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PROOF OF INSURANCE (2018 - 2019) CLOSED CO/�Q® � DATE(MMIDDIYYYY) ................... �wl`y�"� ^ ILITY A'c ^ 1�' C 0211212018 THIS CERTIFICATE IS ISSUED ASMTTER OF CERTIFICATE INFORMATION ONLYAND CONFERS NS ORANC[...'ON THRIGHTS E 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 INSU E , ."u RED, 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 endorsements). _._._,. _ _.�.. ......., _..........._ _ .._.._.._._..._ PRODUCER CONTACT NAME: Michelle Carl Prodigy insurance Services,Inc PHHON��tl Mra„ 818-541-7870 FAX Np):, 818-541-7875 3701 Ocean View blvd,STE D E MfrIM" AhanRCSS: Michelle@Prodigylns.com Montrose,CA 91020 Y ' I, I Ar PORDING 4.. A07k: NAIC# ., INSURER A... Stillwater Insurance Company 25180 INSURED INSURER B, Capitol Specialty Insurance Corporation 10328 Carol Beck DBA:CDB Golf Properties IN SURER r: 324 18th St INSURER D 1 INSURER E: Manhattan Beach CA 90266 wsuRER 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 CONTRACTOR 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 NSURANCE ............... �ADfAG ICY I/ S,ti'.41kZ' ..._.w...._..............L.. Mfp ..... IiV.9POLICY NUMBER dMOLIDhYEFF POLICY Y EXP TYPE OF LIMITS ..... "u, C MM AL LIABILITY AL NER 1,000,000 DAMAGE 10 PEN rLU EACH OCCURRENCE S CLAIMS-MADE ��'" ��,OCCUR PREMISES(Ea occurrence) 5 MED EXP(Any one person) S A X BP8317 02/12/2018 02/12/2019 PERSONAL a ADV INJURY $ 1,000,000 X4 IPEO re(wa�';Yaq1nJaGq;LIMIT APPLIE SPER: GENERAL AGGREGATE " m S 2,000.000 1;Q' , 1000, Loc r5C)IJdYY i MI r 6 00,000 I CTk+k',ae 5 AUTOMOBILE LIABILITY Yv7fIIhJd'a'k w;iIgt+;r t.@':LIhfiV4 td:ti aex'ltdent) ANY AUTO BODILY INJURY(Per person) 'S ALL OWNED iI SCHEDULED BODILY INJURY(Per accident) S' AUTOS AUTOS . NON-OWNED k4w1 I-"M;I,,I u'iAhdM.+I HIRED AUTOS ., i AUTOS Iln{.r,rw,;;.ir'�IaasylF t. ,. .... UMBRELLA LIAB .....,,w,....................................................,.,.,.,.,.,.,.,............ ....__. OCCUR EACH OCCURRENCE: S EXCESS LIAB ALttla AGGREGATE r WORKERS COMPENSATION .... __ NwYd¢Ihh I AND EMPLOYERS'LIABILITY STATI ITE. FORH- k'!N ANY PROPRIETOR/PARTNERIEXECUTIVE E L EACH ACCIDENT S ,OFFICER/MEMBER EXCLUDED? f ��N 8 A (Mandatory in NH) EL DISEASE-EA EMPLOYEE S I{xR:?,d6a+;LR1tl'I!Y'Pd,M u,Rde4 dr rk k'Xrrp;Nd',Yd+d.k .,,..,. .,...O below _F LC"I br,a Pm JI IIC:Y'LIMIT 5 , ..Y..... 7�. .....................��...;'fl'd,;f:t.Adur*ra',�.�...............,,..___.__.. ........... ............ .... .............. B Professional Liability SUB173912-01 02/12/2........... . .,_- PER OCCURRENCE 51,000,000 018 02/12/2019I GENERALPOLICY OL_ICY AGGREGATE $1,000,000 ......................... .............................. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The city of EI Segundo is listed as an additional insured on the general liability policy ...�..................................w.....� CERTIFICATE HOLDER CANCELLATION m........... ...._. ........._.................. SHOULD ANY OF THE ABOVF DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE T EREOF, NOTICE WILL BE DELIVERED IN The City of EI Segundo ACCORDANCE WITH THE POLICY P VISIONS P' 350 Main St �' r AWJi 1'kIOX�kX"r".M� k;&"^'0":S@- "f l'V'Y„ ✓'� a EISe undo . .. ..._.. CA 90245-3813 ..........___....._..... ....................................,., ........... ,...-.. .....,........r ©1988-2014 ACORD CORPORAT'1O _Ajl rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD BUSINESSOWNERS SB 04 36 01 17 THIS ENDORSEMENT CHANGES YOUR POLICY. PLEASE READ CAREFULLY. BLANKET ADDITIONAL INSURED AND BLANKET INSURANCE SU OGATION WAIVER This endorsement modifies insurance provided under your BUSINESSOWNERS COVERAGE FORM Section II—Liability is amended as follows: -Z2A--, The following is added to Paragraph C.Who Is An Insured: Any person or organization in a written agreement with you requiring indemnification is an additional insured on your policy with regard to their respective business interest. However, coverage applies only to liability due to "bodily injury", "property damage", or "personal and advertising injury" caused, in whole or part, by your acts or those performing operations on your behalf, or in connection with your franchise, equipment, or part of premises used by you and listed in your declarations, or, if a vendor, likewise when liability arises from "your product" as distributed or sold in the vendor's regular course of business. Coverage does not apply to liability resulting from the additional insured's sole negligence.And there is no coverage for structural alterations, new construction, and demolition steps performed by or on behalf of additional insureds. Insurance coverage afforded, limits, and the most we will pay on behalf of additional insureds is: 1. Only up to the extent permitted by law; 2. Not broader than your agreement with the additional insured; and, 3. Available under applicable limits of insurance shown in declarations; or whichever is less. However, insurance afforded to vendors does not apply to: 1. Any express warranty unauthorized by you; 2. Any product physical or chemical change made intentionally by the vendor; 3. Demonstration, installation, service or repair, except on vendor's premises for your product's sale; 4. Package or label changes, use as a container, a part, or ingredient of another thing by the vendor; or, 5. Those who supply products, ingredients, or partof containers, in or affecting your products. In addition, agreements with additional insureds must be effective during the policy term; and, must be executed prior to"bodily injury", "property damage", or"personal and advertising injury". A person's or organization's status as an additional insured under this endorsement ends when your ongoing operations, occupancy or lease with that additional insured is complete. Section III—Common Policy Conditions is amended as follows: A. The following is added to Paragraph A. Cancellation 2. and supersedes any provision to the contrary: Additional insureds listed in declarations will be informed of coverage changes and given written notice at least: 1. 10 days before cancellation effective date if we cancel for premium nonpayment; or, 2. 30 days before cancellation effective date if we cancel for any other reason; and, 3. 30 days before expiration if we elect not to renew this policy. B. The following is added to Paragraph H. Other Insurance and supersedes any provision to the contrary: Primary And Noncontributory Insurance(Blanket Insurance Subrogation Waiver) This insurance is primary to, and will not seek contribution from, other insurance available to an additional insured provided: 1. The additional insured is a named insured under such other insurance; and, 2. You have a written agreement stating your insurance would be primary and would not seek contribution from other insurance available to the additional insured. SB 04 36 01 17 Page 1 of 1 Includes copyrighted material of Insurance Services Office,Inc.with its permission 001000000000000031718043 000013 STILLWATER INSURANCE GROUP PRODIGY INSURANCE SERVICES INC 3701 OCEAN VIEW BLVD STE D MONTROSE CA 91020-1646 We appreciate your business ! PLEASE NOTE THIS UPDATED NUMBER: TO REPORT A CLAIM PLEASE CALL 1 (800) 220-1351 CDB Golf Properties 324 18TH ST MANHATTAN BEACH CA 90266-4653 r-1 Ln M r-I O N N O O O 19 w _ � a �i a U av'i Ln u 04 � w Q EQ H N w A v vwi :jQ) U Fl O O 4j EO H H a' PQ CIA >1 �4 x r� W 0) o w H U rzi cc��� > .� a Uri x F U 44 HH www � 0Cc) P ZO 3 � 0o W � riw ww a w b CNx W a M W H 001000000000000031718043 4380A Stillwater Insurance Group A 4905 Belfort Road,Suite 110 STILL'S ATER Jacksonville,FL 32256 855-712-4114 INSURANCE COMPANY NEW BUSINESS OWNER POLICY DECLARATIONS Named Insured and Mailing Address Policy Number BP8000317 CDB Golf Properties 324 18TH ST Agency—and Service Contact MANHATTAN BEACH CA 90266-4653 PRODIGY INSURANCE SERVICES INC (818)541-7870 Policy Period 02/12/2018 to 02/12/2019 12:01AM Standard Time at the Premises location **THIS POLICY DOES NOT COVER EARTHQUAKE OR FLOOD DAMAGE ** In return for timely payment and subject to all policy terms and conditions, we agree with you to provide insurance as stated in this policy,declarations,and every applicable form and endorsement.Also: • Amount of insurance limits shown are not stackable across locations or buildings; • With respect to Business Liability and Medical Expenses—each claim paid reduces the amount of insurance provided during the applicable annual period;and, • If coverage limits or deductibles are indicated as"included"refer to policy provisions for coverage, conditions,and amount of insurance details. PREMIUM AND FEES .Annual Premium $ 370.05 Terrorism - Certified .Acts $ 3.80 Policy Fee - New Business $ 50.00 Total Annual Premium & Charges: $ 423.85 SB DS 01 11 17 1 001000000000000031718043 OOOOB SECTION I • PROPERTY: Coverages, Forms, Limits & Deductibles Applicable for Specified Premises Premises/Location 1, Building 1 324 18TH ST, MANHATTAN BEACH, CA 90266 Square Feet: 0 Building Limit Annual Increase: 40 Use: Management Consulting Additional Insured: City of El Segundo 350 MAIN ST, EL SEGUNDO, CA 90245-3813 Coverage Form Number Limit Deductible Business Personal Property (BPP) BP 00 03 07 13 $15, 000 $1,000 Business Income BP 00 03 07 13 12 Months 72 Hours Accounts Receivable BP 00 03 07 13 $10,000 $1,000 Arson Reward SB 04 02 05 15 $10,000 None Extra Expense BP 00 03 07 13 12 Months None Fire Department Service Charge BP 00 03 07 13 $2,500 None Fire Extinguisher System Recharge BP 00 03 07 13 $5, 000 None Fur, Jewelry or Patterns Theft or Damage BP 00 03 07 13 $2,500 $1, 000 Lock Replacement SB 04 06 05 15 $1, 000 None Pollutant Clean-up and Removal BP 00 03 07 13 $10,000 $1, 000 Valuable Papers and Records BP 00 03 07 13 $10,000 $1, 000 SECTION I PROPERTY: Coverages, Forms, Limits & Deductibles Applicable Per Policy Coverage Form Number Limit Deductible Computer Operations Interruption BP 00 03 07 13 $10,000 72 Hours Electronic Data Damage BP 00 03 07 13 $10, 000 $1, 000 Forgery or Alterations BP 00 03 07 13 $2,500 $500 SECTION II - LIABILITY AND MEDICAL EXPENSES: Coverages, Forms & Limits Applicable Per Policy Additional Insured: City of El Segundo 350 MAIN ST, EL SEGUNDO, CA 90245-3813 Coverage Form Number Limit Medical Expense - $10, 000 Any One Person BP 00 03 07 13 Included Personal & Advertising Injury BP 00 03 07 13 Included Business Liability - Per Occurrence BP 00 03 07 13 $1, 000,000 Business Liability - Aggregate BP 00 03 07 13 $2, 000,000 Business Liability - Prods-Completed Ops BP 00 03 07 13 $2, 000,000 Damage to Premises Rented to You BP 00 03 07 13 $100,000 SB DS 01 11 17 3 001000000000000031718043 OOOOB SECTION III - ADDITIONAL FORMS: Applicable to All Premises and Coverages Coverage Form Number Calculation Of Premium BP 05 01 07 02 California Fraud Statement IL N 018 09 03 California Privacy Statement PRIVACY CA 05 12 Exclusion - Punitive Damages SB 04 03 08 14 Exclusion of Loss Due to By-Products of Production or Processing SB 04 17 08 14 Operations Cap on Losses From Certified Acts of Terrorism BP 05 23 01 15 Disclosue Pursuant to Terrorism Risk Insurance Act BP 05 is 01 is California Disclosure Notice FNIC DN CA 01 06 Primary and Noncontributory - Other Insurance Condition BP 14 88 07 13 Exclusion - Fungi or Bacteria (Liability) BP 05 77 01 06 Blanket Additional Insured & Subrogation Waiver SB 04 36 01 17 California Changes BP 01 55 05 17 Employment-Related Practices Exclusion BP 04 17 01 10 Exclusion - Access or Disclosure of Confidential or Personal BP is 05 05 14 Information and Data-Related Liability Exclusion of Certified Acts of Terror - Nuclear, Biological, BP 05 26 01 15 Chemical, or Radiological Signed: ,I- by: Mark O. Davey, CEO SB DS 01 11 17 5 001000000000000031718043 OOOOB A R INSURANCE BINDER DATE(MM/DDffY-YY) 1 02/12/201,18 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT,SUB!ECT TO THE CONDITIONS SHOWN ON PAGE 2 OF THIS FORM. AGENCY COMPANY BINDER# Prodigy Insurance Services, Inc Nationwide Insurance Comf,,)arly PA 3008634534 3701 Ocean View Blvd, Suite D I nATE EIPI:I TIME DATE (,XPIRATPON TIMI Montrose, CA 91020 02/12/2018 1 12:01 IIIX : kM03/12/2018 PIVI pflo 4 FAX IN",I"r�.xq:(818)54 1-7870 tAIC,��o 1,,(818),541-7875 TI IIS UII IS ISSUED TO EXI :ND COVURAUZ IN TI Ir ABOVE NAMED UC)MI'A10 CODE:52839 SUB CODE: PI I XPIRING,POLICY ft AGr,NdY DESCRIPTION OF OPERATIONS I VEHICLES I PROPERTY(Including Location) Y,5TOM TOM" LR I U; INSURED AND MAILING ADDRESS Carol Beck 324 18th St Manhattan Beach, CA 90266 -COVERAGES TYPE OF INSURANCE COVERAGEIFORMS DI DUCT liW- COINS% AMOUNT I PROPITIRry cAUSFS 04 1,01,S I Ell,�I, 1 kWijPlI, �xl GENERAL LIABILITY ](x,'0jIflfl NCIL i;6:..PJIhtILItC`I(wl PAWN61h H" CM:iiiA?Al,I VV31ure Rt N I,N D I'M MIGs (,LAINAS,MAI)IL 0GICIURI ItrfLIJ (Allv''Iiejpu,oi[1 TW.': &ADV INJURY S GIFINI.IRAI tLIROL)Afl IC*�CLAIMS-II PreGIA)CI'S COMPiOVIAGG, VEHICLE LIABILITY COW IINI 1)1,71ftd 1:LINAI I S ANYAllITO U+NIfl 0 INJURY 11107 owl.o,o 250,000 OWN1.0 ALI US ONI Y -)Ull,v 01SURY aujounir 5 500,000 X sclii ouLl DAI-1105 PROMLIRWIDAMAGI, 5 100,000 I I IIHI.DAU­CG ONLY I PiO MILNTS $ NON OWNI D ALFICjS ONI Y I I IERSONAL LUI I IRC7 UNINSURED I001 01RIS I mora„o iPi R,1,11 Ill S VEHICLE PHYSICAL DAMAGE DED 'J,11 0 �I�l I GA%;1lVA(lJI, X COLLI'SION 1000 2013 Jeep Grand Cherokee STAH DAMOUNT S _jy,1 0 r I il N I HAN CO). 1000 1, 1C4RJEBGODC539217 GA RAGIL LIAITI IT'Y ALI 10 ONI Y-LA ACCIDLINIl' 5, ANY ALI Y 0 011ir-IR lHAN A010 ONLY I A' IA��l„MDI I'll A G G R L 0A I E EXCESS LIABILITY I ACt I OCCURRI.NI 5 11,000,000 X I-11I I A I(_)HKI AGGREGAIIl, $ �)iilioP: [I Wq UMINN 1, A,1:ORIVI IN I HO OAW FLA4 Cl V1,;,1011 N4Skfl<D 11;1: I'l.I Y S TA 10 R' WORKER'S COMPENSATION I 4 Ac!C:00N I AND EMPLOYER'S LIABILITY L I. DIGI­A',V, [A EII OYI 1: S L_ 1311.,&ASU�I L JOIT S . ......... ........... SPECIAL Fl E-S CONDITIONS IS OTHER COVERAGES LS1IMAY Lf01AL PRI.IAIUM .... .......... NAME t ADDRESS AD1ffIQN,`fl. f I OSS PAY1 L IvQk I LOSS PAYAIFII E I I OAN AUn ICIRIZIFID REPIRESIEWwwr. ....................... ——--___- Page I of 2 @ 1993-2016 ACORD CORPORATION. All rights reserved. ACORD 75(2016103) The ACORD name and logo are registered marks of ACORD Printed by on February 12,2018 at 04:35PM 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 1 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. C_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 EI Segundo is executed. My workers'compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone# X► I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not employ any person in any mariner 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 § 37'00 1 must immediately cpNywitnto � � e reernent will automatically become void, Signature Appli � r ma�Date :� :�� Print Name Agreement for: li!-)fb Dated: _! Reviewed by* ,,,., _M.,..._...