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PROOF OF INSURANCE (2019 - 2019) CLOSED CERTIFICATE OF LIABILITY INSURANCE DATE(MM(bbmYY)
00/1412010
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 pollcy(les)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 ICOTACT
VAAe; JERRY MACIAS
No Hassle Insurance Agency PHONE FAX
1400 E, Cooley Dr.Ste.202-A IeI? Io,.sxt)I -(888)440-4094 N fir;Cpl,(909')783-7sao
Colton, CA 92324 ADDRESS: sorwic'er7rllotlassletns.net'
License#: OE74924 tlusuRr:,tstnw xp ,nl„Mc„covrinv e,.S,2Nnnlc ................
...__.._.. ... .... .... .... .��____. ......., INSURERA: UNITI7... .. .I.Ira�m..ILA.r., !Ir� Y..I ,. �L".19E ....�Gxti� ... .....
INSURED
Christpher Heppell INSURERS:
DBA:Precision Reef Systems NS R.. D:
7712 Goddard Ave. IURERD
Los Angeles,CA 90045 _IfN1sURNR E:
SURER F
COVERAGES CERTIFICATE NUMBER: 00000000-18094 REVISION NUMBER: 6
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.
(NSR ACED&.IsuDff 'PaLOCY EFF ppf.)'C'M E>CW' ......."�
LTR TYPE OF INSURANCE INSD.'.VL�VD POLICY NUMBER IMP1IdpDdYYYYB dMMznr(YYYY LIMITS
__. CLAIMS-MAGE Y CL1767885B 06/11/2016 0611112019 EACH OCCURRENCE $ 0_U0 Q
A COMMERCIAL GENERALLIABILITY
Y PIRFIV SPA, l�lGUAIC1H+rw:01 ....$.......,,.,-�I„Q.QaQQU...
r
WA
MED EXP� ny one
P6RSONAA&ADV NJrURY _..............1....00Qa_pQQ
_a ...a..
000
..."EN.AGGREGATE LIMAPP..,.LIE PER:................... ^PREO_D�UmmCS..G.XG..E......A........E......-e_._.a._..$.. 2 xr
RT . 0 POPAG $ 2O0
000rOIGL.'...... JJPELOC
__......... O71ERI'll,........... ..._
AUTOMOBILE LIABILITY GOrrUC'I'dNc'd3wINGN.F.LIMIT $
ANY AUTO BODILY INJURY{Per person)
CMNLO SCIILOULE V BOOILYI JURY,Peracxddan
— ——-AUTOS ONLY AL I O,'i, — _^ R
IRRCU NON,OWNED — .FROf-R"'Y DAMAGE _.
$
AUTOS ONLY AUTOS ONLY II',AY a�cl�Illi)
$
UMBRELLA LIA
EXCESS L1ALI BCCUR EACH OCCURRENCE $
DE. AGGREGATE $
----_.
DEW[
�.._.H_`
L ......_.
WORKERS ucOMPILENS�AT ON RETENTION
$ ..................pok.__..........
r6'pH $
WO KERSEMPLCOMPENSATION
LIABILITY YIN
mm .m -+STAT.UT. L FR, m
ANY
anndat ry In N R EXCLUDED,ECUTIVE ❑ NIA ..E,L..DISEASE-EA.DISEASEGPOEMPLOYEE,..a....^....
EAGHAG DE
If as,
escribe under
D.SCRIPTION OF OPERATIONS below E L. - $
DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES{ACORD 101,Addlflonal Romaft Sohodulo,moy bo plfaohad If mora space Is required)
CERTIFICATE HOLDER LSITED AS ADDITONAL INSURED
CERTIFICATE'.HOLDER CANCELLATION a,
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATETHEREOF.NOTICE WILL BE DELIVERED IN
The City of EI Segundo and its employees ACCORDANCE WITH THE PO Y' PROVISIONS.
350 Main Street
EI Segundo,CA 90245 A UTHORMED REPRESENTATIVE
/ (JMA)
©19188 C)RD CORPORATION, All rights reserved.
ACORD 25(2016!_03) The ACORD name and logo are registered marks ACORD
Printed by JMA on June 14,2018 at 03:50PM
POLICY NUMFJER*, CL•1757885 COMMMIAL GENERALLi?A10 7 04
'M9 SNOOR99MENT CH,ANOESTME POLICY, PLilx S iRFAD IT CAREFULLY.
ADDITIONAL INSURED- OWNERSt LESSEES OR
CONTRACTORS - SCHeDULED-PER ON OR
ORGANIZATION
Yhli on0orsernent modiilon irsturrunno proVided under the following:
Ct.9FAMERCIAaL GENERAL LIABILITY GOVSRAGE PAA
;�Ght�l!tlL�
Mp a Of or ltgrann sf
nntatcn�j, LofttpnlRl Of CoveredCperations
. .dM"M"N4MV+
whent raquirsd by written contract of ogreetnsnt, Ali aerations er ths named Insured
The City Of EI Segundo And Ila Employees $50 Mala Stroet,EI Segundo,CA 90246
I rutr;tiauru�eeutr p rr plet„, e „ o edu4ra.it potgj"nn sataa ve,will be shown Inw_n ih 'r r,s•
A. �ottlon It--Who is An Ina,urotl lux A"Wndsd 10 S. M respect to tho lrurturanu atrordad Io theta
tu°rcttide as ears ndatlttonW Insuadmd tho porswi(aI qr 0010an'si Insureds,the Following aaddlllonol o 'lu-
antxatmon(u) drown In 0 $oNd�a but only 8100 applry
w h rosrAct to fiablity fur'$Wgy Injury","fit want' This Insurance does nol zoptlt to"bodily 1A)ULY'or
dorrup, Cr "porsonal and rrtlyerllsing iu'jltrr/' "property r omono°"oratrtrtrirtg rafter!
rmussdt In waruls or in pert,by. 1. AN w4r4t W0419 ut°uAtarl* parts or equip-
1. Four aets Of 011115siars;or tatont turnMed to r omnaction vrlth rwob wturlt"
Z Thi no't%or orrrlauact'ortru tut(ho*'o Outing on your QA tha proloct('o"r thanaerAce,r Wanollgo
t obnit, or ropntlrs)to tw pat"r'ormoO'W or orad 400 of
1n ttutt paiiormance of your ongoing 0eTatiou�a fuer v'addilllorrsl It1at#fed(4) at th IOWtloa at the
thle uddtttrxrral'InWod(a) tut tho l l�art(s}destp• wyered opamtlons Isas ottani cuorrup'lotodi or
noted awvo• Z. That porilon el "Vovr worts, out of W010h Out
ko ury"or dan o srlsas has beers putto Ito ln�
,.... _ Ivfulett•uso-byy onylppr rn-dr-q dal llon-db .
or Than �ttttli�er con'troclor or sttCcCtrt'l cW
ongaquad In purrotmlrrg o0erbliam for'4 pd"a~
t air a pert oFtho e'0ma project.
CC i31 Q#I?d4 a?ISO ProvirW.ire.,2004 Pao#R of 1 �1
POLICY NUMBER:CL1757885 CCMM914CIAL OLONERAL LIA'SIUTY
CO 20 37 07 04
THM P—NDORSEMSNY CHANGES THE POLICY. PLEASE READ ITCAREPULLY.
ADDITIONAL INSURED —OWNERS, LESSEES OR
CONTRACTORS — COMPLETED OPERATIONS
�'Ptla-ertd�ra�rnac�k.rna�NPfle��n�4�raar�� .G�d�d�sder kN^�et�IN�u�!1nra;
COMMERCIAL GENERAL LIABILITY CCSVE WS PART
SCNEN�Ui.�
NE►tA4P t Or' it,1i•122 �.i93. 60_0 tl�And L'►O*01 1don Of..
...I00661 IiW recd Pofflon(fsa
» Cgmalo#ed 0ccraftna�
Ilse City Of El Segundo And Its Employees -$60 Main Street, E1 Segundo,CA 00246
Intorrs allon reVrroo to ccmol'*td this S art N�3 Et» t sftq above,will be shown In tyre tloolaratiom
Sactlgrt lI — Who fz Aes Niowrod Is amended to
InVAId'a as W e10011'ionat balrocl the aroon( ) Qr
ori;S6 x2IIon($)0(wiltµ,I�n�tphe h uls'rut only Witt)
r a ect to liablMl for"ps+»dby In)ur� cr"" rapari Caw*
sue"%,Md,, In w hoI* 'dr in ert, Iby brnr Vey at
the lam0on 0"rIvI i sn esc'rtt d In ttv soca•
tole of thl and r rraanr pd,»fb(med for'lbat atldltPormt
Irraurarl kAd lrrounkl Irl the "�raad�lt�«cprs��tetad
gpe.,teklert�h��fq".
fl,
,
pV
1
0011*2T 0704 0 ISO t*raft&0S,Ina„2004 Pajau I at a �
u
i
T7<ih11A)DD"WI
CERTIFICATE OF LIABILITY INSURANCE 10/03/2018
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 have ADDITIONAL INSURED provisions or be endorsed.
N SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,Curtain policies may require an endorsemern. A statement an I
PROD
this sc a ...°' of suchNA UEdorsement(sI.
certificate does not confer rights to the corHflcate holder In Ito
u
eXw7ACT m'otis a Sander
ifatc W'm�11"wlm Brent K Whitlock Insurance Agency Inc � oNt 310-821-0BB4 ° Nol, 310 1.6199
841 l9 �9dAIII, �.I
e_kssa.s
a .isak stlefar .co
A PN JGCOVERAM
E8ngHrlls Estates,CA 90247 I
NAlc r
INSURER A State Farm Mutual Automobile Insurance Company 25178
INSURED INSURER e; _............... ....................�..... .. ....
Christopher He
PPe� INSURER C:
DBA Precision Reef Systems INSURER o
7712 Goddard Ave WSURER E:
Los Allgcws,Ca 90045 INSURER r
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
rn P1E
LIMITS
LR TYPE Of INSURANCE POLICY IUNrFR �itmmoryyY dM"=4dOYiF
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCz S
""1iKr„E"T�5"11I'^aTr"r °
...........I CLAHWS-MACE I O'G.culg'
d AGGRE'GATE r_I'IM"'Appl..IES
AUfd";tk'�r- 1 G1'G. °
.
i eI44FFIIcII...wI.4bdM,s.lA:cllgNm"ErBr;4"a9"daiU
hq4LprLIMIT
OMoaeuAsem'
I 5129574-C14-75 09114I201B 03r14Y1019
�§' 'c p rr°INJURY aPm r) S 1.000.000
rMl�l��.+JTo RCYNLY
A a;',�„NPO SCHEDULED JL1 use:sa csef, s 1,000,000
)TC$ONLY AUrOS ,w11”Vvs
4HlRFO N0 ANEn ..d s„1,000,000
A'JIGS ONLY AUTOS ONLY rl4rr;V�,rr
UMORELLA LIAR OCCUR EACHOrC6RRENCE S
EXCESS Wie <:„I'.wrlWr dlJ,n�?Ie ADGREG ATF S
WORKERS C V,IEs; � !�f'Ip"raTutNNS ., I
ELI u:71n.., S ........
AIAd°LCr❑Cy.I IAaArrY s MI
E L EA
T 1,M�pareaEP"EY p+r)rrwE p ^✓1 AGGDENT'Yf
�ANO Err'1 rt4rIYJIi�'., i I YrJiN4'
4
YETI
Msrizosi
W Nrll
a
................ I E L DI..t15_ E4 ELIFCU EE S
'
rr Ye%'!40%4 ince 46"A4p'r ; g.: -
L DISEASE ..
f)F.'�fi�r,a=TYCr)W
Cr d')A"C,'��AF'��"„)'A�IS:'a4IaI`h I Ie:V I1MIT 'f
DEECRPTION OF OPERATIONS J LOCATIONS)VEHICLES[ACORO f01,AddNaml Rmr wks EcheMde,FM V be etochsd if man spice In eageired)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
The City of Et Segundo and its employees ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
AU FII-40MM REP'daE
Et Segundo.CA 9D245
"”-" 988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
rcur.x.Ilq 1224.9x5r ray 03116.:Tr
CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERS' CO PENSATION COVERAGE
IS UNLAWFUL AND SUBJECTS ANEMPLOYER 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:
(_J 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 El 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 Policy Number Expiration Date
Name of Agent �...._
Phone# ... ..,....__.,.u.a......,....,,
(\4-1 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 Califomia, and
agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must
immediately comply with those,ifovision or the a ement 111 automatically become void.
Signature of ApplicantDate
.
Print Names
io
Agreement for:
Dated:
Reviewed by.
w