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PROOF OF INSURANCE (2018 - 2019) CLOSED CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDD/YYYY) 04/20/2018 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(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 CONTACT Isaac RamireZ NAME: Call Patty Insurance Services PHONE/ a,Fxt)I (714)332-0373 FAX No). (714)242-9617 1211 W Imperial Hwy Ste 200 ADDRIESS; csQcallpattyinstuaace.com Brea,CA 92821 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Northfield Insurance Company 27987 INSURED INSURER B Donny Golberg INSURER C 9372 Greenwich Dr Huntington Beach CA 92466 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 gLIR TYPE OF INSURANCE I N 8 SUVA POLICY NUMBER IMMDDPOLICY/YYY1/1 (MMI DIIYYYYI I LIMITS GENERAL LIABILITY 01/07/2018 01/07/20191,000,000 EACH OCCURRENCE $ A COMMERCIAL GE FERAL LIABILITY CPS3021233 PREMISES(MED EXP ( one peDAMAGE TO kLNILrson) 100,000 Ea occianrenre $,000 PERSONAL&ADV INJURY 51n0 00,^000 GENERAL,AGGREGATE $ 2,000,000 ._.......,.rGrrEi'LAGGRiGAT LIMITAPPLIES PER. PtdCCI.dCT,S„„C'f"Mth"P„AGG $ 11000,000 FDi. I O $ AUTOMOBILE LIABILITY lt/t.*INE:0 eN yxi NPS I..(m I.UWi' a BODILY ANY AUTO INJURY(Per person) 5 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) 5 ., NON-OWNED Per PEFt'1'Y'DAMAGE $ HIRED AUTOS AUTOS SII (Per r„„cidenl) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED L... RETENTIONg (S WORKERS COMPENSATION WCS'I AT U- OTH- ANDEMPLOYERS'LIABILITY YIN TORY InI,Pt�17S(, ER, ANY PROPRIETOR/PARTNER/EXECUTIVE "' EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? � N I A (Mandatory in NH) W' EL DISEASE-EA EMPLOYEE $$ If yes,descnbe under DESCRIPTION OF OPERATIONS below El, DISEASE-POLICY LIMIT (5 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) 30 DAYS NOTICE OF CANCELLATION EXCEPT 10 DAYS NOTICE DUE TO NON PAYMENT OF PREMIUM. CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main St, ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo,CA 90245 AUTHORIZED REPRESENTATIVE PlI i ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: CPS3021233 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE . Name Of Additional Insured Person(s) Or Organization(s): Location(s) Of Covered Operations City of EI Segundo, its officers, officials, employees, Recreation Park agents and volunteers 401 Sheldon St. 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 exclu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for "bodily injury", "property This insurance does nota I to "bodilyinjury" or damage" or "personal and advertising injury" property damage occurring after: apply caused, in whole or in part, by: 1. All work, including materials, parts or equip- 1. Your acts or omissions; or ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project (other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) desig- covered operations has been completed; or nated above. 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization oth- er than another contractor or subcontractor engaged in performing operations for a prin- cipal as a part of the same project. CG 20 10 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 13 POLICY NUMBER: CPS3021233 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location And Description Of Completed Opera- Or Organization(s): tions City of EI Segundo, its officers, officials, employees, Recreation Park agents and volunteers 401 Sheldon St. EI Segundo, CA. 90245 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II —Who Is An Insured is amended to include as an additional insured the person(s) or organiza- tion(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location desig- nated and described in the schedule of this endorse- ment performed for that additional insured and included in the"products-completed operations hazard". CG 20 37 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 ❑ INSURANa, ibENTIFICATION CARD INSURANCE IDENTIFICATION CARD .CALIFORNIA ',:I NO t,CALIFORNIA 21st Century Insurance Company 219t Century Insurance Compa,ny' I 1, 1: 1 N. t P.81'12r 5,1 47 COM I'ANYNO' 12 963' 51 47 0A I'l ! FAI010 Nlkr� I VLCIIVI,JI.N"ll 1XV110110N O,XlT, 01/28/18 09/28/18 03/29/18 09/28/18 N'll R('Ll I l:A VIl"N NIAMIA� It 11WNTll`I("ll'TI0?N'101MM H, MI %R: STDZT34 82658 06 STDZT34A369,282658 06 MAKI "M(01 SEQUOIA SINSXI\lo /Mt W)l.t:TOY $EQUOXIA SR5 I I A3r. I T LYNETTE MEIMCON LYNETTE MELANCON 9372 GREENWICH I)R 9372. GRZENWICii DR HUNTINGTOWSCH, CA 9264:111pl HUNTINGTOWEICH, CA 92646 �mvvv"a'isscim 21st CENTU);Y INSURANCE 21st CENTURY INSURANCE 21ST CEN' ULY PLAZA 21ST CENTURY PLAZA, P.O' Box 1,4510, P.O. BOX 15510, WILMINGTON, DE 19850.5510 WILMINGTON, DE 19850-5510 THIS POLICY MEETSAINIMUM COVERAGES REQUIRED BY I.A"" T'HI'S POUCY MEETS,MIMMU10 COVERAGES REGUIREf.)BY LAW IN SECTION 1605f;- IN SECTION 16056 SEE IMPORTAN't NOTICE ON REVERSE!Slb#" SEE IMPORTANT NOTICE ON REV11tta U2: ::!Jd:q:: 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 FOA IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES, ii affimi,uman, i pxmiaqlty of l;a qt.oy undjeo, the 0&Nrs of Ca�,ifcwrv,.3 orie,of l fouloyvling csecaravnxls 11.have+'r Awll rnawitawt a cerbficae cf consens,of seJ,i-si,;ve for%"'kerscompeisalion, by the 0u(,e(Aof of JndusWa�RWa.*mons,as pirowdeq'I for by Lat>oir for clae peirforimancp,�oaf tine nt ework set ole agreerne wAn the Oty D!El Spg�mac) Poky No ..... l Na. ora ar�cfwH ri,iainlalin warkeirs owipprisaiwn wiiskjiranc�..-tas requawl by Latxx Gode,§3700 for the peldwinw,xe of me worfw, fw wt)ic�i the agreement wth 0'ie Clity of B Sequndo os execvtied My%w*iers compensabon msuraince carnorand number are camer ter.6cy Number Exprahon Dalle Nafir�eol`Agent Phone X 11 cxW10y tiat In the. jpeirforrrianc4,.,,^ of Me w(,,)rk set fortbi in the agreerrient v4i the City of Ell SN, eriliy person many rnannr..,�,�f so as to ci-ecome Fo..jbje.K.,,1 to the worlKeirs CoMpensahon himm of Claffrwrida, and agree tl�al ,,�I subiect to Me vio�kers WrnpenSaWp4-,, prcv�s*ns of Labor Cote 3700 1 must uniirn�i��'dilstell`y c�j rop�� 01 ltx,.�se� uvo;�u-s,xttlie agreernent YAHautomatwalfly b—molne void Sat.nah,ve of Date I. Pnni P,tame Agreement for: Dated: Reviewed by