EECT ------ POLICY X OC 2,4100,000, PROD _ PIOPAGG_ - O"I'k1ER; I ---UCTS -Cl)M S .. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT — -s ANY AUTO BODILY,INJURY(Per PCO^) ; _ OWNED SCHEDULED BODILY IN„J„URY„(Par aeoldent) S AUTOS ONLY � AUpOTNNO.ppSWWNNEEpp --- MS ONLY C.,..,.... Al7TOSOlJLV eQaPIMR�"6'M.1,0,�WMd#GE _. . B X UMBRELLA LUAS X OCCUR EACH OCCURRENCE S 1,0010',000 DED �EXCESS LRETENTIONS CLAIMS-MADE 7193OX17CALI 03115/2017 03115/2018 AGGREGATE s............... 1 000'0410 WORKERS COMPENSATIONPER ILIABILITY atory EEIAnN' ... OTH.. - AND RS' PT/TLTE ^ LER ANYPROPRIERPARNER/EXECUTIVE EXCLUDED? NIA m.. .. CIDENT M ___— ... „.......................... E L..DISEASk-EA Nyea describe under E.L.D_SEASE POCEMPLOYE IMI E E................ DESGIRIPTK)N OF OPERATIONS below T A Equipment Floater WPPI14348103 03115/2017 0311512618"Ded$'1,000 310,485 C Errors&Omissions SGCO2589-07 1110112017 11101/2018 Dad$2500 11000,0001 DESCRIPTION OF OPERATIONS'I LOCATIONS I VEHICLE'S(ACORD 141,Additional Remarks Schedule,may be allached N more City of El Segundo,Its officials and arrT to ees are named a additional Insured n space s rancd) 0 P y per attached form. This Insurance Is primary and non contributory per attached farm, 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 AUTHORIZED REPR'ESENTA'TIVE I ACORD 25(2018103) ®1968-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 20 38 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURE - OWNERS, LESSEES O CONTRACTORS S - AUTOMATIC STATUS FOR OTHER E PARTIES WHEN REQUIRED IN WRITTEN CONSTRUCTION AGREEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ,;u A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured: additional insureds, the following additional 1. Any person or organization for whom you are exclusions apply: performing operations when you and such This insurance does not apply to: person or organization have agreed in writing 1. "Bodily injury", "property damage" or"personal in a contract or agreement that such person or and advertising injury" arising out of the organization be added as an additional insured rendering of, or the failure to render, any on your policy;and professional architectural, engineering or 2. Any other person or organization you are surveying services, including: required to add as an additional insured under a. The preparing approving, or failing to ' the contract or agreement described in Paragraph 1.above. prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, Such person(s) or organization(s) is an additional change orders or drawings and insured only with respect to liability for "bodily specifications; or injury', "property damage" or "personal and b. Supervisory, inspection, architectural or advertising injury"caused, in whole or in part, by: engineering activities. a. Your acts or omissions;or This exclusion applies even if the claims against b. The acts or omissions of those acting on any insured allege negligence or other wrongdoing your behalf; in the supervision, hiring, employment, training or in the performance of your ongoing operations for monitoring of others by that insured, if the the additional insured. "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused However, the insurance afforded to such the "personal and advertising injury', additional insured described above: rY, involved the rendering of, or the failure to render, any a. Only applies to the extent permitted by law; professional architectural, engineering or and surveying services. b. Will not be broader than that which you are 2. "Bodily injury" or "property damage" occurring required by the contract or agreement to after: provide for such additional insured. a. All work, including materials, parts or A person's or organization's status as an equipment furnished in connection with additional insured under this endorsement ends such work, on the project (other than when your operations for the person or service, maintenance or repairs) to be organization described in Paragraph 1. above are performed by or on behalf of the additional completed. insured(s) at the location of the covered operations has been completed; or CO 20 38 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 2 b. That portion of'your work'out of which the 2. Available under the applicable Limits of injury or damage arises has been put to its Insurance shown in the Declarations; intended use by any person or organization whichever is less. other than another contractor or subcontractor engaged in performing This endorsement shall not increase the operations for a principal as a part of the applicable Limits of Insurance shown in the same project. Declarations. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III—Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement described in Paragraph A.1.;or Page 2 of 2 0 Insurance Services Office, Inc., 2012 CO 20 38 0413 COMMERCIAL GENERAL LIABILITY CG 20 0104 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the This insurance is primary to and will not seek additional insured. contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance;and CO 20 0104 13 0 Insurance Services Office, Inc.,2012 Page 1 of 1 Pharmacists Mcoal'Insurance Comp y hiss of t 800.247.5930 or 515.295.2461 • P.O. Box 370, 808 Highway 18 West, Algona, Iowa 50511-0370 PERSONAL AUTOMOBILE DECLARATIONS THIS IS NOT A BILL NAMED INSURED AND MAILING ADDRESS CUSTOMER NUMBER 0000302901 WILLIAM J NAUROTH POLICY NUMBER APV 0005577 23 6440 E CALLE DE LAS ESTRELLAS Previous Policy Number APV 0005577 CAVE CREEK AZ 85331.2733 POLICY PERIOD 11/29/17 TO 11/29/18 12 01 A.M. Local Time at the described location ADDITIONAL.NAMED INSURED TRANSACTION JULIA M NAUROTH AMENDED DECLARATION ADD VEHICLE EFFECTIVE: 12/08/17 ------------ DISCOUNTS Y1N Y O w RATE W u, -04 STATED VEH.YEAR MAKElMODEL U) i Ct ASS VIN r ( VALUE GARAGED LOCATION 11"d.. i8 Illi „ I i II illli'II ,I+ AZ 1,4 ";n a.; 1}'h tl. 'r1�0 N,,h,t" y '12 y 'va, 0 .1, 01.1 ' ,l 1a': 54 I. 1,1''i,Fd)'11 .v ( u' 'J' 9'! a4e"n .9 "i Y "tl N VEHICLE 2 VEHICLE 3 VEHICLE 5 VEHICLE 6 PER PER COV'ERAG'E PERSON ACCIDENT PREMIUM DED PREMIUM DED 'PREMIUM' DED PREMIUM DED LIMIT LIMIT Bodily Injury ,?;J,op; 0".V 1,Y G :',to 4.0U N+i I10 Property Damage 10;)'+;'ex:",,r J 7, ,r o') Medical Payments :,, ,t , 0!) !:I-(J ni, 'r,red .100,Motorist , I:z , ; ainjury Rngsdosiu ed Motorist L '^V'1, v,lr,bo Other than Collision 6 0,0 ;ar,i,0 to ' , 00 Collision :"5 (""i ��,,+J '.;I°.',pie P) 1,1„11t g74G iip() 1,i'i1 Full Glass Coverage 00 ': .+;Y+d .• `a VEHICLE PREMI..U... M TOTAL 0 N �;. a�.:'',+.,)r, ..' Ty�:�.rbrn ,s'C ,Q0�...... Additional Premium74 .'G O' AMENDED POLICY PREMIUM TOT .. AL $ 2,993,00 Authorized Representative GAIL f. ''+aVOLFE, CISR, API 4152 a,rVM�C' (911 1) Date Printed:12/22/17 INSURED COPY Pagel of 2 ML ruarmadsts mutual"iunce Company 800.247.5930 or 515.295.2461 • P.O. Box 370, 808 Highway 18 West, Algona, Iowa 50511-0370 THIS IS NOT A BILL NAMED INSURED AND MAILING ADDRESS CUSTOMER NUMBER 0000302901 WILLIAM J NAUROTH POLICY NUMBER APV 0005577 23 6440 E CALLE DE LAS ESTRELLAS Previous Policy Number APV 0005577 CAVE CREEK AZ 85331-2733 POLICY PERIOD 11/29/17 TO 11/29/18 12 01 A.M. Local Time at the described location PACKAGE DISCOUNT SECTION DISCOUNTS YIN Auto & Home Policies Y Auto, Home, Umbrella Policies N Commercial Policies N DISCOUNTS YIN DRIVERS ON THE POLICY GOOD DRIVER DEFENSIVE STUDENT TRAINING DRIVER 1 WILLIAM J NAUROTH N N N 2 JULIA M NAUROTH N N N 3 BENJAMIN R NAUROTH Y N N 4 ANGELA NAUROTH N Y N FORMS AND ENDORSEMENTS 1111°'I II ,I.. I r o 8 "J. I,l,l 0 r I'I'I V I'i'll uh(II YI! ,"111„.i " Q';..I`. II ,'`.III 1'' 11 "Ilii „ I' 'II p'h.. illi Vlbd II I'' PTU; W (I ', r',')1 :III I .II I h'nl^I'• P 4,!0111 „I„ I'11101.,,1y1 , „ I'll''i „a P' p^,'ll ;,n,lu il,ii., Il; ll,ull. in iiii Iln,'I 'II V°IIL➢ p" :'II JI"1[ lJ,1 11),Jill HV blll,l These forms are not included in this policy, however, they were a part of original policy. POLICY INTERESTS ADDITIONAL NAMED INSURED JULIA M NAUROTH 6440 E CALLE DE LAS ESTRELLAS CAVE CREEK AZ 85331-2733 WARNING:A person who knowingly submits an application or files a claim with intent to defraud or helps commit a fraud against an Insurer may be guilty of a crime and may be subject to criminal and civil penalties. APVDEC (9111) Date Printed:12/22/17 INSURED COPY Page 2 of 2 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 ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: U I have and will maintain a certificate of consent of self-insure for workers'compensation, issued by the Director of Industrial Relations as provided for by Labor Code§3700 for the performance of the work set forth the agreement with the City of EI Segundo. Policy No. (_J I have and will maintain workers'compensation insurance as required by Labor Code§3700 for the performance of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone# I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those pro ision or the agre ent will autornatically become void. Signature of Applicant Date 12-2$-17 Print Name William lrl-WMth llAgreement for: U v v U Dated; . .. M Reviewed by: 1 y.„ ..,,