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PROOF OF INSURANCE (2019 - 2019) CLOSED BUFKI-1 OP ID: KC ACORO" DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 03/2812018 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 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). PRODUCER NAME CT Joe F. Parker Parker General Ins.Services CA Insurance License 0545437 (AIC,No,,1;01) 559-224-8222 (A p No); 559-224-8277 5094 N.Fruit,#101 EMAIL Fresno,CA 93711 ADDRESS: Joe F.Parker INSURER(S),AFFORDING COVERAGE NAIC# INSURER A:Colony Insurance Company INSURED Gary V. Bufkin Computer INSURER B: Consu'lt'ing ^1374 N,Linden Avenue INSURER c Fresno,CA 93728 INSURER D 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. INSR' TYPE OF INSURANCE 'A L SUB POLICY EFF POLICY Y YY --IMI LTR I, ,[) POLICY NUMBER OMMPDD�IYW"YWN /dW,iM700R'Y'YW'WI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 — UWAOIIS(aENr'¢rrrrr�rk_,,,, $, 0 0 CLAIMS MADE OCCUR X GL000943404 03101/2018 03/01/2019 w X 100,...0.. MED EXP lAnv one person/ ,L 5,000 PERSONAL S ADV INJURY 1, 1,000 ........ .. 000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 IIU � PRO POLICY IEC1" LOC PRODUCTS.•coMPrGP AGG 1,000,00.,,0 AUTOMOBILE Lfsp CIABILITY ,awwl'1tll^w L:t'7�Sudd'tiid.f°N.p4efiY'p $ " $ . fkrarc�,arantp ANY AUTO BODILY INJURY(Per person) $ ALL OWNED --- NON-OWNED PtlFJN�P I ) (Per accidenq $ AUTOS AUTOS HIRED AUTOS AUTOS BODILY INJURY $ - t 4 �rrl 6 $ UMBRELLA LJAB OCCUR EACH OCCURRENCE $ EXCESS LAB i, CLAIMS-MADE AGGREGATE . ' DED RETENTIONS $ WORKERS COMPENSATION IH AND EMPLOYERS'LIABILITY YIN _ST,ATUTE D,ER . E I' ANY PROPRIETORIPARTNER/EXECUTIVE .. EACH ACCIDENT $ "y'F'F61':.k"'b"ildAFMBEPEXCLUDED? � NIA Mar�afagorY in NiNH) """""" � DISEASE-EA EMPLOYEE $ IN y�kr;Y'.FdII's'All' underN N:'/'tiAN'%KJN.S R?aYIt1'rw' .E,L,,,,,,,, N'7i ^ x DISEASE•POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It more space is required) Certificate Holder is named as an additional insured. CERTIFICATE HOLDER CANCELLATION CITYE-1 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. Lili Sandoval 350 Main St. AUTHORIZED REPRESENTATIVE EI Segundo,CA 90245 - I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 101 G L 0009434-04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL ITIONAL INSURED - OWNERS,S, LESSEES OR CONTRACTORS - BLANKET COVERAGE INCLUDING PRIMARY 1 NOIR-CONT I' UTO Y AND AIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY-COVERAGE PANT SCHEDULE Name of Additional Insured Person(s)or Organization(s) (Additional_Insured)-ww Location(s)of Covered Operations; w All persons or organizations as required by a written Locations as required by a written contract or contract or agreement with the named insured. agreement with the named insured. .......... .............. A. SECTION II -WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. your acts or omissions; or 2. the acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: Additional Insured Contractual Liability "bodily injury" or "property damage" for which the additional insured(s) are obligated to pay damages by reason of the assumption of liability in a contract or agreement. Finished Operations at Work "bodily injury" or"property damage" occurring after: 1. all work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. that portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization. Negligence of Additional Insured "bodily injury" or "property damage" arising directly or indirectly out of the negligence of the additional insured(s), U156A-0313 Includes copyrighted material of ISO Properties, Inc., Page 1 of 2 with its permission. 101 GL 0009434-04 C. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance is amended and the following added: The insurance afforded by this Coverage Part for the additional insured required by a written contract or agreement with the named insured is primary insurance and we will not seek contribution from any other insurance available to that additional insured. D. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 8. Transfer Of Rights Of Recovery Against Others To Us is amended and the following added: We waive any rights of recovery we may have against any person or organization because of payments we make for injury or damage resulting from your ongoing operations or "your work" done under-a contract-with that-person-or-organization-and-included-in-the "products=completed-operations- hazard" if: a. you agreed to such waiver; b. the waiver is included as part of a written contract or lease; and c. such written contract or lease was executed prior to any loss to which this insurance applies. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. U156A-0313 Includes copyrighted material of ISO Properties, Inc., Page 2 of 2 with its permission, Mar 27 2018 02:52PM HP Fax 5594499712 page 2 4111l FARMERS Evidence of Insurance/Lienholder Interest INSURANCE Policy Number: 18300-50-40 Underwritten 8y: Mid-Century Insurance Company Policy Edition: 1st 6301 Owensmouth Ave. Effective;- 8/-17/2008-1-2-01 AM Woodland Hills, -CA91367 Expiration: Continuous until cancelled YourAgent: Nicole M Lerno Expfrotion Time: 12:01 AM 7636N Ingram Ave Ste 102 insured: Gary6ufkin Fresno,CA 93711-6200 1374 N Linden Ave (559)999-9005 Fresno,CA93728-2320 FAX.(559)921-5200 nlernoQfarmersagent.com Vehicle Information Year Make Modef VIN 2003 Isuzu Rodeo 4D 4X4 4S2DM58W234304721 Coverages Coverage Type Limit/Deductible Coverage Type limit/Deductible Bodily Injury Liability $250,000 each person Collision $1,000 Ded uctible $500,000 each accident Additional Equipment $1,000 Property Damage Liability $100,000 each accident Uninsured Motorist Property Permissive User LimitofLiability Full(See Permissive User Limit Damage With Collision Covered of Liability in your policy) Towing and Road Service Covered Medical Coverage Not Covered Other Covered Uninsured Motorist Bodily Injury $250,000 each person $500,000 each accident Comprehensive $1,000 Deductible Lienholders and Additional Interests Additional Interest Loan Number City of EI Segundo NotApplicable 350 Main St EI Sgndo,CA 90245-3813 This evidence is subject to all of the terms,conditions and:imitations set forth in the policy and endorsements attached to it.It is furnished as a matter of information only and does not change,modifyorextend the policy in anyway.Itsupersedes all previously issued certificates. farmers.com 25-9976 413 Page 1 oft Mar 27 2018 02:52PM HP Fax 5594499712 page ] Evidence of8nmurance/Lienholder Interest(continued) Loss payable provisions (Applicable only if|ienho|dmrismamnmd,and mmother Automobile loss payable endorsemem¢|sattached Wnthe pp|ioN |Lisagreed that any payment for loss*rdamage tqthe vehicle —he|ienhu|dershall:owhatever isnecessary tosecure such described i"this policy shall bemade o"the following basis: rights.Nusub,ng#innshall impair the right ufthe|ieoho|d,,to l. Atour*pU �ox�,theh/Uorncwntovimda|m option, . appear mothe pw|icymc0de,anuthe|ienxw\dershmwomthe Wereserve the fight mcancel this policy many time asprovided Declarations,orhyrepair ufthe damaged vehicle. bvisterms.|ocase nfcamceUationorlapse wewill notify the 2. Any act prneglect nfthe policyholder oraperson acting on |ionxo|uerat the address shown inthe Declarations.wewill gIve his behalf shall not void the coverage afforded mthe the|ienhq|dr,advance notice ufnot less than 10days from the |iovho|da/. effective date pfsuch cancellation m,lapse axrespects his 3. Change intitle mrownership ofthe vehicle,ore/n/ in its interest.Mailing nohcetothe loss payee issufficient*oeffe/t description shall not void coverage afforded m ��^�e||a�iun�he . Qenho|do,. ThefnUow|n0applies asrespects any|oesadjusted with the The policy does not cover conversion,embezzlement or mortgagee interest only: secre-ionufthe vehicle bythe policyholder oranyone acting in l. Any deductible applicable toComprehensive Coverage ohd| his behalf while inpossession under acontract with the not exceed$25n. |ienhn|der, Z. Any deductible applicable toCollision Coverage shall not Apayment may bemade mthe Uenholderwhich wewould not exceed$250. have been obligated mmake except 0n/thexeterms.|nsuch event,weare entidedtwall the rights o(the|ienhoWermthe extent ofsuch payment. 3/27/201 8 ____ _ --------- -- Authorized onoe farmrs.00m 25-9976 ms Page uvfz Mar 27 2018 02:52PM HP Fax 5594499712 page 4 FARMERS Personal Umbrella Declaration Page INSURANCE PolicyNumber: 60559-16-27 Premiums(item t) Effective: 1/5/2018 12:01 AM Policy Premium.... ..,... X W #242.00 Expiration: 1/5/2019 17:01 AM Named Insured(s):Gay Bufkin This is not a bill. 1374 N Linden Ave Your bill with the amount due will be mailed separately. Fresno,CA 93728-2320 e-mail garyb@psiiw.com Ad dress(es): Underwritten By. Truck Insurance Exchange 6301 Owensmouth Ave. Woodland Hills,CA 91367 Rated Exposures(item 2) Exposure Type Quantity Exposure Type Quantity Owner Occupied Residence 1 Motorized Vehicle 1 Schedule of Underlying Insurance(item 3) You havetoki us you have underlying insurance policies yr th liability limits listed below.If the underlying policies terminate or the liability limits are less than shown below,in the event of a covered losswe will only pay those damages we would have paid if the limits and policies were in place as scheduled.You must keep the coverages and limits below in effect to avoid gaps in your protection. Limit of Insurance Insurance Carrier PoiicyNumber Coverage (in thousands of dollars) Mid-Century Insurance Company 183005040 Auto Liability 250/500/100 Fire Insurance Exchange 936520422 Homeowner 300 1374 N Linden Ave,Fresno,CA Limits(item 4) Limit Limit Coverage Type (each occurrence) Coverage Type (each occurrence) General Liability $1,000,000 Uninsured/Underinsured Motorist Not Covered Retained Limit $250 Driver information Name Driver Status Gary Bufkin Covered farmers.com Policy No. 60559-16-27 Questions? (Manage your account; Call your agent Nicole Lerno Insurance Go to vmw,farrners.com tc access Agency Inc at(559)999-9005 oremail your account anytime! nlernogfa-marsagent.com 56.6118 1st Edition 4-15 11/9/20117 Page l of 2 Mar 27 2018 02:52PM HP Fax 5594499712 page 5 Declaration Page(continued) Policy and Endorsements This section lists the policy form number and any applicable endorsements that makeup your insurance contact-Any endorscmrents that you have purchased to extend coverage on your policy are also listed in the coverages section of this declarations document: 56-52803rd ed.;CA029A 1st ed.;CA103A 1st ed.;E0117 1st ed.;E0118 1st ed.;J6951A 1st ed.;25-8531 10-12 Other Information At The Attorney-In-Fact(AIF)or Management Fee(or your renewed policy will never exceed 20%of the policy's premiums and will be paid out ofthe premiums.You may wish to consider Ih:s information in deciding whether to acceptor decline this offer to renews your policy. "information on Additional Fees The"Fees'stated in the"Premium/Fees"section on the front apply on a per-policy,not an account basis.The following additional fees also apply: 1. Service Charge per installment(Inconsideration of our 2. Late Fee:$10.00(applied per account) agreement to allow you to pay in installments): 3. Returned Payment Charge:$25.00(applied per check, For Recurring Electronic Funds Transfer(EFT) and fully electronic transaction,or other remittance which is not enrolled online billing(paperless):$0.00(applied per honored byyourfinancial institution forany reason including account) but not limited to insufficient funds or a closed account) For other Recurnrg EFT plans:$2.00(applied per account) 4. Reinstatement Fee:$0.00(applied per policy) For all other payment plans:$5.00(applied per account) One or more of the fees or charges described above maybe If this account is for more than one policy,changes in these fees are deemed a part of premium under state law. not effective until the revised fee information is provided foreach policy. Coun tersignoture .. Authorized _.... ... w..... ......_...__..........� Representative farmers.com Polley No. 6D559-16.27 Questions? Manage youraccount: Call your agent Nicole Lemo Insurance Go to h%w.farmers.com to access Agency Inc at(559)990-9005 oremail youraccountany time! n I e rno@rfarmersagent.co m 56{178 1stEdidan 4-15 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: (�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. (_)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# (Yl certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not dmploy 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 th 'provisi9.1,s r A agreement-will automatically become void. Signature of Applicant , DateIJ J�— L Print Name Agreement for: 'Cary Sufkin Computer Consulting-Agr.#2999K Dated: Reviewed by: