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PROOF OF INSURANCE (2019 - 2019) CLOSED CERTIFICATE OF LIABILITY INSURANCE I DATE11/113!203120 YYYY) 18 THIS CERTIFICATE IS ISSUED ASA 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 Service k'AME�° Carroll Insurance Agency,Ltd, PHONE (281)656-3000 I t�Ax (281)656-3001 Aro Ne.Exlj, L. c,NaaY. 14906 FM 529 EMAIL service@carrollins corn ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC It Houston TX 77095 INSURERA: Valley Forge Insurance Company 20508 ... ...... _. ............ INSURED INSURER B: Continental Insurance Company I 35289 Fogarty and Klein,Inc,DBA 9th Wonder INSURER C: Continental Casualty Company 20443 1800 West Loop S INSURER D: Capitol Specialty Insurance Corporation 10328 Suite 2001INSURER E: Houston TX 77027 INSURER F COVERAGES CERTIFICATE NUMBER: 18-19 MASTER 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS """'.'.'.'.'.'.'.'.""".' AMDL Wt1R POLICY EFF' POLICY EXP ILTR �', TYPE OF INSURANCE IVSD WVD POLICY NUMBER (MM/DDIYYYY) (MMIDDIYYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 .. DAMAGE t0 REN I Eu CLAIMS-MADE ®OCCUR PREMISES(Ea occurrence) S 3®0,000 MED EXP(Any one Person) $ 10,x00 A B 6011433249 05/01/2018 05/01/2019 PERSONAL&ADV INJURY $ 1,000,000 .cR4'L✓4P„rP'RLs;f,u,l"C-:I.IM1"rAl'I'I II ESV+I..:I i...................... ...... � G ..,. GENERAL AGGREGATE S 2,aa0,000 POUCY Ll 7SC7' �...........� I G?G PRODUCTS-COMP/OPAGG S 2 000 000 )IHI"R 5 . _ ........... ,.,.,.,.,.,. ..._..._.�..�-..a. AUTOMOBILE LIABILITY COME)IN'EDSlNrt„E",Lifer s 1,000,000 dEa mctrd&nli —�'ANYAUTO BODILY INJURY(Per person) 5 B OWNED cGi Ir l)I u i..} 8 6016671563 05/01/2018 05/01/2019 IIODHY IN,IURY tl ar arri nlrr.} $ AUTOS ONLYAUTOS •..-._-. HIRED NON-OWNED FROPERT Y'P,:I✓MAa E $ AUTOS ONCY ,,,,,,,,,,,, AUTOS ONLY Iter 7crigtlrsmt'I UMBRELLA LIAR 10,p00,000 X 1"OCCUR EACH OCCURRENCE S CLAIMS-MADE AGGREGATE 5 C EXCESS LIAR B 6011433753 05(01(2018 05(01(2019 10,000,000 �I DFD I X1 RETL101011 S 10,000 5 WORKERS COMPENSATION YIN 4?I R J'fN- AND EMPLOYERS'LIABILITY �:1 fnt rU'I y E I FR ANY PROPRIETORIPARTNERIEXECUTIVE r""" 1NIA I E L EACH ACCIDENT S OFFICERIMEMBER EXGLUDED9 �''-i (Mandatory in NH) E L DISEASE-_.EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ Media-Limit $5,000,000 Media Liability CID Media Liability Excess 596461634/ME2018085-01 05(01!2018 05/01/2019 Media Excess-Limit $5,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) See attached Comments/Remark page(Form OFREMARK)for additional information CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of EI Segundo,its officials ACCORDANCE WITH THE POLICY PROVISIONS. and employees AUTHORIZED REPRESENTATIVE 350 Main St. EI Segundo CA 90245-3813 I ✓✓✓ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD SB146932F NA (Ed. 6-16) Policy#B 6011433249 BLANKET ADDITIONAL INSURED AND LIABILITY EXTENSION ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESSOWNERS LIABILITY COVERAGE FORM BUSINESSOWNERS COMMON POLICY CONDITIONS TABLE OF CONTENTS I. Blanket Additional Insured Provisions A. Additional Insured—Blanket Vendors B. Miscellaneous Additional Insureds C. Additional Provisions Pertinent to Additional Insured Coverage 1. Primary Noncontributory orov'ision .... .. ............._. ................. ................ 2. Definition o ......................... f"written contract." ..................................... li. Liability Extension Coverages A. Bodilv Iniury—Expanded Definition ............ B. Broad Knowledqe of Occurrence C. Estates, Legal Representatives and Spouses D. Legai Liability—Damage to Premises w.............. .............................................. �............_ E. Personal and Advertisino In"u —D'iscriminat'ion or Humiliation F. Personal and Advertisinq lniyg—°Broadened Eviction G. Waiver of Subrogation-Blanket I. BLANKET ADDITIONAL INSURED PROVISIONS A. ADDITIONAL INSURED—BLANKET VENDORS by Who Is An Insured is amended to include as an additional insured any person or organization (referred to below as vendor) with whom you agreed under a "written contract" to provide insurance, but only with respect to "bodily injury"or"property damage" arising out of"your products"which are distributed or sold in the regular course of the vendor's business, subject to the following additional exclusions: 1. The insurance afforded the vendor does not apply to: a. "Bodily injury" or"property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; b. Any express warranty unauthorized by you; c. Any physical or chemical change in the product made intentionally by the vendor; d. Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing, or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container; mm. ......... ..... _ ........... ...._... ........................................................ SB146 932F (6-16) Page 1 of 7 Copyright,CNA All Rights Reserved. SB146932F CNA (Ed. 6-16) e. Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products; f. Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; g. Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor; or h. "Bodily injury" or "property damage" arising out of the sole negligence of the vendor for its own acts or omissions or those of its employees or anyone else acting on its behalf. However, this exclusion does not apply to: (1) The exceptions contained in Subparagraphs d. or f.; or (2) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products. 2. This insurance does not apply to any insured person or organization, from whom you have acquired such products, or any ingredient, part or container, entering into, accompanying or containing such products. 3. This provision 2. does not apply to any vendor included as an insured by an endorsement issued by us and made a part of this Policy. 4. This provision 2. does not apply if "bodily injury" or "property damage" included within the "products- completed operations hazard" is excluded either by the provisions of the Policy or by endorsement. B. MISCELLANEOUS ADDITIONAL INSUREDS 1. Who Is An Insured is amended to include as an insured any person or organization (called additional insured) described in paragraphs 3.a. through 3.j. below whom you are required to add as an additional insured on this policy under a"written contract.": 2. However, subject always to the terms and conditions of this policy, including the limits of insurance, we will not provide the additional insured with: a. A higher limit of insurance than required by such"written contract",- b. ontract";b. Coverage broader than required by such "written contract" and in no event greater than that described by the applicable paragraph a.through k. below; or c. Coverage for "bodily injury" or "property damage" included within the "products-completed operations hazard." But this paragraph c. does not apply to the extent coverage for such liability is provided by paragraph 3.j. below. Any coverage granted by this endorsement shall apply only to the extent permitted by law. 3. Only the following persons or organizations can qualify as additional insureds under this endorsement: a. Controlling Interest Any persons or organizations with a controlling interest in you but only with respect to their liability arising out of.- (1) f:(1) such person or organization's financial control of you; or (2) Premises such person or organization owns, maintains or controls while you lease or occupy these premises; provided that the coverage granted to such additional insureds does not apply to structural alterations, new construction or demolition operations performed by or for such additional insured. SB146932F (6-16) Page 2 of 7 Copyright,CNA All Rights Reserved. SB146932F CNA (Ed. 6-16) b. Co-owner of Insured Premises A co-owner of a premises co-owned by you and covered under this insurance but only with respect to the co-owners liability for"bodily injury", "property damage" or"personal and advertising injury" as co-owner of such premises. c. Grantor of Franchise Any person or organization that has granted a franchise to you, but only with respect to such person or organization's liability for "bodily injury", "property damage", or "personal and advertising injury" as grantor of a franchise to you. d. Lessor of Equipment Any person or organization from whom you lease equipment, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused in whole or in part by your maintenance, operation or use of such equipment, provided that the "occurrence" giving rise to such "bodily injury" or "property damage" or the offense giving rise to such "personal and advertising injury" takes place prior to the termination of such lease. e. Lessor of Land Any person or organization from whom you lease land, but only with respect to liability for"bodily injury", "property damage" or"personal and advertising injury" arising out of the ownership, maintenance or use of that specific part of the land leased to you, provided that the "occurrence" giving rise to such "bodily injury" or "property damage" or the offense giving rise to such "personal and advertising injury", takes place prior to the termination of such lease. The insurance hereby afforded to the additional insured does not apply to structural alterations, new construction or demolition operations performed by, on behalf of or for such additional insured. f. Lessor of Premises An owner or lessor of premises leased to you, or such owner or lessor's real estate manager, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" arising out of the ownership, maintenance or use of such part of the premises leased to you, and provided that the"occurrence" giving rise to such "bodily injury"or"property damage" or the offense giving rise to such "personal and advertising injury", takes place prior to the termination of such lease. The insurance hereby afforded to the additional insured does not apply to structural alterations, new construction or demolition operations performed by, on behalf of or for such additional insured. g. Mortgagee, Assignee or Receiver A mortgagee, assignee or receiver of premises but only with respect to such mortgagee, assignee, or receiver's liability for"bodily injury", "property damage" or"personal and advertising injury" arising out of the ownership, maintenance, or use of a premises by you. This insurance does not apply to structural alterations, new construction or demolition operations performed by, on behalf of or for such additional insured. h. State or Political Subdivisions A state or government agency or subdivision or political subdivision that has issued a permit or authorization, but only with respect to such government agency or subdivision or political subdivision's liability for"bodily injury", "property damage"or"personal and advertising injury"arising out of: (1) The following hazards in connection with premises you own, rent, or control and to which this insurance applies: (a) The existence, maintenance, repair, construction, erection, or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoistaway openings, sidewalk vaults, street banners, or decorations and similar exposures; or (b) The construction, erection, or removal of elevators; or (c) The ownership, maintenance or use of any elevators covered by this insurance; or ...... .................... ......, m. SB146932F (6-16) Page 3 of 7 Copyright,CNA All Rights Reserved. SB146932F CNA (Ed. 6-16) (2) The permitted or authorized operations performed by you or on your behalf. But the coverage granted by this paragraph does not apply to: (a) "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the state or government agency or subdivision or political subdivision; or (b) "Bodily injury"or"property damage" included within the"products-completed operations hazard." With respect to this provision's requirement that additional insured status must be requested under a "written contract", we will treat as a "written contract" any governmental permit that requires you to add the governmental entity as an additional insured. i. Trade Show Event Lessor With respect to your participation in a trade show event as an exhibitor, presenter or displayer, any person or organization .whom you are required to include as an additional insured, but only with respect to such person or organization's liability for "bodily injury", "property damage", or "personal and advertising injury"cause by: a. Your acts or omissions; or b. Acts or omissions of those acting on your behalf; in the performance of your ongoing operations at the trade show premises during the trade show event. j. Other Person or Organization Any person or organization who is not an additional insured under paragraphs a. through i. above. Such additional insured is an insured solely for"bodily injury", "property damage" or"personal and advertising injury"for which such additional insured is liable because of your acts or omissions. The coverage granted by this paragraph does not apply to any person or organization: (1) For"bodily injury,""property damage,"or"personal and advertising injury"arising out of the rendering or failure to render any professional services; (2) For"bodily injury"or"property damage" included in the "products-completed operations hazard." But this provision (2) does not apply to such "bodily injury"or"property damage" if: (a) It is entirely due to your negligence and specifically results from your work for the additional insured which is the subject to the"written contract"; and (b) The "written contract" requires you to make the person or organization an additional insured for such"bodily injury"or"property damage"; or (3) Who is afforded additional insured coverage under another endorsement attached to this policy. C. ADDITIONAL PROVISIONS PERTINENT TO ADDITIONAL INSURED COVERAGE With respect only to additional insured coverage provided under paragraphs A. and B. above: 1. The BUSINESSOWNERS COMMON POLICY CONDITIONS are amended to add the following to the Condition entitled Other Insurance.- This nsurance:This insurance is excess of all other insurance available to an additional insured whether primary, excess, contingent or on any other basis. However, if a"written contract" requires that this insurance be either primary or primary and noncontributing, then this insurance will be primary and non-contributory relative solely to insurance on which the additional insured is a named insured. 2. Under Liability and Medical Expense Definitions, the following definition is added: "Written contract" means a written contract or agreement that requires you to make a person or organization an additional insured on this policy, provided the contract or agreement: a. Is currently in effect or becomes effective during the term of this policy; and b. Was executed prior to: SB146932F (6-16) Page 4 of 7 Copyright,CNA All Rights Reserved. SB146932F CNA (Ed. 6-16) (1) The"bodily injury"or"property damage"; or (2) The offense that caused the "personal and advertising injury", for which the additional insured seeks coverage. II. LIABILITY EXTENSION COVERAGES It is understood and agreed that this endorsement amends the Businessowners Liability Coverage Form. If any other endorsement attached to this policy amends any provision also amended by this endorsement, then that other endorsement controls with respect to such provision, and the changes made by this endorsement to such provision do not apply. A. Bodily Injury—Expanded Definition Under Liability and Medical Expenses Definitions,the definition of"Bodily injury" is deleted and replaced by the following: "Bodily injury" means physical injury, sickness or disease sustained by a person, including death, humiliation, shock, mental anguish or mental injury by that person at any time which results as a consequence of the physical injury, sickness or disease. B. Broad Knowledge of Occurrence Under Businessowners Liability Conditions, the Condition entitled Duties In The Event of Occurrence, Offense, Claim or Suit is amended to add the following: Paragraphs a. and b. above apply to you or to any additional insured only when such "occurrence," offense, claim or"suit"is known to: (1) You or any additional insured that is an individual; (2) Any partner, if you or an additional insured is a partnership; (3) Any manager, if you or an additional insured is a limited liability company; (4) Any"executive officer"or insurance manager, if you or an additional insured is a corporation; (5) Any trustee, if you or an additional insured is a trust; or (6) Any elected or appointed official, if you or an additional insured is a political subdivision or public entity. This paragraph applies separately to you and any additional insured. C. Estates, Legal Representatives and Spouses The estates, heirs, legal representatives and spouses of any natural person insured shall also be insured under this policy; provided, however, coverage is afforded to such estates, heirs, legal representatives and spouses only for claims arising solely out of their capacity as such and, in the case of a spouse, where such claim seeks damages from marital common property, jointly held property, or property transferred from such natural person insured to such spouse. No coverage is provided for any act, error or omission of an estate, heir, legal representative or spouse outside the scope of such person's capacity as such, provided however that the spouse of a natural person Named Insured and the spouses of members or partners of joint venture or partnership Named Insureds are insureds with respect to such spouses'acts, errors or omissions in the conduct of the Named Insured's business. D. Legal Liability—Damage To Premises 1. Under B. Exclusions, 1. Applicable to Business Liability Coverage, Exclusion k. Damage To Property, is replaced by the following: k. Damage To Property "Property damage"to: 1. Property you own, rent or occupy, including any costs or expenses incurred by you, or any other person, organization or entity, for repair, replacement, enhancement, restoration or maintenance of _.........._............................. __.............. ...._ SB146932F (6-16) Page 5 of 7 Copyright,CNA All Rights Reserved. SB146932F CNA, (Ed. 6-16) such property for any reason, including prevention of injury to a person or damage to another's property; 2. Premises you sell, give away or abandon, if the "property damage" arises out of any part of those premises; 3. Property loaned to you; 4. Personal property in the care, custody or control of the insured; 5. That particular part of any real property on which you or any contractors or subcontractors working directly or indirectly in your behalf are performing operations, if the "property damage" arises out of those operations; or 6. That particular part of any property that must be restored, repaired or replaced because "your work" was incorrectly performed on it. Paragraph 2 of this exclusion does not apply if the premises are "your work" and were never occupied, rented or held for rental by you. Paragraphs 1, 3, and 4, of this exclusion do not apply to "property damage" (other than damage by fire or explosion) to premises: (1) rented to you: (2) temporarily occupied by you with the permission of the owner, or (3) to the contents of premises rented to you for a period of 7 or fewer consecutive days. A separate limit of insurance applies to Damage To Premises Rented To You as described in Section D— Liability and Medical Expenses Limits of Insurance. Paragraphs 3,4, 5, and 6 of this exclusion do not apply to liability assumed under a sidetrack agreement. Paragraph 6 of this exclusion does not apply to "property damage" included in the "products-completed operations hazard." 2. Under B. Exclusions, 1. Applicable to Business Liability Coverage, the following paragraph is added, and replaces the similar paragraph, if any, beneath paragraph (14) of the exclusion entitled Personal and Advertising injury: Exclusions c, d, e, f, g, h, i, k, I, m, n, and o, do not apply to damage by fire to premises while rented to you or temporarily occupied by you with permission of the owner or to the contents of premises rented to you for a period of 7 or fewer consecutive days. A separate limit of insurance applies to this coverage as described in Section D. Liability And Medical Expenses Limits Of Insurance. 3. The first Paragraph under item 5. Damage To Premises Rented To You Limit of the section entitled Liability And Medical Expenses Limits Of Insurance is replaced by the following: The most we will pay under Business Liability for damages because of "property damage" to any one premises, while rented to you or temporarily occupied by you with the permission of the owner, including contents of such premises rented to you for a period of 7 or fewer consecutive days, is the Damage to Premises Rented to You limit shown in the Declaration. E. Personal and Advertising Injury—Discrimination or Humiliation 1. Under Liability and Medical Expenses Definitions, the definition of "personal and advertising injury" is amended to add the following: h. Discrimination or humiliation that results in injury to the feelings or reputation of a natural person, but only if such discrimination or humiliation is: (1) Not done intentionally by or at the direction of: (a) The insured; or m........................._, ....................... ................. SB146932F (6-16) Page 6 of 7 Copyright,CNA All Rights Reserved. ��II�� S B 146932 F CNA (Ed. 6-16) (b) Any "executive officer," director, stockholder, partner, member or manager (if you are a limited liability company) of the insured; and (2) Not directly or indirectly related to the employment, prospective employment, past employment or termination of employment of any person or person by any insured. 2. Under B. Exclusions, 1. Applicable to Business Liability Coverage, the exclusion entitled Personal and Advertising injury is amended to add the following additional exclusions: (15)Discrimination Relating to Room, Dwelling or Premises Caused by discrimination directly or indirectly related to the sale, rental, lease or sub-lease or prospective sale, rental, lease or sub-lease of any room, dwelling or premises by or at the direction of any insured. (16)Employment Related Discrimination Discrimination or humiliation directly or indirectly related to the employment, prospective employment, past employment or termination of employment of any person by any insured. (17)Fines or Penalties Fines or penalties levied or imposed by a governmental entity because of discrimination. 3. This provision (Personal and Advertising Injury — Discrimination or Humiliation) does not apply if Personal and Advertising Injury Liability is excluded either by the provisions of the Policy or by endorsement. F. Personal and Advertising Injury -Broadened Eviction Under Liability and Medical Expenses Definitions, the definition of "Personal and advertising injury" is amended to delete Paragraph c. and replace it with the following: c. The wrongful eviction from, wrongful entry into, or invasion of the right of private occupancy of a room dwelling or premises that a person or organization occupies committed by or on behalf of its owner, landlord or lessor. G. Waiver of Subrogation—Blanket We waive any right of recovery we may have against: a. Any person or organization with whom you have a written contract that requires such a waiver. h All other terms and conditions of the Policy remain unchanged. Fy O N N SB146932F (6-16) Page 7 of 7 Copyright,CNA All Rights Reserved. COMMENTS/REMARKS The tion cral Liability policy includes as blankct additional insured cn&=zcwnT provislun that provides additional insured staLus to Ac certificate holder ono, k&en Acre io a wriMcn contract that requirco such status. The contractual liability covc.xagc by the Gencral. Liability is standard d"d may not covcr all liabilities assume( by 1-11c, named insured under its contract with the ccrtiticate holder. The Gcncral Liability policy includus a Blanket Waiver oi Suhroqation EndorscnNl. War, pnwides this Nature only when there is a written corkract that rcMArcs such status. 0FREMARK COPYRIGHT 2000, AMS SERVICES INC. CNA CNA8( 31 ( 094) Policy # B 6011433249 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY- OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: BUSINESSOWNERS COMMON POLICY CONDITIONS The following is added to Paragraph H. Other Insurance and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: 1. The additional insured is a Named Insured under such other insurance; and 2. You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. All other terms and conditions of the Policy remain unchanged. a N CNA80103XX (09-14) Page 1 of 1 Copyright,CNA All Rights Reserved,Includes copyrighted material of Insurance Services Office,Inc,with its permission DATE(MMIDDIYYYY) AC"R CERTIFICATE OF LIABILITY INSURANCE 11/6/2018 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 Risk Management Depar'Rnnel�rl Commercial Lines-(305)443-4886 PHONE FAX (AIC.No,Ext): (866)443-8489 1Aro, (800)889-0021 USI Insurance Services National, Inc. E-NIAIL Work Clar`n ITrnnet com ADDRESS: p'lr.. 2601 South Bayshore Drive,Suite 1600 INSURER(S)AFFORDING COVERAGE NAIC h Coconut Grove, FL 33133 INSURERA: ACE American Insurance Company 22667 INSURED INSURER B: TriNet HR III, Inc, INSURER C L/C/F:Fogarty&Klein, Inc dba The Company INSURER D: 9000 Town Center Parkway INSURER E: Bradenton, FL 34202 INSURER F COVERAGES CERTIFICATE NUMBER: 13640599 REVISION NUMBER: See below 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 LTR ADCIL SU'SR E R POI.IC1"EFF (' POLlt"Y EXP }"�1;.'unw�'ern,N�:,(/a'hl-kfN q{4°ItlS LTR ''INSr1 WVO POLICY NUMBER TYPE OF INSURANCE gIWYM,JC(YEFF 1MVN18DDPYYYYI LIMIT COMMERCIAL GENERAL LIABILITY of S 1 {'IU:UF! I`RI3M1JU$ES yEu r�fl S „ . IMr r)C M-iA,nv unr.p,,r!�uDw S . I-[W.rCP NAI_,µADV II'-0.11URY 5 :.;r r,d"L/,Y'^a:41"¢"„r�,If 1,III/nr LSI"T1H C>4"IR �Glr NL ',AL,M+. ,F".I-I,nAfI S ., i :S AUTOMOBILE LIABILITY N.:r;16,1fiINEI:t;1PEul'"JLELIM111i S P9 d:s,x.,d'nI IN.11.11-'L...... la,+r I�r rs�r,rj 5 11W NkryI': �i,GMiF ljrlyl II_U .Rl:vl Y P IV_ F" �,- S JII I:.,� UY^kl.''r ,III os d.7 i� lf?'N�'r""!N�P�'Gµ1'"I .,rrld AU u 11l.!"Y0;CN10 .,....•.•. ,tilllf."F.1.,N1 i' PM,:.:.�.'u�.'"qN:l S UMBRELLA LIAB EXCESS LIAB C;I.AII,A:;hA v�i AC &1r SCA"G f .� DED RETENTIONS 5 WORKERS COMPENSATION II A WLR C65550854 ' P nn! F I oRH AND EMPLOYERS LIAB E Y—IN — ✓ �Mlanda�KrrfrniNMlh:PI'✓•��1VPIIuf��,UvECUTIVE N NIA 7/1/2018 7/1/2019 I-II II".,h�Na:�l Ilati.lrnrulrrrlr s ... ':rlt,ln('tl t Y Y _ mm If yes,describe under E L DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Workers'Compensation coverage is limited to worksite employees of Fogarty&Klein, Inc dba The Company through a co-employment agreement with TriNet HR III, Inc, CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo,CA 90245 AUTHORIZED REPRESENTATIVE The ACORD name and logo are registered marks of ACORD ©1988-2015 ACORD CORPORATION. All rights reserved, ACORD 25(2016103) Workers'Compensation and Employers' Liability Policy Named insured Endorsement Number TdNet HR III,Inc. Policy Number WLR C65550854 UC/F:Fogarty&Klein,Inc.dba 9th Wonder Symbol: Number: Policy Period Effective Date of Endorsement 7/1/2018 TO 7/1/2019 _.Q?-01-2018 Issued By(Name of Insurance Company) ACE American Insurance Company Insert the policy number The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract to obtain this waiver from us. You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. Schedule 1. (X) Specific Waiver Name of person or organization: City 350 Main i Segundo ain Street EI Segundo,CA 90245 ( ) Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Operations: 3. Premium: The premium charge for this endorsement shall be percent of the California premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. 4. Minimum Premium: Authorized Agent WC 99 03 22 1