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PROOF OF INSURANCE (2019 - 2019) CLOSED CERTIFICATE OF LIABILITY INSURANCE DATE(MMtQOrYYYY)
11/28/2018
THIS CERTIFICATE 18 TION ONLY AND CONFERS NO
UPON THE CERTIFICATE HOLDER. THIS"''
CERTIFICATE 0013
SDCER PLOT OFAFFIRMATIVELY OR INSURANCE DOES NSSUED AS A MATTER OF OT CONSTITUTE E TEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
CONTRACT 897WEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
If
cBROGAe does WAIVED,rightssusubject
o the terms
..,.nd INSURE It .f t
11
J arms and condition
holder is an ADDItl a policy(ies)'must have ADDITIONAL INSURED provislona or be endorsed,
the policy, oetfialn pI•rllclos may require an endorsement. A statement an
lMP if the csMtlft
cEte
lis o such endorsement(s),
PRODStatUCER
SKALA INSURANCE �Certificate holder III.. �tcl eek.. ..
NCE AGENCY INC(1216) ri NE 9Q&l�$83-8881 __.
4214 N SIERRA WAY s+
It.
SAN BERNARDINO,CA 92407 INSURER(R At f, O;RG Inq COVERAGENAIc#
INSURER A, State Farm General Insurance Company x8161
NSURaD INsuriERa. 'State Farm Mutual Autom.ablleInsurance Company 25178
NANCY K BOHL INC INaURER c:
DSA THE COUNSELING TEAM INTERNATIONAL INSURER 0:
AND QBA THE ORGANIZATIONAL NETWORK INSURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN!ISSUFO TO THE IN'SUR'ED NAMED ABOVE FOR THE POLICY PERIOD I
INDICATED. i•OTWTHSTANDINC ANY REQUIREMENT,,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VATH RESPECT TO WHICH THIS
CERTIFICATE MAY BE iSSUED OR. MAY PERTAIN, THE INSURANCE,AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
TNSR AOtal E'U1$R PC}UC�V'#VF " �8�1't,.i�CY EXP
TYPE OF INSURANCE.
POLIRX Nl�ip BER ,1MMPODAYtlYYb i1atM+TIC11yYYYl I LIMITS
COMMERCIAL GENERAL LIABILITY -�EACH OCCURRENCE s 1.000,000
AIMS-MAGE OCCUR "AIMAQ300,000
Fl SeHIR�D AUTOAO 92L814261&92YD04220 07112!2018 ny ran! arTc'n s 5.000
E
L 07/12/2019
PERSONAL d V„IIJIURY S
GEN`L AQC+REGATE LIMIT APPLIES PER: GCI�£Rn%L GL�R£CA"%E s 2,400,000
POLICY 0 JEC LOC ptPiOP A!IOr S
PRODUCT"+=CQ
19 t)THER: S
AUTOMOBILE LIABILITY 4414187F2475 06/24/2018 06/24/2019 EQVWNEUw INGLELIMIT s
ANY AUTO
B
SC
DILY INJURY(Per
portion) S
000OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY(Per accident) S 1,000,000
HIRED _rRn "1AO£AOS ONLY AUTOS ONLY
S 1,000,000
.....�.,..... .,, OCCUIS-twiADe,., ...,. „ ..,,
S
UMBRELLA LV1B OCCUR � � EACH OCCURRENCE S
EXCESS LIAR I AGGREGATE li S
I DED � I RETENTION S
I h�
WORXERS COMkNSATIONER
AN,0 EMPLOYERS'LIABILITY YIN 15 ATUTE I I FRH
ANY PROPRIETOR'PAR:TNFRIEXE TiVE E.L.EACH ACGi'DEN7 $
'OPPICErtPM EMSER EXCLUDED? ❑ NIA II
(Mondatory in NN) f e,o0scr6ba under E.L.DI$1'AS£..£AEMPLOY££�5
Irg+ti
G3ESCRIPTION DR OPERATIONS tinkriv E .DIS'EA'SE•POLICY UMIT S
I
068CRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required)
Business Office Policy Property Locations;
1881 Business Center Dr,San Bernardino, CA 92408 39755 Murrieta Hat Springs Rd,Ste 0160,Murrieta,CA 92563
1545 Anacapa Rd Ste 7C,Victorville,CA 92392 135 S State College Blvd Ste 200,Brea,CA 92821
444 Camino Del Rio Ste 2015,San Diego,CA 92108 7220 Avenida Encinas Ste 125,Carlsbad,CA 92011
74075 EI Paseo Ste A9,Palm Desert,CA 92260
232 W Harrison Ste D.Claremont,CA 91711
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 officers,officials,employees,agents ACCORDANCE WITH THE POLICY PROVISIONS.
and volunteers, Aa
350 Main St
EI Segundo,CA 90245 Au .p
ATPr
ell
1
0 1988011eACOR6 GOR ORATIO A 'r t
11erved»
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
601456 132549.12 03-16-2016
92-YD-0422-0 028378 CMP-4786 1
b Page 1 of 2
THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY
CMP-4786.1 ADDITIONAL INSURED — OWNERS, LESSEES, OR CONTRACTORS
(Scheduled)
This endorsement modifies insurance provided under the following,
BUSINESSOWNERS COVERAGE FORM
SCHEDULE
Policy Number: 92-YD-0422-0
Named Insured:
NANCY K BOHL INC
DBA THE COUNSELING TEAM
INTERNATIONAL AND DBA THE
ORGANIZATIONAL NETWORK
PO BOX 10427
SN BERNRDNO CA 92423-0427
Name And Address Of Additional Insured Person Or Organization:
CITY OF EL SEGUNDO
ITS OFFICERS OFFICIALS
EMPLOYEES AGENTS &VOLUNTEERS
350 MAIN ST
EL SEGUNDO CA 90245-3895
1. SECTION II — WHO IS AN INSURED of b. If coverage provided to the additional in-
SECTION II — LIABILITY is amended to in- sured is required by a contract or agree-
olude, as an additional insured, any person or ment, the insurance provided to the
organization shown in the Schedule, but only additional insured will not be broader than
with respect to liability for "bodily injury', that which you are required by the contract
"property damage"', or ""personal and adverbs- that
agreement to provide for such addition-
ing injury" caused, in 'whole or in part, by:
a. Ongoing Operations al insured; and
c. If the contract or agreement between you
(1) Your acts or omissions; or and the additional insured is governed by
(2) The acts or omissions of those acting California Civil Code Section 2782 or
on your behalf; 2782.05, the insurance provided to the
additional insured is the lesser of that
in the performance of your on�oing opera- which:
tions for that additional insure " or
b. Products–Completed Operations (1) Is allowed for the satisfaction of a de-
p fense or indemnity obligation by Cali-
"Your work" performed for that additional fornia Civil Code Section 2782 or
insured and included in the "products- 2782.05 for your sole liability; or
completed operations hazard". (2) You are required by contract or
However, Paragraph 1. above is subject to the agreement to provide for such addi-
following: tional insured.
a. The insurance afforded to the additional We have no duty to defend or indemnify the
insured only applies to the extent permit- additional insured under this endorsement un-
ted by law; til a claim or"suit" is tendered to us,
©,Copyright, State Farm Mutual Automobile Insurance Company,2013
Includes copyrighted material of Insurance Services Office, Inc.,with its permission.
CONTINUED
;''iw..V�'..;p, i'wa°.. p r�";�'������"8 M 28370 OMP-117861
Page 2 of',
2. Any iaa;:,uar ;mce pr()�-^''iet-1 to thi:' additional in- (3) The nature and location of any injury
";cured shall only apply with respect to a claim or damage arising out of the "occur-
I-n ade o'r' a "stair"" l.arotugM for damages for rence" or offense;
which you are provided coverage. b. Tonder the defense and ind'ennnity of any
3. With Respect to the insurance afforded to the claina or "suit" to us and to all other insur-
additional insured, the following is added to ers who may have; Insurance potentially
SECTION II — LIMITS OF INSURANCE: available to the additional insuredand
If coverage provided to the additional in Urecl c. Agree to make available any other insur-
is rega.rire'd by contract or agreement, the most ance the additional insured has for de-
we willpaaay on behalf of the additionalinsur°ed fense or damages for which we would
will be tWae lesser of the amount of insurance, provide coverage under SECTION II —
a. Required by the contract or agreement; or LIABILITY.
b. Available under the applicable Limits Of 5. With respect to the insun..)i'u o afforded the ad-
Insurance shown in the Declarations. ditional insured, the following replaces SEC-
TION II —LIABILITY of l-'aragra'ph 7. Other
This endorsement shall not increase the ap- Insurance of SECTION I AND SECTION II —
plicable Limits Of Insurance shown in the COMMON POLICY CONDITIONS:
Declarations. a. This insurance is primary to and will not
4. With respect to the insurance afforded to the seek contribution from any other insurance
additional insured, the following is added_ to available to the_additional insured, provided
Paragraph 3. Duties In The Event Of Occur- th;par t.l"ae addition al insured is a nrariu'vcl in-
rence, Offense, Claim Or Suit of SECTION sured under such other insurance.
II —GENERAL CONDITIONS: b. lRegardless of any agreernent between
The additional insured must: yoga aml the ade.,it'ional irasa.raed, this insur-
ance is excess over any other insurance
a. See to it that we are notified as soon as whethei, primary,, excess, cuntingent or ori
faracticable of an "occurrence" or an of- any other basis for which the additional in-
ense which may result in a claim. To the sured has been gadded as an additional in--
extent possible, notice should include: sured on other policies.
(1) [low, when and where the "occur- There will be no refund of premium in the event
rence" or offense took place; this endorsement is cancelled.
(2) The nan-ies and addresses of any in-
jured p or ons and witnesses; and All other policy provisions apply.
CMP-4786 1
0,Copyright, State Farm Mutual Automobile Insurance Company,2013
Includes copyrighted material of Insurance Service=Office, Inc,with its permission
92-YD-0422-0 028380
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
CMP-4787 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST
OTHERS TO US
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
SCHEDULE
Policy Number: 92-YD-0422-0
Named Insured:
NANCY K BOHL INC
DBA THE COUNSELING TEAM
INTERNATIONAL AND DBA THE
ORGANIZATIONAL NETWORK
PO BOX 10427
SN BERNRDNO CA 92423-0427
Name And Address Of Person Or Organization:
CITY OF EL.SEGUNDO
ITS OFFICERS OFFICIALS
EMPLOYEES AGENTS & VOLUNTEERS
350 MAIN ST
EL SEGUN'DO CA 90245-3395
The following is added to Paragraph 10.b. of SECTION I AND SECTION II — COMMON POLICY
CONDITIONS:
We waive any right of recovery we may have against the person or organization shown in the Schedule
because of,payments we make for injury or damage arising out of.-
a.
f:a. Your ongoing operations; or
b. "Your work" done under contract with that person or organization and included in the "products-
completed operations hazard".
This waiver applies only to the person or organization shown in the Schedule.
All other policy provisions apply.
CMP-4787
©,Copyright,State Farm Mutual Automobile Insurance Company,2008
Includes copyrighted material of Insurance Services Office, Inc., with its permission
PHILADELPHIA
CPH INSURANCE COMPANIES
MAUS
Certificate of Liability Insurance
Date Issued:11/20/2018
Underwritten by:Philadelphia Indemnity Insurance Company-Ono Bala Plaza,Butte 100-Bala Cynwyd,PA 10004-NAIC#:18050
Administered by:CPH S Associates-711 S.Dearborn St.Ste 206,Chicago,IL 00005,P 800,876,1011 -F 310.087,0002-Info®cphlns,com
DISCLAIMER:This certificate Is Issued as a matter of Information only and confers no rights upon the certificate holder,The Certificate of Insurance dons not
constitute a contract between the tseuing Ineurar(s),authorized representative or producer,and the certlfimts holder,nor does It affirmetivsly or negatively amend,
eWord,or altar thin ooverege afforded by the policies listed thereon,
Insured: Nancy K. BON Inc, dbe The Counseling Policy Number: 025826
Team International
Nancy BON Policy Term: 08/31/2018 to 08/31/2019
1881 Business Center Dr, #11
San Bernardino, CA 92408
Covered Locations
Professional Liability: Portable coverage, not location specific
Coverage Type Per Incident Aggregate
(Occurrence Form) (Per Individual claim) (Total amount per yeah)
Professional Llabillty $ 1,000,000 $ 5,000,000
Supplemental Liability $ 1,000,000 $5,000,000
Licensing Board Defense $36,000 $ 35,000
Commercial General N/A N/A
Liability N/A N/A
Fire/Water Legal Llablllty
Business Personal Property N/A N/A
Vicarious Sexual $1,000,000 $ 1,000,000
Misconduct
Comments/Special Descriptions:
Certificate Holder
EI Segundo Police Department
348 Main Street
EI Segundo, CA 90245
®Certificate Holder has been added as an additional Insured
If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed.A statement on this certificate does not confer rights to the certificate holder in
lleu of such endorsement(s).Notice of Cancellation will only be provided to the first named Insured In accordance with policy provisions,who shall act on behalf of all
additional Insureds with respect to giving notice of cancellation,
oC1
Alift-
Authorized Representative
C.Philip Hodson
TH
10Y. tLEA$E ReAD II GAREELILLY
Additional Insured Endorsement
This endorsement modifies Insurance provided under the following:
ALLIED HEALTHCARE PROVIDERS PROFESSIONAL
AND SUPPLEMENTAL LIABILITY POLICY
In consideration of the premium paid,this policy Is amended as follows:
EI Segundo Police Department Is hereby added as an Additional Insured, solely for Damages arising out
of a Professional Incident covered under this policy,The Professional Incident must arlse out of
services provided by the Insured, under contract with EI Segundo Police Department,
Additional Insured Name and Melling Address:
EI Segundo Police Department
348 Main Street
EI Segundo, CA, 90245
"Added to the policy effective 11/26/2018, at the additional premium of$25
All other terms and conditions of this policy remain unchanged, This endorsement Is part of your policy and
takes effect on the effective date of your Policy,unless another effective date Is shown below.
Policy: 025826
Effective on and after: 11/26/2018
Issued to: Nancy K. Bohl Inc, dba The Counseling Team Internatlonal
Expiration date: 08/31/2019
PI-PHCP-05(03/01)
e&,_�Q�
By: Robert O'Leary, Authorized Representative
POLICYHOLDER CY
182, PLEASANTON, CA 94588
FUNO
CERTIFICATE I INSURANCE
ISSUE DATRi 11-20-2018 GROUP®
POLICY U SER: 0702761-2010
CERTIFICATE Iii; 94
CERTIFICATE EXPIRES; 08-12-2019
08-12-2010/00-12-2019
L SEGUNDO POLICEENT SP
348 MAIN ST
L SEGUNDO CA 00245-3813
This Is to certify that we have Issued a valid Workers' Compensation Insurance policy In a form approved by the
California Insurance Commissioner to the employer named below for the policy period Indicated.
This policy Is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer.
We will also give you 3 days advance notice should this policy be cancelled prior to Its normal expiration
This certificate of Insurance Is not an Insurance policy and does not amend, extend or alter the coverage afforded
by the pol°oy listed herein. Notwithstandlne any requirement, term or condition of any contract or other document
with respect to which this certificate of Insurance may be Issued or to which It may pertain, the insurance
afforded by the policy described herein Is subject to all the terms, exclusions, and conditions, of such policy,
i,atl�or'ized RCpreOrsrrtetive President and CEO
EMPLOYER'S LIABILITY L L I E $1,000,000 PEROCCURRENCE.
ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2018-11-28 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED:
EL SEGUNDO POLICE DEPARTMENT
ENDORSEMENT #2088 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08-12-2011 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2018-11-28 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME:
EL SEGUNDO POLICE DEPARTMENT
ENDORSEMENT #1881 - NANCY K ROHL P,S,T - EXCLUDED.
EMPLOYER
NANCY K ROHL INC SP
1881 BUS CTR OR STE 11
SAN BERNADINO CA 92408
[P1X,HO]
(REv.7-2074) PRINTED : 11-28-2018
ENDORSEMENT AGREEMENT
compeNSATION WAIVER OF SUBROGATION
702761-18
, FUND RENEWAL
SP
HOME OFFICE 2-47-86-99
SAN FRANCISCO PAGE 1 OF 1
ALL EFFECTIVE DATES ARE
AT 12:01 AM PACIFIC EFFECTIVE NOVEMBER 26, 2018 AT 12.01 A.M.
STANDARD TIME OR THE
TIME INDICATED AT AND EXPIRING AUGUST 12, 2019 AT 12.01 A.M.
PACIFIC STANDARD TIME
NANCY K BOHL INC
1881 BUS CTR DR STE 11
SAN BERNADINO, CA 92408
ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING,
IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND
WAIVES ANY RIGHT OF SUBROGATION AGAINST,
EL SEGUNDO POLICE DEPARTMENT
WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS
POLICY IN CONNECTION WITH WORK PERFORMED BY,
NANCY K BOHL INC
IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN
PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION
OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE
EMPLOYER.
IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH
EMPLOYEES SHALL BE INCREASED BY 03%.
NOTHING IN THIS ENDORSEMENT SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND
ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY
OTHER THAN AS ABOVE STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE
HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR
LIMITATIONS IN THIS ENDORSEMENT.
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: NOVEMBER 28, 2018 2570
AUTHORIZED REPRESENTA 'IVE PRESIDENT AND CEO
-SG_ F FORM 10217 IREV.4.2018) OLD DP 217