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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