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PROOF OF INSURANCE (2018 - 2018) CLOSED Commercial General Liability Coverage Part Declarations Policy No: BDG-3008422-04 Effective Date:12117/201712:01 A.M.STANDARD TIME AT YOUR MAILING ADDRESS NAMED INSURED:Steven A.Tillmann DBA:Tillmann Forensic Investigations LLC LIMITS OF INSURANCE General Aggregate Limit. $2,000,000 Products-completed Operations Aggregate Limit Subject to General Aggregate Personal and Advertising Injury Limit $1,000,000 Each Occurrence Limit $1,000,000 Damage to Premises Rented to You Limit $100,000 Any One Premise Medical Expense Limit $5,000 Any One Person DESCRIPTION OF BUSINESS Form of Business: ® Individual ❑ Partnership ❑ Joint venture ❑Trust ❑ Limited Liability Corporation ❑ Organization,including a corporation(but not including a partnership,joint venture,trust,or limited liability company) Location(s)(including Zip Code)of All Premises You Own, Rent or Occupy 840 S.Cavados Ave,Covina,CA 91723 CLASSIFICATION AND PREMIUM Rate Advance Premium Classification Code No. Premium Basis* Pr/CO All Other Pr/CO All Other Refer to DECBGLS (07-05) *See backside of DECBGL for definitions Total Additional Insured Premium:$0.00 Total Advance Premium:$500.00 FORMS AND ENDORSEMENTS (other than applicable Forms and Endorsements shown elsewhere in this policy) Forms and endorsements applying to this Coverage Part and made a part of this policy at time of issue: Refer to Endorsement E849. THESE DECLARATIONS AND THE COMMON POLICY DECLARATIONS,IF APPLICABLE,TOGETHER WITH THE COMMON POLICY CONDITIONS,COVERAGE FORM(S)AND FORMS AND ENDORSEMENTS,IF ANY,ISSUED TO FORM A PART THEREOF,COMPLETE THE ABOVE NUMBERED POLICY Includes copyrighted material of Insurance Services Office,Inc.,with its permission Copyright,Insurance Services Office,Inc,1985 DECBGL(07-05) When,used as a premium base; 3. The value of special rewards for Individual Invention or discovery; "Area' ranniurn basis symbol a)means: 4. Dismissal or severance parilnenis except fm fi = kinin worked Of Rffld Vacation; The total?number of square feel of floor space at the insured premises,computed as 5. The payroll of clerical office employees. Clerical office employees are those follows: employees who work in an area which is physically separate b walls,floors,or 1. For entire buMin s, by multiplying the loduct of the horizontal dimensions of Nions from all oflier work areas of the insured anT whose YL ties are strictly Ole oulside of I�e outer building wall's by Ille number of floors, including li"Illited to keeping the insured's books or records or conducling correspondence, besernents,but do not use the area of Ithe foMwinig indudirliq any other enriployces engaged in clerical'work in The same area; a Courts and mezzanine types of floor opprii I figs 6• The payroll of satesaren, collectors or messengers who work principally away b. Portions of basements or floors where 50%or rnore of the area is used for frorn the Insured"s premises, shop at storage for building maintenance,dwelliIno by bdIdirg maintenance Salesmen,collectors or messengers are those employees engaged principally in employees,heating units,power plants or ak-con itroning equipment any such duties away from therernises of the employer; 2 For Wants, determine the area they occupy in fine same manner as for lhe Excepliory This term does no ropily to any empi ee whose duties include the entire buildings doIiviiry of an merchan6se handed,treated or soll , 3. The rates apply per 11,000 square feet of area The payroll Wdrivers,and their helpers if their principal duties are to work on or "Total Cost" preiiiiunil)asrssymbol c)mear)s, in connection with auilorn:obilei. The total cos� of all work lot or sublet in, oonnec6on with each specific project 8. The payroll of aircraft pilots or co-fi4ots,it their principal duties are to work off or Irriciuding: in connection with aircraft in either capacity. I 'Tire cosi of all labor, malefials rand equiipment furnished,used or d0vered for 9. The payrollf of dfalsinen,if Ihelr duties are limited to office work only,and who use iin the execution of tire work, however,do not Include the cost of finishedare engaged sitictly as draftsman in such a manner 1hat they are not exposed to equipnivill installed but riot finisher,!!by the subcontractor If the subcon0aclor the opera Ive hazards,of the biusiness, does no other work an or in connection with such equipment;and and rates a1rply per$1,0100 of Payroll, 2 All fees,bonuses urr commissions made,paid or due. Overtime 3 The rates apply per$1,000 of total cost 1 Definition "Admissions'"(piremium basis symbol in)means Overtime means those hours worked for which there is an increase in the rate of The total number of persons,other than emtoyees or,the narled insured,admitted to pay: the event insured or to events conducted on the premises whelher oil paid a. For work In any day or in any week in excess of the number of hours admissions,tickets,com timentary tickets or passes, normally worked,or The rates apply per 1,008 adriftsions. b. For hours worked in excess of 8 hours in any day or 40 hours in any week; *Payroll'(ptemium basessyriiibol p)means or 1 Commissions: c For vvW on Satutdn Sundays of holidays. 2. Bonuses; In the carr �wage agreements.overtime means only those hours 3 Extra pay for overlirne work,In accordance with the manuals in use by us: worked In Xc6s of the number specified III such agreement. 4 Pay for holidays,vocations or periods of sickness,: 2, Exclusion Of Overfifne Paynoill 5, Payment by an employer of arnounts otherwise required by law to,beaid'by The extra pay for Overtime shall be excluded from the payroll on which premium elliplu fies to,slah Alory insio ance of perision plans,such as the FederarSociall is computed as indicated in(1)or(2),provided the insured's books anrecords Securilly Act, are inaintained to show Overtime pay separately by employee and in summary 6than time walked,such as piecework, by classification a. If the records show separately Ihe extra pay earned for overtime,the entire 7 wer tools used Ig hand provided by extra pay shall be excluded empfoyeos and used in their work yr ons to the insurert;, b If the records show the total pay earned for ovellime(regular pay 1plus 8 provided for an emiployee based on, Overtime pay in one combined wiriount 1/3 of this ictal pay shat be exduded. I double time is paid for overtime slid!the total pay for such 9 nl or house,received by employees overtime is recorded!separalely, Yi of the total pay for double lime shall be as par!of their pay„ o the extent shown on he Insured's records; excluded, 10. Tlnc vague of inerts received by ernpfoyeea as,past of thin pay to the extent Exclusion of overlinle pay does not apply to payroll assigned to the shown in the insured's records "Stevedoring"classifications '11. The vaikie of store certificates, merchandise,credits or any other substitute for 'Gross Sates"('premium basis symbol s)means: money recetiver9'byy armhployees as part of ir1. The gross amount char ed by the named insured,concessionaires of the named 12, an5aXeir helpers,whether air riot the insurbd or by others Ira(ing Under the insured's name for: operators arca de5igraafed or I!Ncerhsed to operate automobiles. If the operators aAM goods or products,sold or distributed; insuredand fNheur heB,pems are providett to lire along with equipment hired under b Operations performed during lhe policy period; known,contract and their actural paaynofl is mol use 1r3 of the total amount paid al Rentals:and out by the insured fore dire tiro of the a ril. Does and fees 13corporation andindividuat Insureds arld co. 2 riclusions partners For true puarposes of pa,yaoNJ' minalion,nianaers of fim0ed iabi ity The following items shall riot be deducted from the gross sales: conhparhpes shelf the considered exe,cutuve officers and firlercgers of hirnited�iabli�ity (a Forei ri exchange discotii CoMparlies a be considered,co-pariners, b Freit allowance to cuslomers; The executive officers of a,corporation are those persons holding ashy of file c Totalsales of consigned goods and warehouse receipts; officer positions created by the named insured's charter,constitution of bylaws d Trade or cash discounts; of any other similar governing document e Bad debts,and Ithe payrWll of all executive officers of a corporation and Individual insureds of 0 Repossession of items sold on installments(amount actually collected). co-partiesi engaged principally In dii operations or as satespeiisons, and 1 xduslon officers and copartners who,are Inactive for file entire poticy period, shall be The following items shall be deducted'fromrosssales: (a) Sales&excise taxes which,are collected and submitted to a governmental payroll amounts may be reduced by 2 division; paeroarht for each full capend'aa'week In ss of IwOve during which the risk (b) Credits for repossessed merchandise and products returned. Allowances glerforms no operations to;damaged and spoiled,goods. 14 he,named Insured by a latior teasing ice charges for items sold on installments; firm, Preminuam an such pa roll shall be III $ ised off the dassificalloris and rates �F�,r% charges on !sales if freight is charged as a separate item on whrcfn would(have applied i�1he leased aes 0"" e; kers bad been the direct ernMo " ",Oc of the rnarrhed'insured 1f payroll is ble,use 100%of the total cost al�the (e) Ro ally fricarne from patent rights or copyrights which are not product sales; contract leased workers, The prernium shall arii be charged on that amount as pat ti (0 Rental receipts from products liability coverage only. If inves gation of a specific employee leasing con!lrad discloses that a definite The rates apply per$jT000 of gross sales arnourd of the contract price represents payrop,such arnount shall be considered 'Units'(prennuriff basis symbol u)means: for prorriJurn computation purposes. A slip le room or group or rooms intended! occupancyforoccupancy as separate living quarters 15. �,:,,olp aid to employment agencies for temporary personnel provided' to Ole ainily b�a group of unrelated persons living logether, or by a person living insured alone, The rates Tipty per each unit Payroll does riot include: 'Each'�premiu asis Smbol't)Means 1. Tips and other gtatuities received by employees, Each unit exposure as doFined in the classification footnotes 2. Payments by an employer to group insurance or group pension plans for employees In accordance with the manuals in use by us; Commercial General Liability Coverage Part Declarations Policy No: BDG-3008422-04 Effective Date:12/17/201712:01 A.M.STANDARD TIME AT YOUR MAILING ADDRESS NAMED INSURED:Steven A.Tillmann DBA:Tillmann Forensic Investigations LLC CLASSIFICATION AND PREMIUM Rate Advance Premium Classification Code No. Premium Basis* Pr/CO All Other Pr/CO All Other Detective or Investigative Agencies- 91636-1 p 17,500 INCL 16.640 INCL $500.00MP private CG2010 Additional Insured-Owners,Lessees Or Contractors-Scheduled Person Or Organization- Limit INCL (Fully Earned) CG2010 Additional Insured-Owners,Lessees Or Contractors-Scheduled Person Or Organization- Limit INCL (Fully Earned) CG2010 Additional Insured-Owners,Lessees Or Contractors-Scheduled Person Or Organization- Limit INCL (Fully Earned) CG2010 Additional Insured-Owners,Lessees Or Contractors-Scheduled Person Or Organization- Limit INCL (Fully Earned) CG2010 Additional Insured-Owners, Lessees Or Contractors-Scheduled Person Or Organization- Limit INCL (Fully Earned) *See backside of.. DECBGL for definitions !! Total Additional Insured Premium:$0.00 Total Advance Premium:$500.00 DECBGLS(07-05) POLICY NUMBER: BDG-3008422-04 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON O ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE W Name Of Additional Insured Person(s) Location(s) Of Covered Operations Or Organization(s) City of EI Segundo, Various Locations 348 Main street, EI Segundo, CA 90245 Information required to complete this Schedule, if not shown above,will be shown in the Declarations A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage or personal and advertising injury" "property damage"occurring after: caused, in whole or in part, by: 1. All work, including materials, parts or 1. Your acts or omissions; or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work" out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of the same project. required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 C. With respect to the insurance afforded to these 2. Available under the applicable Limits of additional insureds, the following is added to Insurance shown in the Declarations; Section III—Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the most we applicable Limits of Insurance shown in the will pay on behalf of the additional insured is the Declarations. amount of insurance: 1. Required by the contract or agreement; or CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 2 of 2 PCA State Farm® Statf"Iftyri Providing Insurance and Financial Services M 900 Old River Road Bakersfield,CA 93311 Attached as requested are your replacement insurance identification cards. If the attached cards are not accepted by a law enforcement agency or your Department of Motor Vehicle office, please contact your agentto receive additional assistance. Thank you for choosing State Farm for your insurance needs, IMPORTANT- IDENTIFICATION CARDS STATE FARM f'f Sfl�f �bi „ CALIFORNIA THIS CARD MUST BE KEPT IN THE INSURED MOTOR INSURANCE CARD VEHICLE FOR PRODUCTION UPON DEMAND, State Farrn Mutual Automobile Insurance Company � IF YOU HAVE AN ACCIDENT-NOTIFY THE POLICEE IMMEDIATELY ^M� MMMMMMMMMM ����� 900 Old River Road Bakersfield,CA 93311 1 Get names,addrea sas,and phone numbers of persons involved and witnesses. INSURED TILLMANN,STEVE& MUTL Also V0 driver License numbers of persons involved and license plate VOL numbei0oates of vehicles. 2 Don't admit fault or discuss the accident with anyone but State Farm or police 3,Promptly notify your agent,log on to statefarm com®,or visit State Farm Pocket Agent*to file a claim. For Emergency Road Service call 1-877-627-5757 POLICYNUMBER EFFECTIVE EXAMINE POLICY EXCLUSIONS CAREFULLY.THIS FORM DOES NOT YR 2017 MAKE FORD MAR 29 2018 TO SEP 29 2018 CONSTITUTE ANY PART OF YOUR INSURANCE POLICY. MODEL F150 VIN 1 How to identify your coverage,See policy for full name and definition AGENT MEREDITH THOMPSON 1317-AED PHONE (6' NAIC 25178 A Liability H Emergency Road Service U Uninsured Motor Vehicle COVERAGE PR VIDEO BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS C Medical Payments L Physical Damage U1 Uninsured Motor Vehicle PD PRESCRIBED BY LAW. D Comprehensive R1 Car Rental and Travel Expenses Z Loss of Earnings COVERAGES A C D1000 G1000 H U U1 G Collision S Death,Dismemberment and "�.. ...................................� .........................rrrr...w. Loss of Sigh KEEP A CARD IN YOUR CAR. THIS CARD IS INVALID IF THE POLICY FOR WHICH IT WAS ISSUED LAPSES OR IS TERMINATED. KEEP YOUR CURRENT CARD UNTIL THE EFFECTIVE DATE OF THIS CARD. ONE COPY OF THIS FORM SHOULD BE CARRIED IN THE VEHICLE AT ALL TIMES.THE FORM MAY BE NEEDED AS EVIDENCE OF INSURANCE IN COURT. SUBMIT ONE CARD,OR A PHOTOCOPY OF A CARD,WITH YOUR VEHICLE REGISTRATION RENEWAL A toll free number is available for Emergency Road Service and is located on your insurance card. — IMPORTANT- IDENTIFICATION CARDS STATE FARM S ` tefivni CALIFORNIA THIS THIS CARD MUST BE KEPT IN THE INSURED MOTOR . ,„ (. VEHICLE FOR PRODUCTION UPON DEMAND, INSURANCE CARD �",; � ,, StateMFarm Mutual Automobile InsuranceCompany ...IF YOU HAVE ,900 EANAC NOTIFY ser POLICE sPseOldRiver Road 9311 1Getna ndphonenmpf involved and Mri INSURED �NN,STEVE&RITMUTL Also einvolved VOL numbers/stotes 2,Dont admit fault or discuss the accident with anyone but State Farm or police. 3.Promptly notify your agent,log on to statefarm.com®,or visit State Farm Pocket Agent®to file a claim. For Emergency Road Service call 1-877-627-5757 POLICYNUMBER EFFECTIVE EXAMINE POLICY EXCLUSIONS CAREFULLY-THIS FORM DOES NOT YR 2017 MAKE FORD MAR 29 2018 TO SEP 29 2018 CONS77TUTE ANY PART OF YOUR INSURANCE POLICY. MODEL F150 VIN 1 How to identify your coverage See policy for full name and definition AGENT MEREDITH THOMPSON 1317-AED PHONE ( NAIC 25178 A Liability H Emergency Road Service U Uninsured Motor Vehicle COVERAG 'Pfd V1DFD BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS C Medical Payments L Physical Damage U1 Uninsured Motor Vehicle PD PRESCRIBED BY LAW. D Comprehensive R1 Car Rental and Travel Expenses Z Loss of Earnings COVERAGES A C D1000 G1DD0 H U U1 G Collision S Death,Dismemberment and oss^f 5!SL.M....,..,..,........................................... .....................................................................ww.....,............. .......r.,.r KEEP A CARD IN YOUR CAR. THIS CARD IS INVALID IF THE POLICY FOR WHICH IT WAS ISSUED LAPSES OR IS TERMINATED. KEEP YOUR CURRENT CARD UNTIL THE EFFECTIVE DATE OF THIS CARD. ONE COPY OF THIS FORM SHOULD BE CARRIED IN THE VEHICLE AT ALL TIMES.THE FORM MAY BE NEEDED AS EVIDENCE OF INSURANCE IN COURT. SUBMIT ONE CARD,OR A PHOTOCOPY OF A CARD,WITH YOUR VEHICLE REGISTRATION RENEWAL. 143295 2 (oleccalc) 10-20-2014 A toll free number is available for Emergency Road Service and is located on your insurance card. FEB 21 2018 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 re:Carrier _... Policy Number Expiration Date Name of Agent _ .._...._............. Phone# _ (�>Q I certify that, in the perform ince 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 worker;' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediycomply wlhhs or _e a.9reemenmm#willautomatically become void. Signature of App . . D ate ....�,� ( .'...�_. ... Agreement for � ' . �, �, ry )6 G �r Dated; Reviewed by m ...__ ._........ ..............m ....'�. 1