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PROOF OF INSURANCE (2019 - 2019) CLOSEDClient#: 12641 GROMA ACORD. CERTIFICATE OF LIABILITY INSU ANCEDATE(20,$ ) � PERSONAL &ADV INJURY slncluded PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Ashbrook-Clevidence, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 3000 W. MacArthur Blvd., #320 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. License #0188788 Santa Ana, CA 92704 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Fireman's Fund Insurance Co. Mark Groh INSURER B Scottsdale Indemnity Co. 5481 Vallecitc, Avenue INSURER C: Westminster, CA 92683 I INSURER D I ...................._� INSURER E COVERAGES 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 AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. KgR-wl. LTR ,NSRC TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE (MMIDD/YYI DATE IMMJ'DDPYYI LIMITS A GENERAL LIABILITY AZC80896701 07/06/18 07/06/19 1 EACH OCCURRENCE 51,,000,000 X I COMMERCIAL GENERAL LIABILITY = CLAIMS MADE ® OCCUR Hired -Non -Owned Auto -Limit Included GEN'L AGGREGATE LIMIT APPLIES PER 7 POLICY F7JEC7 F LOC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS GARAGE LIABILITY IANY AUTO EXCiESSIUMBRELLA LIABILITY 7i OCCUR FICLAIMS MADE DEDUCTIBLE RETENTION 5 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below B OTHER Errors 8r Omm IEK13263035 DAMAGE TO RENTED Grp) $100.000 _MED EXP (Any one person) $10,000 PERSONAL &ADV INJURY slncluded GENERALAGGREGATE $2,000,000 (PRODUCTS-COMP/OPAGG $ COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) I BODILY INJURY (Per accident) PROPERTY DAMAGE $ (Per accident) AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC I., $ AUTO ONLY AGG 5 EACH OCCURRENCE $ AGGREGATE $ 5 $ IAC STATUS I IOTH- V I IMITR F„ E L EACH ACCIDENT I $ E L DISEASE - EA EMPLOYEE $ II E L DISEASE - POLICY LIMIT �5 07/11/18 07/11/19 $1,000,000 Limit $2,500 Retention DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS I The City of EI Segundo and its officers, employees, elected officials, volunteers, and members of boards and commissions are included as additional insureds, but only insofar as the operations under this agreement or contract are concerned per Endorsement ABC Multicover-AB91890807. This policy includes a Blanket Waiver of Subrogation. CERTIFICATE HOLDER City of EI Segundo 350 Main Street EI Segundo, CA 90245 CANCELLATION 10 Bays for Non-P'ayonent SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _Q DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. I AUTHORIZED REPRESENTATIVE I q & ACORD 25 (2001/08) 1 of 2 #S32157/M32156 MXC © ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25-S (2001/08) 2 of 2 #S32157/M32156 ABC MultiCover - AB 91 89 08 07 This endorsement modifies insurance provided under the following: American Business Coverage Your policy is broadened and clarified as follows: I. Non Employment Discrimination Liability Unless Personal Injury or Advertising Injury is excluded from this policy: A. Section III - Definitions, Item 17. Personal Injury is amended to include: f. Discrimination B. Section III - Definitions, Item 2: Advertising Injury is amended to include: e. Discrimination C. Section III - Definitions is amended to in- clude: 30. Discrimination means the unlawful treat- ment of individuals based on race, color, ethnic origin, gender, religion, age, or sexual preference. D. Section H - Liability, Coverage, Part H. Ex- clusions, Item 1.p Personal Injury or Adver- tising Injury is amended to include: (11) Arising out of discrimination directly or indirectly related to the past employ- ment, employment or prospective em- ployment of dray person or class of persons by any insured; or (12) Arising out of discrimination directly or indirectly related to the sale, rental, lease or sub -lease or,prospective sale, rental, lease or sub -lease of any dwelling, permanent lodging, or premises by or at the direction of any insured; or (13) Arising out of discrimination, if insurance thereof is prohibited by law; or (14) Fines, penalties, specific performance, or injunctions levied or imposed by a go- vernmental entity, or governmental code, law, or statute because of discrimination. 2. Blanket Additional Insured Section H - Liability Coverage, Part L Who Is An Insured, Item 2. is amended to include: f. Any person or organization that you are re- quired by a written insured contract to include as an insured, subject to all of the following provisions: (1) Coverage is limited to their liability aris- ing out of: (a) the ownership, maintenance or use of that part of the premises, or land owned by, rented to, or leased to you; or (b) your ongoing operations performed for that insured; or (c) that imured's financial control of you; or (d) the maintenance, operation or use by you of equipment leased to you by such persons) or organization(s); or This Form must he attached to Change Endorsement when issued rafter the policy is written. One of the Fireman's Fund Insumooe Companies as named in the policy "�ecy President AB9I89 8-07 �' A �CCJO Page i of 6 e (e) a state or political subdivision per- assumption of liability in a contract mit issued to you. or agreement. This exclusion does not apply to liability for damages (2) Coverage does not apply to any occur- that the vendor would have in the rence or offense: absence of the contract or agree- ^ —�' (a) which took place before the exe- resent' cution of, or subsequent to the b, Any express warranty unauthorized completion or expiration of, the by you; written insured contract, or c. Any physical or chemical change in (b) which takes place after you cease to the product made intentionally by be a tenant in that premises. the vendor; (3) With respect to architects, engineers, or d. Repackaging, unless unpacked solely surveyors, coverage does not apply to for the purpose of inspection, dem- Bodily Injury, Property Damage, Per- onstration, testing, or the substi- sonal Injury or Advertising injury arising tution of parts under instructions out of the rendering or the failure to from the manufacturer, and then re render any professional services by or for packaged in the original container. you including - a Thepreparing, approving, or failinge. () Any failure to make such in- to prepare car approve maps, draav- spections, adjustments, tests or ser- iztgs, opinions, reports, surveys, vicing as the vendor has agreed to make or normally undertakes to change orders, designs or specifica- y wake in the usual course of busi- tions; and ness, in connection with the distrib- (b) Supervisory, inspection, or engi- ution or sale of the products; p neering services. p m f. Demonstration, installation, servic- If an Additional Insured endorsement is attached ing or repair operations, except such to this policy that specifically names a person or operations performed at the vendor's organization as an insured; then this coverage does premises in connection with the sale not apply to that person or organization, of the product; 3. Blanket Additional Insured for Vendors g. Products which., after distribution or sale by you, have been labeled or Unless the Products -Completed Operations Haz- relabeled or used as a. container, part and is excluded from this policy, Section II - Li- or ingredient of any other thing or ability Coverage, Part I. Who Is an insured, Item substance by or for the vendor. 2. is amended to include: 2. This insurance does not apply to any in - g. Any vendor but only with respect to Bodily sured person or organization, from Injury or Property Damage arising out of your whore you have acquired such products, products which are distributed or sold in the or any ingredient, part or container, en - regular course of the vendor's business, sub- tering into, accompanying or containing ject to the following additional exclusions: such products: 1. The insurance afforded the vendor does If an Additional Insured - Vendors endorsement not apply to: is attached to this policy that specifically names a W a. Bodily Injury or Property Damage person or organization as an insured, then this o for which the vendor is obligated to coverage does not apply to that person or organ - N pay damages by reason of the ization. v Q AU9199 8-07 m Page 2 of 6 4. Blanket Waiver of Subrogation Section H - Liability Coverage, Part K. Liability and Medical Payments General Conditions, is amended to include: 6. Transfer of Rights of Recovery Against Oth- ers to us and Blanket Waiver of Subrogation a. If the insured has rights to recover all or part of any payment we have made under this Coverage Part, those rights are transferred to us. The insured must do notlaing after loss to impair those rights. At our request, the insured will bring, suit or 'transfer those rights to us and help us enforce them. b. If required by a written insured contract, we waive any right of recovery we may have against any person or organization because of payments we make for injury or damage arising out of your operations or your work for that person or organ- ization, 5. Broadened Named Insured Section iI - Liability Coverage, Part L Who Is An Insured, Item 4. is replaced with: 4. All of your subsidiaries, companies, corpo- rations, firms, or organizations, as now or hereafter constituted, quaiilY as Named In- sured under this policy if: (a) you have the responsibility of placing in- surance for each such entity; and (b) coverage for the entity is not otherwise more specifically provided; and (e) the entity is incorporated or organized under the laws of the United States of America. But each entity is insured only while you own, during the policy ' period, a controlling interest in such entity of greater than, 50% of the stock or assets. However. (a) Coverage under this provision is afforded only until the end of the policy period, or the 12 month anniversary of the policy inception date, whichever is earlier; (b) Coverage C does not apply to bodily in- jury or property damage that occurred AB9189 8-07 before you acquired or formed the or- ganization; (c) Coverage C does not apply to personal injury or advertising injury arising out of an offense committed before you ac- quired or formed the organization. 6. Medical Payments Unless Coverage D. Medical Payments is excluded from this policy. A. Section H - Liability Coverage, Part IL Ex elusions, Item 21. is replaced with: f. Included within the products -completed operations hazard. However, this exclu- sion does not apply to expenses for den- tal services. B. Section H - Liability Coverage, Part G. Cov- erage, Item 2., is amended to include: c., Coverage D. Medical Payments is pri- mary and not contributing with any other insurance, even if that other insur- ance is primary also. 7. Tenant's Legal Liability A. Section III - Liability Coverage, Part J. Li- ability and Medical Payments Limits of In- surance, Item 3. is replaced with: 3. The most we will pay under Coverage C - Liability for damages because of prop- erty damage to premises while rented to you, temporarily occupied by you with the permission of the owner, or managed by you under a written agreement with the owner: a. arising out of any Covered Cause of Loss shall be the greater of - (1) f(1) $1,000,000; or (2) The Tenant's Legal Liability limit shown in the Declarations. 8. Chartered Aircraft Section H - Liability Coverage, Coverage C, Part 11 Exclusions, item l.g. is amended to include: (5) An aircraft in which you have no ownership interest and thatyou have chartered with crew. Page 3of6 9. Coverage Territory Broadened Payments Definitions, Items 17.b., d. and e. are replaced with: Section III - Definitions, Item 5.a. is replaced with ' b. Malicious prosecution or abuse of process; a The United States of America (including its territories and possessions), Puerto Rico, Ca- d. Oral, written, televised or videotaped publica- nada, Bermuda, the Bahamas, the Cayman tic, of material that slanders or libels a person Islands and the British Virgin Islands. or organization or disparages a persons or 10. Broadened Advertising Injury organization's goods, products or services; Unless Advertising Injury is excluded from this e. Oral, written, televised or videotaped publica- policy: tion of material that violates a persons right '-- of privacy; A. Section III - Definitions, Item 2. is replaced 12. Broadened Personal or Advertising Injury with 2. Advertising Injury means injury arising Unless Personal Injury or Advertising Injury is out of one or more of the following of-, excluded from this policy, Section It - Liability fenses: Coverage, Coverage C, Part H. Exclusions, Item l.p.(4) Exclusions is deleted in its entirety. a. Oral, written, televised or videotaped, publication of material that slanders 13. Fellow Employees Coverage or libels a person or organization or II - Liability Coverage, Part I. Who Is an disparages a person's or organize -Insured, tion's goods, products or services; Insured, Item 2.a (1) is amended as follows: 4 o b. Oral, written, televised or videotaped (1) Personal Injury to you or to a co=employee publication of material that violates. while in the course of his or her employment, a person's right of privacy; or the spouse, child, fetus, embryo, parent, brother, sister or any member of the house - c. Misappropriation of advertising hold of that employee or co -employee as a ideas or style of doing business; or consequence of such Personal Injury, or for any obligation to share damages with or repay d. Infringement of trademark, copy- someone else who must pay damages because right, title or slogan. of the injury; or B. Section H - Liability Coverage, Coverage C; I4. Mental Anguish Is Included in Bodily Injury Part H. Exclusions, Items i.p.(I) and (2) are replaced with: Section III - Definitions, Item 4. is replaced with: (1) Arising out of oral, written, televised or 4. Bodily injury means bodily injury, sickness or videotaped publication of material, if disease sustained by a person. It includes done by or at the direction of the insured death or mental anguish which result at any with knowledge of its falsity; time from such physical harm, physical sick - ness or physical disease. Mental anguish me - s (2) Arising out of oral written televised or ans any type of mental or emotional illness videotaped publication of material whose or disease. o lust publication took place before the abeginning of the policy period; 15. Unintentional Failure to Disclose Hazards 11. Broadened Personal Injury Section II - Liability Coverage, Part H. Liability fl Unless Personal Injury is excluded Ervin this pril- and Medical Payments General Conditions, is N icy, Section III - Property, Liability and Medical amended to include: u to AiI91898-07 9 Pae 4 of 6 $ 6. Unintentional Failure to Disclose Hazards If ;you unintentionally 11W to disclose any ha- zards exisIbig at the inception date of your policy, we will not deny coverage under this Coverage Form because of such failure. However, this provision does not affect our right to collect additional premium or exercise our right of cancellation or non -renewal. 16. Supplementary Payments, Increase I imus Section H - Liability Coverage, Part G. Coverage, Items Le. (2) and (4) are replaced with: (2) The cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds. (4) All reasonable expenses incurred by the in- sured at our request to assist us in the inves- tigation or defense of the claim or suit including substantiated loss of earnings up to $ 500 a day because of time off work. 17. Per Location Aggregate A. Section II - Liability Coverage, Part J. Limits of Insurance, Item 4. is amended to include: The Aggregate Limit of Insurance applies se- parately to each location owned by you, rented to you, or occupied by you with the permission of the owner.. B. Section III - Property, Liability and Medical Payments Definitions, is amended to include: 31. Location means premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway, waterway or right-of- way of railroad. 18. Amended Duties in the Event of an Occurrence, Offense Claim or Suit Section 'H Liability Coverage, Part K. Liability and Medical Payments General Conditions, Items 2.a. and b. are. replaced with: a. In the event of an occurrence, offense, claim, or suit, you must promptly notify us. Your duty to promptly notify us is effective when Your executive officers, partners, members, or AB9189 8-07 legal representatives are aware of the General Liability occurrence, offense, claim, or suit. Knowledge of an occurrence, offense, claim, or suit by other employee(s) does not imply you also have such knowledge. b. To the extent possible, notice to us should include: (1) How, when and where the occurrence or offense took place; (2) The names, addresses, and telephone numbers of any injured persons and wit- nesses; and (3) The nature and location of any injury or damage arising out of the occurrence, of- fense, claim, or suit. 19. Common Policy Conditions (AB 00 09 A 01 87), Part H. Other Insurance, Item 2. is replaced with: 2. Coverage C -Liability If other valid and collectible insurance is available to any insured for a loss we cover under Coverage C of this Coverage Part our obligations are limited as follows: a. The insurance provided under this policy is primary if you are required by a written insured contract to include any person or organization as an insured, but only with respect to that insured's liability arising out of the ownership, mainte- nance, or use of that part of the premises owned by or rented to you, or your work for that insured by or for you. Any other insurance available to that person or or- ganization is excess and noncontributory with this insurance, or; b. Except for the circumstance described in 2;a., above, the insurance provided under this policy is excess over any other l- ability insurance available to any insured whether such other insurance is written as primary, excess, contingent or any other basis. An exception applies when any insured specifically has purchased excess insurance to apply in excess of the limits of insurance shown in the Decla- rations of this Coverage Part for Cover- age C. Page 5 of 6 U a a N Z 20. Damage to Invitees' Automobiles from palling Trees or Tree Limbs - Limited Coverage The policy applies to direct physical damage to automobiles owned by invitees subject to all of the following: 1. provided such damage originates from prem- ises owned, managed, Ieased or rented by an insured; 2. Coverage applies only to invitees of an in- sured or an insured's tenant; 3. Such damage is directly caused by wind -driven falling trees or tree limbs; 4. The most we will pay for any one loss is the Iesser of the actual cash value of the darnaged automobile as of the time of the loss; or the cost of repairing or replacing the damaged automobile with another automobile of like 0 N U AB9189 9.07 CV CV kind and quality; subject to a limit of $25,000 in any one policy period; and 5. This coverage is not subject to the General Liability General Aggregate Limit. 21. Expected or Intended Injury - Amendment to Ex- clusion xclusion SECTION 1. - 2. EXCLUSIONS a. Expected or Intended Injury, is replaced by the following: a. Expected or Intended Injury Bodily injury or property damage expected or intended from the standpoint of the insured. This exclusion does not apply to bodily injury or property damage resulting from the use of reasonable force to protect persons or prop- erty. All other terms and conditions of the policy apply. Page 6 of 6 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 Name of Agent Policy Number Expiration Date Phone # (X) I 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 subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those Drovisions or the aareement will automatically become void. Signature of Applicant '�A,4 Date 4-27-17 Agreement for: Mark L. Groh, Independent Hearing Officer Dated: .,_ ..�... Reviewed by: