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PROOF OF INSURANCE (2019 - 2019) CLOSED DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 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(ies) 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 Fatty insurance Services PHONE (714)Ext): (714)332-0373 [Algin N,), (714)242-9617 E-MAIL CsGcallpattyinsurance.com 1211 W imperial Hwy Ste 200 ADDRESS: Brea,CA 92821 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Northfield Insurance Company 27987 INSURED INSURER B: Donny Golberg INSURER C: 9372 Greenwich Dr INSURER D Huntington Beach CA 92466 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. INSR TYPE OF INSURANCE ADDL suaR POLICY EFF POLICY"EXP LIMITS LTR. INSR WVD POLICY NUMBER IMM/DDIYYYYI IMMIDDWYYYM GENERAL LIABILITY 01/07/2018 01/07/2019 EACH OCCURRENCE 0AMAGE,'r I('Id8(1(V(p A ;,/M COMMERCIAL GENERAL LIABILITY CPS3021233 P' t'�M^'''°ti t0"''''6"^'�''"""�r�1 . CLAIMS-MADE y/ OCCUR MED EXP(Any one person) 'S 5„Cltul"b' PERSONAL 8 ADV INJURY ,a I,000'000 GENERAL AGGREGATE $ 2,0100„(I00 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG S 1,I,hOdI,(i(1C! POLICY "IFC $ I� ' AUTOMOBILE LIABILITY ."WA141IQE0 SRNGL E LIVi�'I" dEnaWc:nJPflu6N,,,,,,,, �, ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS , AUTOS NON-OWNED PROPERTY DAMAGE .$ HIREDAUTOS AUTOS I,Per gr,,denl1 $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION S $ WORKERS COMPENSATION WCST'ATU- OfH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS, ER ANY PROPRIETOR/PARTNER/EXECUTIVE E L,EACH ACCIDENT 5 OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I 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 El 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. I � EI Segundo,CA 90245 AUTHORIZED REPRESENTATIVE ©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 OrganizationLs): 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 not apply to "bodily injury" or damage" or "personal and advertising injury" "property damage"occurring after: caused, in whole or in part, by: 1. Your acts or omissions; or 1. All work, including materials, parts or equip- 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 ❑ 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 ❑ j, JNSI.'lR,,%'\CFI IDENTIFICA-MN CART.) CAL 1 F&4 1"A" %,N CALIFOP.141A Ilst Centur insurance Cca-pany 21st, rentury Insurance company y 8112 5;1 4*7 o 0" !o12 963 81,12 Sl 47 74 li 11, y 03/28/19 09128/18 03/28119 5TDITA 8:2658 06 5 TO ZT 3 4•AI 6'S2 8,2 6,5,Sr 06 ll'CY SFQUOIA SPP TOY SEQUO2A SR5 LYNXTIE MELANCON I�TXETTE W1.42% Dc;mly 607,I)SERG DONNY GOLPBERG 9272 Gn,!."Icm DR 93'12' GRE1.21WICH DR HUNTINGTON BCH, C'A 92646 l3m;T-ING-1-ON SC,H, Ch 92646 n Vr I 1� I SIN k:l S 1I 2,1,st CENTU i INSURmics 21st CENTURY INSUPANCE 21V �; PZAZA ZIST CIEN-4wy PLA?A P'o. BOX '1!x'9'1,0 P'o. BOX 4155'10 WILNUNGTolmll DE WI'XINGTO4, VE 19850-5510 0, '' 7 I'll, f"11A 114 kiaq.)IR4o Ww u"V4, 'R*i4oAfV1J C. � FECTCJPV,,.RAZ E Pf,YL4#ZG0 P)kAsW 014�! IW,14 �wj 5-:cTp"*. 5EEM,IIPCOZ;A,�J NOVOUS 04,M ER",'=.5lHh CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES ANP 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, affirm,,�d,, pena!ly of perjun,�under the fa,&s of Ca*;'D,,n a orie of the ioflo:vjng dec�aratlons (—) I have w^j will maintain a certificate of corsert of self-insure for wo.rkers, compensa4on issued by the Director of Industrial as provdad for by Labor C--de§3700 for the performance of the work set forth the agreement with the City(ri, B Segundo Policy No- T-1- I havea^j+;j will maintain workers compensation insurance as required by Labor Code§3700 for the performance of the work fir which the agreement with the City of El Segundo is executed My workers compensation insurance carrier and c number are Camer Policy Number Expiration Date Name of Aaf,,rt -–---- Phone 9 i_j i certify Ji;I in the performance of the work set forth in the agreement wth We City of El Segundo, 1 will not employ any qers:n in any manner so as to become subject to the workers compensation laws of California. and agree that, " , t­­�A z-;- subject to the workers' compensation provisons of Labor Code 4 3700 1 must immediately . ...... those 11'vu-i!,��.�onsor the agreement wil!automatically become void S.9nat u re ofAV C�: A 1� el- Date Print Name "Ole, 4— Agreement for. Dated. Reviewed by