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PROOF OF INSURANCE (2018 - 2019) CLOSED 0 DATE(MM/DD/YYYY) AC R" CERTIFICATE OF LIABILITY INSURANCE 07/30/2018 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). PRODUCER CONTACT NAPA[ American Specialty Insurance&Risk Services, Inc, PHONEEM) 260-969-5203 FAXlA) Nib; 260-969-4729 dba A,S.I,R S,I Insurance Agency E-MAILADDRESS 7609 W.Jefferson Blvd., Suite 100 INSURER(S)AFFORDING COVERAGE NAIC O' Fort Wayne IN 46804 INSURER Arch Insurance Compa'n'y 11150 INSURED INSURER B: National Association of Sports Officials(NASO) INSURER c 2017 Lathrop Avenue INSURER D.- INSURER :INSURER E: Racine WI 53405 INSURER F COVERAGES CERTIFICATE NUMBER: 1001593268 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 SUBR POLICY EFF POLICY EXP LIMITS LTR INSQD POLICY NUMBER (MMIDD/YYYY) (MMIDDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 X OCCUR FIREMISES(, , N1vr 1,000,000 DAMAGE 1 RE CLAIMS-MADE ISIS(c;a a,p4;,r;r}ir4rt��CN,y S MED EXP(Any one person) l s Excluded A Y SBCGL0279601 08/01/2018 08/01/2019 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGAT'E LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,000,000 POLI'CYPIdC3 [� LOC PRODUCTS-COMP/OPAGG $ 5,000,000 JE9�:'r I X O,',j.tE'R, OFFICIAL AUTOMOBILE LIABILITY Cr1'Iw4BIhJED SINOZy.E%,IMP7 $ ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED P'RrOP'F:KSW'PlAMAGE AUTOS ONLY AUTOS ONLY dF"'tyrt,Atac'.Ir9entV,,, $ S UMBRELLA LIAR X OCCUR EACH OCCURRENCE S 5,000,000 A X EXCESS LIAB CLAIMS-MADE SBFXS0044401 08/01/2018 08/01/2019 AGGREGATE S 9,000,000 DED RETENTION S WORKERS COMPENSATION PER 0TH- 'AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETORIPARTNERIEXECUTIVE ENIA/A E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ' (Mandatory in NH) E L DISEASE-EA EMPLOYEE S It yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Coverage applies to JOHN ZIELLO,704 CAMINO REAL,REDONDO BEACH,CA 90277 The Certificate Holder is only an Additional Insured with respect to liability caused by the negligence of the Named Insured as per Form 00 SGL0026 00 Additional Insured-Certificate Holders,effective August 01,2018. CERTIFICATE HOLDER CANCELLATION THE CITY OF EL SEGUNDO, ITS OFFICERS,OFFICIALS, EMPLOYEES, AGENTS,AND VOLUNTEERS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 MAIN STREET AUTHORIZED REPRESENTATIVE EL SEGUNDO CA 90245 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC#: ADDITIONAL REMARKS SCHEDULE 1 of 1 A�i�`�' Page .................. AGENCY NAMED INSURED American Specialty Insurance&Risk Services,Inc. National Association of Sports Officials(NASO) ....... ...................... _ ,................................... POLICY NUMBER 2017 Lathrop Avenue SBCGL0279601 CARRIER NAIC CODE Racine,WI 53405 Arch Insurance Comp...................... �............__........ any 11150 EFFECTIVE DATE: .......................................... ............... 08/01/2018 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE: INSURANCE-Certificate#1001593268 ACORD 25' CERTIFICATE OF LIABILITY I ................____,,,_,_mmm Unintentional Errors&Omissions,$100,000 each wrongful act/$100,000 Annual Aggregate per official/assignor -Other Named Insured:National Association of Sports Officials(NASO)&NASO-member officials,including officials enrolled by associations,contracted with NASO, -Other Named Insured(cont'd):but only while acting in their capacity as officials during sports events organized by a recognized sanctioning body or organized by another entity,but the rules of a recognized sanctioning body are followed,such as local Park Department or any formal organized association, and/or while attending seminars,conferences,and similar meetings designed to improve their officiating knowledge and skills. -The excess Aggregate Limit applies separately to each"official"insured under this policy. However,in the event of a suit by one or more plaintiffs against more than eight"officials",the Aggregate Limit will not apply separately to each"official",and a single aggregate limit of$20,000,000 will apply collectively to all individual"officials"covered under this policy VI ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: SBCGL0279601 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 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 EL SEGUNDO, ITS OFFICERS, ELECTED AND APPOINTED OFFICIALS, EMPLOYEES AND MEMBERS OF BOARDS, COMMISSIONS and volunteers 350 Main Street EI Segundo, CA 90245 but only with respect to John Ziello 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 organization(s) shown in the Schedule, but only exclusions 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. All work, including materials, parts or 1. Your acts or omissions; or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work" out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of the same project. 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. CG 20 10 04 13 ©ISO Properties, Inc., 2004 Pagel of 2 ❑ C. With respect to the insurance afforded to these 2. Available under the applicable Limits of additional insureds, the following is added to Insurance shown in the Declarations; Section III—Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the most we applicable Limits of Insurance shown in the will pay on behalf of the additional insured is the Declarations. amount of insurance: 1. Required by the contract or agreement; or CG 20 10 04 13 ©ISO Properties, Inc., 2004 Page 2 of 2 ❑ CSE Insurance Bill nNSURAINCIE GIROUIP Renewal Personal Auto Policy PO h­ QLiV6 Civil Service Employees Insurance Company ""M Notice Date: 04/05/2018 Bill To: Agent BICHLMEIER INSURANCE SRVS INC caryb(t_i)bisins.coni Address Code 41644-41644 730 S.PACIFIC COAST HWY 11201 REDONDO BEACH.CA 90277 ZIELLO.MARY P AND JOHN E 704 CAMINO REAL REDONDO BEACH,CA 90277-4317 Phone: 800-888-7187 Fax: 310-540-2215 Insured: ZIELLO.MARY P AND JOHN E Policy: CAA8002278 Term: 05/11/2018 to 11/11/2018 For detailed inforination regarding your coverage.please refer to your declaration pages. Othenvise,for any insurance needs or questions.please contact your independent agent. Billing Activity as of 04/05/2018 Balance From N Tolal Policy Installment Fee Amount Current Minimum Premium Prior Term Y Premium To Date Received Balance I Due by:05/11/2018 $0.00 $1,777.46 $0.00 $0.00 $1,777.46 $599.60 Payment Plan Options ............... .............. To pay the current balance in full: To pay the premium in installments: Return the payment coupon with your check for $1,777.46 Due 05/11/2018 $599.60 Due 08/09/2018 $302.01 Or pay by phone or via the internet. See reverse side for details. Due 06/10/2018 $302.01 Due 09/08/2018 $301.83 If you make changes to your policy resulting in premium Due 07/10/2018 $302.01 adjustments,you will receive an updated installment schedule. Each installment includes a$6.00 service charge. This is your renewal billing. Your policy renewal,which indicates your coverages and limits, is enclosed. Your coverage will not continue unless we receive the minimum premium due before 12:00 a.m. Standard Time on 05/11/2018. See reverse for important information regarding CSE's installment payment plans. Keep top porfionforyour records insured Bill Please defach and return ivithyourpayment. Allow fivedad's for delivel). CSE Insurance Group Policy Number: CAA8002278 Effective: 05/11/2018 Notice Date: 04/05/2018 Insured's Name: ZIELLO.MARY P AND JOHN E To Pay In Full Minimum Due Due Date Amount Enclosed $1,777.46 $599.60 05/11/2018 Make check payable to Civil Service Employees Insurance Company. Send check with policy number to: CSE Insurance Group, P.O. Box 60289, Los Angeles, CA 90060-0289 Pay by phone:888-645-2586. Pay on-line:MyCSEpolicy.com. Automated payment:see reverse 04680022?800600011805111805110001783460000599609 EVIDENCE OF INSURANCE COVERAGE Insurance identification cards are provided below. Please retain one card in the referenced vehicle. An additional card is available as required by some states for vehicle registration. CSE provides insurance information electronically to the CA, AZ and NV Department of Motor Vehicles. California Proof of AutomobileM��► California Proof of Automobile Liability4"W 111111111 Insurance Liability Insurance INSURANCi GROUP NAIL 10693 INSURANCE GNOUP MAIC 10693 Insured Name and Address Agent: Insured Name and Address Agent: ZIELLO,MARY P AND JOHN E BICHLMEIER INSURANCE SRVS INC ZIELLO,MARY P AND JOHN E BICHLMEIER INSURANCE SRVS INC caryb@bisins com caryb@bisins com 704 CAMINO REAL 704 CAMINO REAL REDONDO BEACH,CA 90277-4317 Address REDONDO BEACH CA 90277-4317 Address 730 S.PACIFIC COAST HWY#201 730 S PACIFIC COAST HWY#201 REDONDO BEACH,CA 90277 REDONDO BEACH,CA 90277 Policy Number: CAA8002278 Policy Number: CAA8002278 Effective Date: 05/11/2018 Effective Date: 05/11/2018 Expiration Date: 11/11/2016 Expiration Date: 11/11/2018 Ph.800-886-7187 Fx 310-540-2215 Ph 800-888-7187 1`0 10-540-2215 Year/Make/Model VIN Year/Make/Model VIN 2012 FORD TRANSIT CONNECT XLT NMOKS9CN9CT113461 2012 FORD TRANSIT CONNECT XLT NMOKS9CN9CT113461 Am��am �'California Proof of Automobile M California Proof of Automobile Liability Insurance Liability Insurance INSURANCE GROUP NAIC 10693 INSURANCE GROUP NAIC 10693 Insured Name and Address Agent: Insured Name and Address Agent: ZIELLO,MARY P AND JOHN E BICHLMEIER INSURANCE SRVS INC ZIELLO,MARY P AND JOHN E BICHLMEIER INSURANCE SRVS INC caryb@bisins com caryb@bisins,com 704 CAMINO REAL 704 CAMINO REAL REDONDO BEACH,CA 90277-4317 Address REDONDO BEACH,CA 90277-4317 Address 730 S PACIFIC COAST HWY#201 730 S,PACIFIC COAST HWY#201 REDONDO BEACH,CA 90277 REDONDO BEACH,CA 90277 Policy Number: CAA8002278 Policy Number: CAA8002278 Effective Date: 05/11/2018 Effective Date: 05/11/2018 Expiration Date: 11/11/2016 Expiration Date: 11/11/2018 Ph.600-888-7187 Fx310-540-2215 Ph.800-888-7187 1`010-540-2215 Year/Make/Model VIN Year/Make/Model VIN 2016 FORD EDGE SEL 2FMPK3J91GBB60321 2016 FORD EDGE SEL 2FMPK3J91GBB60321 CITY OF EL SEGUNDO COMPENSATIONI WARNING: FAILURE 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, FOR IN LABOR CODE § , INTEREST, AND ATTORNEYS 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 workerscompensation, 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 El Segundo. Policy No, (_) I have and will maintain workers'compensation insurance as required b Labor Code§3700 for theperformance Y of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance mer and policy number are: Carver Policy Number Expiration Date Name of Agent Phone# ..._.. — NI certify that, in the performanceset forth in the agreementwith the City of El Segundo, I will not moy 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 theworkers' compensation provisions of Labor Code § 3700 1 must Signature of Applicant _ �� ent willutoatiautomatically become void. � Date r� immediately ply with thos ro i bar r ern Print Name a Agreement for: Dated: Reviewed by: '