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PROOF OF INSURANCE (2019 - 2019) CLOSED
ACC)RE), CERTIFICATE OF LIABILITY INSURANCE p DATE(MMIDD/YYYY) " I.. 0611111 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 a 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). PRODUCER a:ONt AC l' PHONE PdAOwVls', COMPLETE EQUITY MARKETS INC (A/CC.No,Ext): (847)541-09_0.0 FAX E-MAIL (AIC, Nall__(847)541-0444 1190 Flex Court ADDRESS: Lake Zurich, IL 60047 INSURERISIAFFORDING COVERAGE NAIC4 INSURER A: Underwriters at Lloyd's, London I INSURED MAK Fire Protection Engineering INSURER BINSURERC: I & Consultinq, Inc. NSURERD: 12130 Rahn Avenue INSURER E: Cr5N1O'da Fllll'is, Cly 91344 1NSURIRI:. 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. t SRI Y P E OF INSURANCE LIOY Nt9 fV%e E'ft PhtlMR N=frF POLICY PX ITS Otb" ADUL SUMR iCLWY . :CLT. ......... NN"�fa'N �n;,'b, ._.. t'VIdY"k",h","df,..ir"?1eNdCad)YYYY..I..., LIMITS $ r'hu 1�6 a�AA'1'a, X COMMERCIAL GENET XAL LIABILITY OCCUR ..... tyY f 1f tl11 tN ff IIP YwY�,Ii�l,tiwrrx, s.( $ 50,004N 2,000,000 AIMS MADE i'I'� y�yry/{ EX-16J'��^rye a�n!�l,�o;r��ll!d'11 $ 5,00;0 A 1700919 03/16118 03116/19 0;.otl"¢,rNAL 4^',La4'Nrl,ucars^,' $ 2,000,.000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,9400 li POLICY JECOT i. -OC PRODUCTS-COMP/OP AGG $ 2.000,000 OTHER: AUTOMOBILEOWNED ED AUTO BODILY SCHEDULED ...................... COMBINED (Per fLpetll rson>..........$ ,mm., ...,.. AUTOS ONLv AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY j AUTOS ONLY � Per accident UMBRELLA ......... OCCUR ...................... � EACH OCCURRENCE.....,.,.,. .......-........._., e1 NCE LA LIAB I ............................_�.. EXCESS LIAB .ti IL';' I'NY,!Lal4 AGGREGATE 0 CI 4L 'r l'd'I M1'bl 5 WOR EMPLD.COMPENSATION... ,,. ...... Y,N........ w, .......... .,,,,.........�._. ... �, ` ...,,... ___' ,ANia- YERS'LIABILITY r ANY PROPRIETORIPARTNERlEXECUTIVE E.L EACH ACCIDENT $ O`-FICERIA'EMBER EXCLUDED? ,NIA Mandato in NH)i EL DISEASE-EA EMPLOYEE £ IY ya^'�, describe under - — - - 1.'u.d;l RA"1:f, N s J 'it r H~ I l;r! below E L,DISEASE-POLICY LIMIT ,..,......, .�,..m.�.... _m........ ...._. ......... ,,,, .„,,..,.....,, A Professional Liability 94597 06/01118 1 06/01119 Each Claim $1,000,000 Aggregate 1,000,000 ..DESCRIPTI.O.N.. ...............................................(.- -- - Y P OF OPERATIONS I LOCATIONS I VEHICLES ACORD 101,Additional Remarks Schedule,may be attached if more ace is required) Please see pages 2, 3 and 4 for additional information. ............... . .._.............w _wwww. CERTIFICATEHOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of EI Sequndo, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN its officers,officials,employees,agents and volunteers ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Carol Lvnn Anderson . _....._............._.... -...�...........�................................. AUTHORIZED REPRESENTATIVE I _..w.�....... 314 Main Street �. EI Sequndo, CA 90245. _._w..........w.. _............................................�............. ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AMENDATORY ENDORSEMENT NO.:1700919 ADDITIONAL PREMIUM: $50.00 INSURED:MAK FIRE PROTECTION ENGINEERING& CONSULTING, INC. Purchasing Group Tax for CA @ 3% $1.50 EFFECTIVE: May 15, 2018 to March 16, 2019 TOTAL: $51.50 Ali TI NAL 1Na'QR-., 'D (Primary) It is hereby agreed and unders'tw)d that the person(s) or entity(ies) listed below Ware included as Additional Insaurod(s) under the lx.alicy a°:,aurn'ber referenced above, but only with respect to claians or damages arising solely out of actions of the Named Insured: City of El Segundo, its officers, officials, employees, agents and volunteers 314 Main Street E1 Segundo CA 90245 The coverage provided hereunder to the above-named Additional Insured shall be primary and non-contributory to any insurance or self-insurance maintained by the Additional Insured. All other terms, conditions, limits and exclusions remain unchanged. Attached to and forming part of Certificate No.: NI 9023 Dated: June 8, 2018 Underwriters at Lloyd's,London LII 442-3(04/12) AUTHORIZATION NO.: (UMR) B0429BA1801027 Coraaplete Equity Markets,, 'Inc.... dba Complete t'-,quity M5vktu Insurance Agency,Inc. E199-104a :AM.OrA,tor) By 7--PX6�*' Lawrence T.P. Molloy Endorsement #34 AMENDATORY ENDORSEMENT NO.: 94453 ADDITIONAL PREMIUM: $100.00 ASSURED: MAK FIRE PROTECTION ENGINEERING& Purchasing Group Tax for CA @ 3% $3.00 CONSULTING, INC. EFFECTIVE: May 15, 2018 to June 1, 2018 TOTAL: $103.00 EXTENSION OF COVERAGE VICARIOUS LIABILITY It is hereby agreed acrid understood that Underwriters will pay Dainagusaod, Claims Exjxnises ori behalf of' the untity/entities listed below for its/their vicarioas or pited liability whichariws frorn Clainis catised by the mghgent orrors or omissions of the Narned A%skjreds identified in the Declaratiom iri the jxrfonriaxice of their Professional Services for the below idetitified Additional Assureds: The City of El Segundo, its officers, officials, employees, agents and volunteers It is further understood and agreed that such coverage stated above shall apply only to the listed entity/entities arid its/their employees. This extomion of'coverage does not increase the Limits of Insurance nor amend aiq other provision in the Certificate which shall remain the same. All other terms,conditions, limits and exclusions remain unchanged. Attached to and forming part of Certificate No.: CEM 58-17 Dated: June 11, 2018 UNDERWRITERS AT LLOYD'S, LONDON LII 197-1 (08/15) Coniplete r.'xitity Markets, hic. (UMR) B0429BA1701026 d,,Cumplete ujuiiy Markets Insurance AgpicY,h I(CASL#OD44077 Lib-502 k—/— TP By Lawrence T.P. Molloy Endorsement #13 AMENDATORY ENDORSEMENT NO.:1700919 INSURED:MAK FIRE PROTECTION ENGINEERING&CONSULTING, ADDITIONAL PREMIUM: Included INC. RETURN PREMIUM: N/A EFFECTIVE: May 15, 2018 to March 16, 2019 YNOT -'-C' N ENWRSEMENT In consideration of' the additional prenmil-fl, paid as shown above, it is hereby miderstood and agreed thtit Under niters shall provide a 30-day written notice of' cancellation regarding this policy of' insurance to: Ms. Carol Lynn Anderson City of El Seprido 314 Main Street El Segundo CA 90245 All other terms, conditions, limits and exclusions remain unchanged. Attached to and forinitig part of Underwriters at Lloyd's, London Cover Note/C'erfificate/Policy No.: NI 9023 COMPLETE EQUITY MARKETS, INC. Dated: June 8,2018 dba Car Aete Liquft�r Ktrkot,.1nzm%iiw Agancy,4%, AUTHORIZATION NO.: (UMR)B0429BA1801027 11&,A`W,#01'r 4077) 7p IV46y By , AIF 2391 J (06/99) E199P*104b Lawrence T.P. Molloy Endorsement #35 2 Certificate of Insurance MAK FIRE PROTECTION ENGINEERING & CONSULTING, INC. Policy Number: 1700919 /94597 Cil £ ss�sclo 11,S ofYis-w^ Wlrcialw to avc,iits and ��obljbteers is an addict f)TcAI insXisvd but only per the y � employees, lil.oarana of the enenrtc:d for vssrc1 res cra°t'ivc. policy and subject d.t;s all grc°alas y terms, i°�°rx`�altlia.rpn�, a°xc„]rrsp<apa� ;snarl +.asusla"a�'��;+�°s'o,�saA�. ***Primary/Non-Contributory and a 30 Day Notice of Cancellation only applies to the General Liability Policy. SURPLUS LINES NOTICE TO POLICYHOLDER- PLEASE SEE ATTACHED Y Lawrence T.P. Molloy bindegrw`z 6 NOTICE: 1. THE INSURANCE POLICY THAT YOU HAVE PURCHASED IS BEING ISSUED BY AN INSURER THAT IS NOT LICENSED BY THE STATE OF CALIFORNIA. THESE COMPANIES ARE CALLED "NONADMITTED" OR "SURPLUS LINE" INSURERS. 2. THE INSURER IS NOT SUBJECT TO THE FINANCIAL SOLVENCY REGULATION AND ENFORCEMENT THAT APPLY TO CALIFORNIA LICENSED INSURERS. 3. THE INSURER DOES NOT PARTICIPATE IN ANY OF THE INSURANCE GUARANTEE FUNDS CREATED BY CALIFORNIA LAW. THEREFORE, THESE FUNDS WILL NOT PAY YOUR CLAIMS OR PROTECT YOUR ASSETS IF THE INSURER BECOMES INSOLVENT AND IS UNABLE TO MAKE PAYMENTS AS PROMISED. 4. THE INSURER SHOULD BE LICENSED EITHER AS A FOREIGN INSURER IN ANOTHER STATE IN THE UNITED STATES OR AS A NON-UNITED STATES (ALIEN) INSURER. YOU SHOULD ASK QUESTIONS OF YOUR INSURANCE AGENT, BROKER, OR "SURPLUS LINE" BROKER OR CONTACT THE CALIFORNIA DEPARTMENT OF INSURANCE AT THE FOLLOWING TOLL-FREE TELEPHONE NUMBER: 1-800-927-4357 OR INTERNET WEB SITE WWW.INSURANCE.CA.GOV. ASK WHETHER OR NOT THE INSURER IS LICENSED AS A FOREIGN OR NON-UNITED STATES (ALIEN) INSURER AND FOR ADDITIONAL INFORMATION ABOUT THE INSURER. YOU MAY ALSO CONTACT THE NAIC'S INTERNET WEB SITE AT WWW.NAIC.ORG. 5. FOREIGN INSURERS SHOULD BE LICENSED BY A STATE IN THE UNITED STATES AND YOU MAY CONTACT THAT STATE'S DEPARTMENT OF INSURANCE TO OBTAIN MORE INFORMATION ABOUT THAT INSURER. 6. FOR NON-UNITED STATES (ALIEN) INSURERS, THE INSURER SHOULD BE LICENSED BY A COUNTRY OUTSIDE OF THE UNITED STATES AND SHOULD BE ON THE NAIC'S INTERNATIONAL INSURERS DEPARTMENT (IID) LISTING OF APPROVED NONADMITTED NON-UNITED STATES INSURERS. ASK YOUR AGENT, BROKER OR "SURPLUS LINE" BROKER TO OBTAIN MORE INFORMATION ABOUT THAT INSURER. 7. CALIFORNIA MAINTAINS A LIST OF APPROVED SURPLUS LINE INSURERS. ASK YOUR AGENT OR BROKER IF THE INSURER IS ON THAT LIST, OR VIEW THAT LIST AT THE INTERNET WEB SITE OF THE CALIFORNIA DEPARTMENT OF INSURANCE: WWW.INSURANCE.CA.GOV. 8. IF YOU, AS THE APPLICANT, REQUIRED THAT THE INSURANCE POLICY YOU HAVE PURCHASED BE BOUND IMMEDIATELY, EITHER BECAUSE EXISTING COVERAGE WAS GOING TO LAPSE WITHIN TWO BUSINESS DAYS OR BECAUSE YOU WERE REQUIRED TO HAVE COVERAGE WITHIN TWO BUSINESS DAYS, AND YOU DID NOT RECEIVE THIS DISCLOSURE FORM AND A REQUEST FOR YOUR SIGNATURE UNTIL AFTER COVERAGE BECAME EFFECTIVE, YOU HAVE THE RIGHT TO CANCEL THIS POLICY WITHIN FIVE DAYS OF RECEIVING THIS DISCLOSURE. IF YOU CANCEL COVERAGE, THE PREMIUM WILL BE PRORATED AND ANY BROKER'S FEE CHARGED FOR THIS INSURANCE WILL BE RETURNED TO YOU. LMA9098A 04 May 2017 D-2 (Effective January 1, 2017) AMENDATORY ENDORSEMENT NO.: 1700919 ADDITIONAL PREMIUM: $859.00 (pro rata) INSURED: MAK , INC.TION ENGINEERING& Purchasing Group Tax for CA @ 3% $25.77 EFFECTIVE: May 8, 2018 to March 16,2019 TOTAL: $884.77 (pro rata) lf'', 5ING 1AMU-5 consideration of the premium as sliowii above, it is liereby understood and agreed that Endorse incti t No.: 170019 is amended to read: LIMITS OF INSURANCE $2,000,000.00 General Aggregate Limit $2,000,000.00 Prodtacts-Completed Operatioiis Ag negate Limit $2,000,000.00 Persomil & Advcrtisiiil, Injury l-imit $2,000,000.00 1 alcli Occtarreiice Limit $50,000.00 l'iire Damage ge Limit $5,000.00 Medical 6�.; Denise Limit $250.00 Deductible All other terms,conditions, limits and exclusions remain unchanged. Attached to and forming part of Certificate No.: NI 9023 Dated: May 14, 2018 UNDERWRITERS AT LLOYD'S, LONDON AUTHORIZATION NO.: (UMR) B0429BA1801027 Complete E�(jLi'rty Markets, Inc. dbaa Coine Etjuc ty Mw'kets Insurance Agency,Inc. 0SL#0t:.4401?) AIF 2391 V(12/08) E199"`45 (10015994 UW 10/08) f� By Lawrence T.P. Molloy Endorsement #33 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. U 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# 41 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 object tote workers' compensation provisions of Labor Code § 370 1 must immediately comply with thos � lsions46,, agreement will automatically become void. Signature of Applicant Date ' r Agreement for: cow; 1 Q� "I, °:w'..� ;.,�!m111�PiVl i'I��` �h�'lit��"I Yt ►��, i Ld Dated: Lo— Reviewed by 1