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PROOF OF INSURANCE (2018 - 2019) CLOSED C" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 4/27/2018 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 this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER Sparrow General Insurance Agency prAMr: Y senia Castro 310-379-0605 . ...............3.....7..,9-,0,63,12629 Manhattan Ave.#281 I4X.NoF.Id: 310 Hermosa Beach CA 90254 DIss: yesenia@sparrowgeneral.com INSURERIS)AFFORDING COVERAGE NAIC# Phone: 310-379-0605 Fax: 310-379-0631 -- Nautilus Insurance INSURERA:NaU nc Company INSURED Russell Neese INSURER B: ....... ........ DBA Great American Cleaning Systems INSURERC: 740 Maryland St. INSURER D: INSURERS: EI Segundo CA 90245 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. INS TYPE OF INSURANCE ADDL SUBR POLICYe0F Pbutl y'EXP LIMITS LTR iNSD MIVD POLICYNUMBER (MMIDD/YYYYI IMMIDDIY'YY'Y9 X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 - -- X OCCUR -1YAMAGI' �Id�r�'rt J ., --------- CLAIMS-MADE PREP,_.` V•_+s_a>e:currenu;e $ 100,000 A MED EXP(Any one person) $ 5,000 Y N N902055 04/30/2018 04/30/2019 PERSONAL&ADV INJURY $ 1,000,000 X GENLAGGREGATEjAPPLIES PER: UCG $ 2,000,000 PRO- ECT OC PRODTSCOMP COMP/OP $ INCLUDED OTHER ,,$,,,,,,,,,,,,, AUTOMOBILE LIABILITY COM'SMNE70SiNGV,FLIMIT $ (Ea acoda nt) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PI^tOFTy DAMAGE _ AUTOS ONLY AUTOS ONLY (Par art:�:IdenC)i $ UMBRELLA LIAB OCCUR EACH CE .... .... ... EXCESS LIAB .... ........ CLAIMS-MADE AGGREGATE„ .... .....$ DED .... .... ....... RETENTION$ $ WORKERS 1. I COMPENSATIONPER............._STAT,UT.1,-................,OTH ................................ AND EMPLOYERS'LIABILITY Y/N 1. ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E .L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of EI Segundo, Its Officials and Employees are named as additional insured with respects to their interest in the operations of the named insured. *10 Day Notice of Cancellation Due for Non-Payment of Premium. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Citof EI Se undo, Its Officials, and THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN y g ACCORDANCE WITH THE POLICY PROVISIONS. Employees 350 Main Street AUTHORIZED REPRESENTATIVE EI Segundo, CA 90245 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: NN902055 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED - PRIMARY AND NONCONTRIBUTORY This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person(s)or Organization(s): CITY OF EL SEGUNDO, ITS OFFICIALS, AND EMPLOYEES 350 MAIN STREET EL SEGUNDO, CA 90245 Location(s)of Covered Operations: 740 MARYLAND STREET EL SEGUNDO CA 90245 — Description of Work Performed forthe Additional Insured; PRESSURE WASHER 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 of this endorsement, but 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, as described in the Schedule of this endorsement, for the additional insured at the location(s) shown in the Schedule of this endorsement, but only for "occurrences" or coverages not otherwise excluded in the Coverage Part to which this endorsement applies. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is 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. B. With respect to the insurance afforded to the additional insured,the following additional exclusions apply: This insurance does not apply to: 1. 'Bodily injury", "property damage", "personal and advertising injury"or medical payments arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. The preparing, approving, or failure to prepare or approve, maps, shop drawings, opinions, reports, surveys,field orders, change orders or drawings and specifications; or L803(01/17) Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 1 of 2 b. Supervisory, inspection,architectural, or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring,employment,training or monitoring of others by that insured, if the"occurrence"which caused the"bodily injury"or"property damage", or the offense which caused the"personal and advertising injury", involved the rendering of or the failure to render any professional architectural,engineering or surveying services. 2. 'Bodily injury"or"property damage"occurring after: a. 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 at the location of the covered operations has been completed; or b. 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 other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. With respect to the insurance afforded to the additional insured, the following is added to Section III -Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement,the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. D. The following is added to 4.a. of Other Insurance of Section IV-Commercial General Liability Conditions: If required in a written contract,the Coverage Part to which this endorsement applies is primary and noncontributory in the event of an"occurrence"caused, in whole or in part, by your acts or omissions, or the acts or omissions of those acting on your behalf that occurs while performing ongoing operations for the additional insured at the location(s)designated in the Schedule of this endorsement. All other terms and conditions remain unchanged, L803(01/17) Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 2 of 2 R VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE I�11�o B D" 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. This form Is used to report coverages provided to a single specific vehicle or equipment.Do not use this form to report liability coverage provided to multiple vehicles under a single policy.Use ACORD 25 for that purpose. PRODUCER C TACT Carol R Cl" $tateArM Michael Karas Jr xtd; 31'0 376.194'0' IFAX 310 376-0354 m `.� �. ,,__. 2401 Pacific Coast Highway Suite 201A-IY: acarol.clarlt.itloskatefarrm"tXDm1 Hermosa Beach,CA 90254 DER INSURERIS)AFFORDING COVERAGE MAIC# INSURED6'U ERA; State Farm Mutual Automobile Insurance Company' 25178 Neese,Russell USURER B 740 Maryland Street INsuAEq c: — El Segundo,CA 90245-3117 INSURER D V INSURER E DESCRIPTION OF VEHICLE OR EQUIPMENT YEAR MAKE I MANUFACTURER MODELVEHICLE IDENTIFICATION NUMBER 2001 1 Ford � F150 PicltUpBODY TYPE 1FTRX17L21NA29707 DESCRIPTION SER1A4 NUMBER COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICY(IES)OF INSURANCE LISTED BELOW HA IHAVE LEEN ISSUED TO TIME INSURED NAMELY ABOVE FOR THE OL -,Y PERIOD(S)INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENTWITH RESPECT TO 'IIWHICH"I'HIS CERTIFICATE MAY HE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLIC'Y(tES)DE'SC'RIBED HEREIN ISIARE SUBJECT TO ALL THE TERMS,EXCLUSION$AND CONDITIONS OF SUCH POLICY(IES). *NSR ADot POLICY EFFECTIVE POLICY EXPIRATION LTR MAD TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDNYYY) DATE(WAMONYYY) LIMITS }(�VEHICLE LIARI.ITY COMBINED SINGLE LIMIT $ BODILY INJURY(Per PC-on) S 1,000,000 A 04/13/2018 1011312018 BODILY INJURY(Per acdderd) S 1,000,000 '! PROPERTY DAMAGE S 1,000,000 � GENERALLIABILITY EACH OCCURENCE S OCCURRENCE t GENERAL AGGREGATE $ CLAIMS MADE ,$ 1MSR LOSS POLICY EFFECTIVE POLICY EXPIRATION ! LTR 0AYEt TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDIYYYY) DATE(MMODNYYY)1 LIMITS I DEDUCTIBLE A R VEH COLLISION Loss 04/13/2018 10113/2016 0 ACV ❑AGREED AMT s LIMP ❑ ❑STATED AMT $500.00 A VEH COMP L—V VEH OTC 0411312016 10!1312018 [K]ACV [:]AGREED AMT $ LIMIT _-.. � Q ❑STATED AMT i 5QQ,QQ DEO PROPERTY ❑ACV ❑AGREED AMT LIMIT BASIC R BROAD ❑RC [3 ST, AMT # DED SPECIAL Cl S DED ®L REMARKS(INCLUDING SPECIAL CONDmONS I OTHER COVERAGES)(Attach ACORD 101,Addllonal Ramarhs Schadulo,K more space N required) ADDITIONAL INTEREST CANCELLATION Select one of the following: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED The additional interest described below has been added to the polcyges)neted herein by policy number(s). BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE A zuest hos bean oub0tiod to add the additional interest described below to the pd'wy(iee) DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. X I1sia�1 berg 'icy'.rdadna'bnrl(x), II p - VEHICLE I EQUIPMENT INTEREST: M V LEASED FINANCED W DESCRIPTION OF THE ADDITIONAL INTEREST NAME AND ADDRESS OF ADDITIONAL INTEREST IAWMI:WL INSUREDH LOSS PAYEE City Of El Segundo LENDER'S LOSS PAYEE �` 350 Main Street LOAN 1 L E NUMBER EI Segundo,CA 90245 AUTH VED W.P , NT I � 01997-2010 ACORD CORPORATION.All rights reserved. J ACORD 23(2010105) The ACORD name and logo are registered marks of ACORD P 1004361 142987.2 01-28-2013 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 J with the City of EI Segundo. II Policy No. (_)I have and will maintain workers'compensation insurance as required by Labor Code§3700 forthe 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# _— (V ) 1 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 bjec:t to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with thos pr+ inion or thea r4ment will automatically become void.Date C` Signature of Applicant �" J ' � / ��� LIM Agreement for: Dated: Reviewed by: _. ....." ... w*........ .W_. 1