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PROOF OF INSURANCE (2020) CLOSED AC's CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 2/5,/2019 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 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 doss not confer rights to the PR a Companies Inc. i#F+M urs Aguinaga certificate holder in Ileu o such en orsomen s PHONECT (909)243-8200 M_.. _.. PRODUCER La Y omp AX PHO Nca Esti ... �1 Nn! 4200 Concours, Suite ))350 MAllp � !N+lsuR�f�i�)a��ts�faw�a�OOv�G�aa� { Nalc,r Ontar„i.°........ _ _.................... ......... ...... CA..._91764.... INSURER n, dimtinel, 1nsur&;ceC9;WpnY..S,td 11000 INSURED INSURER S: ........ __........ „„ iI ...................................._.., Rr Dynamics cPerformance RC ........ 461 Green P . NIIVRERp jN'URERE: _ ,,... Riverside CA 92506 INSURER F: COVERAGES CERTIFICATE NUMBER:CL192574768 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 SEEN REDUCED BY 'AID CLAIMS. . .r.,w r TIR.,.. TYPE OF INSURANCE 'A�Ot)i.�9'ERR, POLICY NUMBER 4M16,,G4'EFPI,,.,P�LI�Y kP..,- ,,. LIMITS X COMMERCIAL O ,,•,• nen g 1,�, 6J�f'!"yyy) fMMIDDJYYYYi .,. 000,000 ENE ABILITY Ckt $a Y �1RIJY c w , .5 1.',. ..10,000 000 A CLAIMS- RE X OCCUR X 416BAM0763 1/9/2019 1/9/2020 mr" E�xP�A,Y..,.,w.F'?r���y „ .... 2,000 000,. PERSCNAI�AC4'tR4JU'iY 5 a I G:afi:RrG'FRALAGGREG.,....E a E:r�dn.Ar:3CaNTE:C'aATI"LIMIT APPLIES ATE 4,000,000 X rN PRO- El LOC ^ C 4,000,000 UIl.cy I JECT 41kN.5ElVNL4; arae L[ L AGG 5,,,,. 000 b P Ell M..4S d ... _ I UTW�fiII;�R � XCY&3R ,. � S I I U'rBhtOaiLE LIABILITY sl{rr'nyara,y,) $ 1,000,000 A..... ANY AUTO BPDLY rkitlNgJriUh,I R'Y( A ALL OWNED SCHEDULED 416BANNO763 1/9/2019 1/9/2020 BODILY INJURY(Per w.dd.e_n t.m�$ — . PUEO UA � S HIRED AUTOS AUTOS ........ .............. u UMBRELLA LIAR OCCUR I•,a�° (X',E.4IYARE NE,r,, ..... ..,.,, , EXCESS UA8 �4 tpiry��7�AGHk' Ip I .GCrTfik'.ar'e'I S DE,D II �RET1,0TIO1III ...,, 3 . AND EMPLOYERS'LIABILITY PCdk I 1*RO ukillk'EkWPARTNE,WEXV.0"IJT1V0 EL IALH UQ "' WORKERS COMPENSATION' �Y°°j°"gip NlA� rTAl1A iG7EN'T�&WTrd.,,,• IER GMandatorAi�.9tNH)EXCLUCbECi� .,......,,.,o� ...r L DISEASE PG's&E,,MP ..,, ...,.. .,,.,.__,.., ANY' tibia �„ (Mgsldufio�ry in NH !r of tMN�CPYbdc unrdar' EA E' PC YCE ON OF OK"RAILIONu rM10 E L G}! EA � I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addibon0l Remuks Schedule,may be aWched If mon epace Is required) City of 91 Segundo is additional insured ger attached policy form. a CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. E1 Segundo, CA 90245 AUTHORIZED REPRESENTATIVE i IW MerBhon/NGARCT 019882014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD INS025 wuo1) SPECTRUM POLICY DECLARATIONS (Continued) POLICY NUMBER: 41 SBA NN0763 BUSINESS LIABILITY LIMITS OF INSURANCE LIABILITY AND MEDICAL EXPENSES $2, 000, 000 MEDICAL EXPENSES -ANY ONE PERSON $ 10, 000 PERSONAL AND ADVERTISING INJURY $2, 000, 000 DAMAGES TO PREMISES RENTED TO YOU $1,000, 000 ANY ONE PREMISES AGGREGATE LIMITS PRODUCTS-COMPLETED OPERATIONS $4, 000,000 FORM SS 05 09 GENERAL AGGREGATE $4, 000,000 BUSINESS LIABILITY OPTIONAL COVERAGES HIRED/NON-OWNED AUTO LIABILITY $2, 000,000 UNMANNED AIRCRAFT LIABILITY FORM: SS 42 06 Form SS 00 02 12 06 Page 005 (CONTINUED ON NEXT PAGE) Process Date: 10/24/18 Policy Expiration Date: 01/09/20 BUSINESS LIABILITY COVERAGE FORM F. OPTIONAL ADDITIONAL INSURED 3. Additional Insured -Grantor Of Franchise COVERAGES WHO IS AN INSURED under Section C. is If listed or shown as applicable in the Declarations, amended to include as an additional insured one or more of the following Optional Additional the person(s) or organization(s) shown in the Insured Coverages also apply. When any of these Declarations as an Additional Insured - Optional Additional Insured Coverages apply, Grantor Of Franchise, but only with respect to Paragraph 6. (Additional Insureds When Required their liability as grantor of franchise to you. by Written Contract, Written Agreement or Permit) 4. Additional Insured - Lessor Of Leased of Section C., Who Is An Insured, does not apply Equipment to the person or organization shown in the a. WHO IS AN INSURED under Section C. is Declarations. These coverages are subject to the amended to include as an additional terms and conditions applicable to Business insured the person(s) or organization(s) Liability Coverage in this policy, except as shown in the Declarations as an Additional provided below: Insured — Lessor of Leased Equipment, 1. Additional Insured - Designated Person Or but only with respect to liability for "bodily Organization injury", "property damage" or "personal WHO IS AN INSURED under Section C. is and advertising injury" caused, in whole or amended to include as an additional insured in part, by your maintenance, operation or the person(s) or organization(s) shown in the use of equipment leased to you by such Declarations, but only with respect to liability person(s)or organization(s). for "bodily injury", "property damage" or b. With respect to the insurance afforded to "personal and advertising injury" caused, in these additional insureds, this insurance whole or in part, by your acts or omissions or does not apply to any 'occurrence" which the acts or omissions of those acting on your takes place after you cease to lease that behalf: equipment. a. In the performance of your ongoing 5. Additional Insured - Owners Or Other operations; or Interests From Whom Land Has Been b. In connection with your premises owned Leased by or rented to you. a. WHO IS AN INSURED under Section C. is 2. Additional Insured - Managers Or Lessors amended to include as an additional Of Premises insured the person(s) or organization(s) shown in the Declarations as an Additional a. WHO IS AN INSURED under Section C. is Insured—Owners Or Other Interests From amended to include as an additional insured Whom Land Has Been Leased, but only the person(s)or organization(s)shown in the with respect to liability arising out of the Declarations as an Additional Insured - ownership, maintenance or use of that part Designated Person Or Organization; but only of the land leased to you and shown in the with respect to liability arising out of the Declarations. ownership, maintenance or use of that part of the premises leased to you and shown in the b. With respect to the insurance afforded to Declarations. these additional insureds, the following additional exclusions apply: b. With respect to the insurance afforded to these additional insureds, the following This insurance does not apply to: additional exclusions apply: (1) Any 'occurrence" that takes place This insurance does not apply to: after you cease to lease that land; or (1) Any 'occurrence" which takes place (2) Structural alterations, new after you cease to be a tenant in that construction or demolition operations premises; or performed by or on behalf of such (2) Structural alterations, new person or organization. construction or demolition operations 6. Additional Insured - State Or Political performed by or on behalf of such Subdivision—Permits person or organization. a. WHO IS AN INSURED under Section C. is amended to include as an additional insured the state or political subdivision shown in the Declarations as an Additional Page 18 of 24 Form SS 00 08 04 05 BUSINESS LIABILITY COVERAGE FORM Insured — State Or Political Subdivision - (e) Any failure to make such Permits, but only with respect to inspections, adjustments, tests or operations performed by you or on your servicing as the vendor has agreed behalf for which the state or political to make or normally undertakes to subdivision has issued a permit. make in the usual course of b. With respect to the insurance afforded to business, in connection with the these additional insureds, the following distribution or sale of the products; additional exclusions apply: (f) Demonstration, installation, This insurance does not apply to: servicing or repair operations, except such operations performed (1) Bodily injury", property damage or at the vendor's premises in "personal and advertising injury" connection with the sale of the arising out of operations performed for product; the state or municipality; or (g) Products which, after distribution (2) "Bodily injury" or "property damage" or sale by you, have been labeled included in the "product-completed or relabeled or used as a operations" hazard. container, part or ingredient of any 7. Additional Insured—Vendors other thing or substance by or for a. WHO IS AN INSURED under Section C. is the vendor; or amended to include as an additional (h) "Bodily injury" or "property insured the person(s) or organization(s) damage" arising out of the sole (referred to below as vendor) shown in the negligence of the vendor for its Declarations as an Additional Insured - own acts or omissions or those of Vendor, but only with respect to "bodily its employees or anyone else injury" or "property damage" arising out of acting on its behalf. However, this "your products" which are distributed or exclusion does not apply to: sold in the regular course of the vendor's (i) The exceptions contained in business and only if this Coverage Part Subparagraphs d provides coverage for "bodily injury" or ( 1 or(fl; or "property damage" included within the (ii) Such inspections, "products-completed operations hazard". adjustments, tests or servicing as the vendor has agreed to b. The insurance afforded to the vendor is make or normally undertakes subject to the following additional exclusions: to make in the usual course of (1) This insurance does not apply to: business, in connection with (a) "Bodily injury" or "property the distribution or sale of the damage" for which the vendor is products. obligated to pay damages by (2) This insurance does not apply to any reason of the assumption of insured person or organization from liability in a contract or agreement. whom you have acquired such This exclusion does not apply to products, or any ingredient, part or liability for damages that the container, entering into, vendor would have in the absence accompanying or containing such of the contract or agreement; products. (b) Any express warranty 8. Additional Insured—Controlling Interest unauthorized by you; WHO IS AN INSURED under Section C. is (c) Any physical or chemical change amended to include as an additional insured in the product made intentionally the person(s) or organization(s) shown in the by the vendor; Declarations as an Additional Insured — (d) Repackaging, unless unpacked Controlling Interest, but only with respect to solely for the purpose of inspection, their liability arising out of: demonstration, testing, or the a. Their financial control of you; or substitution of parts under b. Premises they own, maintain or control instructions from the manufacturer, while you lease or occupy these premises. and then repackaged in the original container; Form SS 00 08 04 05 Page 19 of 24 BUSINESS LIABILITY COVERAGE FORM This insurance does not apply to structural The limits of insurance that apply to additional alterations, new construction and demolition insureds are described in Section D. — Limits Of operations performed by or for that person or Insurance. organization. How this insurance applies when other insurance 9. Additional Insured — Owners, Lessees Or is available to an additional insured is described in Contractors — Scheduled Person Or the Other Insurance Condition in Section E. — Organization Liability And Medical Expenses General a. WHO IS AN INSURED under Section C. is Conditions. amended to include as an additional G. LIABILITY AND MEDICAL EXPENSES insured the person(s) or organization(s) DEFINITIONS shown in the Declarations as an Additional Insured—Owner, Lessees Or Contractors, 1. "Advertisement" means the widespread public but only with respect to liability for "bodily dissemination of information or images that injury", "property damage" or "personal has the purpose of inducing the sale of goods, and advertising injury" caused, in whole or products or services through: in part, by your acts or omissions or the a. (1) Radio; acts or omissions of those acting on your (2) Television; behalf: (3) Billboard; (1) In the performance of your ongoing (4) Magazine; operations for the additional i (5) Newspaper; nsured(s); or (2) In connection with "your work" b. The Internet, but only that part of a web performed for that additional insured site that is about goods, products or and included within the "products- services for the purposes of inducing the completed operations hazard", but sale of goods, products or services; or only if this Coverage Part provides c. Any other publication that is given coverage for "bodily injury" or widespread public distribution. "property damage" included within the However, "advertisement"does not include: "products-completed operations a. The design, printed material, information hazard". or images contained in, on or upon the b. With respect to the insurance afforded to packaging or labeling of any goods or these additional insureds, this insurance products; or does not apply to "bodily injury", "property b. An interactive conversation between or damage" or "personal an advertising injuryarising out of the rendering of, or among persons through a computer network. the failure to render, any professional 2. "Advertising idea" means any idea for an architectural, engineering or surveying "advertisement". services, including: 3. "Asbestos hazard" means an exposure or (1) The preparing, approving, or failure to threat of exposure to the actual or alleged prepare or approve, maps, shop properties of asbestos and includes the mere drawings, opinions, reports, surveys, presence of asbestos in any form. field orders, change orders, designs or 4. "Auto" means a land motor vehicle, trailer or drawings and specifications; or semi-trailer designed for travel on public (2) Supervisory, inspection, architectural roads, including any attached machinery or or engineering activities. equipment. But "auto" does not include 10. Additional Insured — Co-Owner Of Insured "mobile equipment". Premises 5. "Bodily injury" means physical: WHO IS AN INSURED under Section C. is a. Injury; amended to include as an additional insured b. Sickness; or the person(s) or Organization(s) shown in the c. Disease Declarations as an Additional Insured — Co- Owner Of Insured Premises, but only with sustained by a person and, if arising out of the respect to their liability as co-owner of the above, mental anguish or death at any time. premises shown in the Declarations. 6. "Coverage territory" means: Page 20 of 24 Form SS 00 08 04 05 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 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, 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: U 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 EI 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# XI certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not ploy 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 the workers' compensation provisions of Labor Code § 3700 i must immediately comply with those rovisions or the agreement will automatically become void. Signature of Applicant '1*V -- / ,. . � Date �.��—.�...., Print Name Agreement for: 14� ���A-fl CC S � r-OR rZA-oU CAZ Dated: f Reviewed by: