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PROOF OF INSURANCE (2019 - 2019) CLOSED COMM-35 OIC ID JMX MIDD/YYYY)TE(M CERTIFICATE OF LIABILITY INSURANCE DATE 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 riqhts to the certificate holder in lieu of such endorsement(s). PRODUCER 626-795-9921 CONTACT Jessica Munoz Supple-Merrill&Driscoll Inc. PHONE 626-795-9921 PAX 626-577-6656 ---___, Insurance Agents and Brokers INC.No,EMtl: P.O.Box 2408 Pasadena,CA 91102 David L.Merrill INSURERIS)AFFORDING COVERA ... INSURER A: &Forster Ins.Co. m........,, ........................................................................................... ....._— INSURED INSURERS,State Compensation Ins. Fund CommemlallrTransportation sery INSURER Nautilus Insurance Company . 701'S.Tire4narAvenue RE ...: i . ............._........ San Dimas,CA 91773 INSURERD; .......................................................................................................................__.. lNSUR E INSURER F: 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 BEENREDUCEDBY PAID CLAIMS. ." INSR AIDDL SUBR POLICY EFF POLICY EXP I. TYPE OF INSURANCE IN II vn POLICY NUMBER IM WWI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 P 100,000 MAGE 9 RENTED LAIMS-MADE �OCCUR X X BAK-32872-2 09/01/2018 09/01/2019 ��� MI ` r�;tlww'J $ MED FXP An one ersonl ,smmm 5'000' PERSONAL B ADV INJURY S 1,000,000' GEN'L AGGREGAAE LIMIT APPLIES PER: GENERAL AGGREGATE $ ,000,000 POiLKIly PRO LOC PRODUCTS-COMP/OP AGG S 2,006,00 O".I"/flE F2 $ Olul'MNEDI. T ..AU.OMOBILE LIABILITY ..CEJ....dkGSa,.'41.0--.k„It1 1^F.LIMIT ....._$ ANY AUTO BODILY INJURY(Per AUTOS ONLY AUTOSULEDp(SIL;Y,INm,I,IJR,Y,,,,�Paraacidan ,,.,.8,,,,,,,,,,,,, HIRED N0 'D AUTOS ONLY _....... AU O� ;YNG.,Y PPer"cc giant AM.F'. .............-,...-m..-I.. ............................................____-- $ 000,000 AGGREGATERRENCE $" "....ITz,000,000 UMBRELLA S ADE AN057432 09/18/2018 09/01/2019 2......„” IT..._... C X EXCESSLABCLAIMS-MADEOCCUR .................X....................M....... DED T V RETENTION$ .PERYY S KERS COMPENSATION B ANY PROPRIETOR/PARTNER/EXECUTIVE ER XCLU ED?ECUTIVE Y/N N/A X 1650779-18 09/01/2018 09/01/2019 X� qCH qTL"� L. k?H- AND EMPLOYERS'LIABILITY "- 1,000,00 OFFICE ❑ 0 DISEASE-EA ICY LIMIT S 000,000 If ,describe rON under OPERATIONS below E.L DISEASE_pOEMPLQYEE,$,IT,,,,m 1 ,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required( City of EI Segundo is named as additional insured as respects the insured's operations per CG 20 10 07 04,Waiver of Subrogation applies.Workers Compensation Waiver of Subrogation,applies, CERTIFICATE.HOLDER CANCELLATION CITYELS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF EL SEGUNDO ACCORDANCE WITH THE POLICY PROVISIONS. 350 MAIN STREET EL SEGUNDO,CA 90245 AUTHORIZED REPRESENTATIVE id ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: BAK-32872-2 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A� SCHEDULE Name Of Additional Insured Person(s) p Or Organization(s): Location(s) Of Covered Operations All persons or organizations as required by written Various contract with the insured — ................ ............... .. It is further agreed that this insurance shall be primary and non-contributory but only in the event of a named insured's sole negligence Information required to complete this Schedule, if not shown above, will be shown in the Declarations. li A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage" or "personal and advertising injury" "property damage" occurring after: caused, in whole or in part, by: 1. All work, including materials, parts or 1. Your acts or omissions; or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 13 POLICY NUMBER: BAK-32872-2 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO U'S This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: All persons or organizations as required by written contract with the insured Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a 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 above. CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 mi0"l PERUDI1 OP ID; EF CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)02/1112019 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 626-795-9921 C'ON AC'T'Gary B.Merrill P suranc 240Supple-Merri en Driscoll Inc. f AI 'm"""""""""° Agents �t) ... .. ... ... ... a FAX N�)626_. 56 Pasadena,CA91102 Brokers I L.,,. 626.795.9921 - Supple-Merrill&Driscoll Inc. INSURER,(S,)AFFO„R,pINGCOVERA,9E ,,,,,,,,,,,,,,,,,,,,,,,,,,,, --- NAIC.#,,, - 70"20S,Treggnor.... INSURER A:Mercury Insurance Group 11908 SURAD San Dimas CA 91773-3 R B. INSURER 420 INSURER INSURER D: INSURER E INSURER F: COVERAGES C'ERTIFI'CATE(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 VVITH 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. 7R TYPE OF INSURANCE ... POLICY NUMBER.........................."i36 .EPF......,,,,. ................... ........................._ .............Ill .........�.�...�..r,466CS BR LICY ...POLICY EXP LIMITS IN-6 wvn COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE OCCUR CLAIMS-MADE DAMAGE TO YC7 C.....,, O� EIV I MED EXP,(Any pn,e„person) ..,.Jk PERSONAL&ADV INJURY S —;a..d_NLAC4k&�G-ATEp LIMIT APPLIES I-'LR GENERAL POLICY Rai LOC COMP/OP AGO .,.D OTHER ..... .. ...--......_. A AUTOMOBILE LIABILITY .iI'';97 f1-q IrJ LrL!F..�..N�1.I.T $ ........... ...... ONLY ......, AUT -BODILY,INJ, ;6 OWNED ANY AUTO 040104120149615 01115/2019 07/15/2019 �RYplPerpersont, 100,000 AUTOSX OSULEDUR (Per accident)-..? 300,000 HIRED R NON.L7WVrd 0 aT;!"YPHR°'YDAMaAGE100,000 AUTOS ONLY Ad ITO„” �N. .G COOMP/LOLL 500/500 UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S _ DED I I RETENTIONS S WORKERS COMPENSATIONOTH AND EMPLOYERS'LIABILITY YIN STpT,,I�T,E �,,, R uJFh"NCER MI,IMBOE)EXCLUDED?ECUTIVE ❑ NIA DISEASE 5 Mandator do NH E L _ $ If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY.LIMIT s DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 2006 CHRYSLER 300C SED 4 2C3LA63H26H509160 2001 CHEVROLE SILVERAD PKP 4 2GCEC19T911396791 CERTIFICATE HOLDER I CANCELLATION u SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cit of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Y g ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street EI Segundo,CA 90245-3895 AUTHORIZED REPRESENTATIVE Supple-Merrill&Driscoll Inc. P ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION STATE RENEWAL SC FUND 0-58-54-42 PAGE 1 HOME OFFICE Effective February 11, 2019 AT 12 . 01 A.M SAN FRANCISCO AND EXPIRING September 01, 2019 AT 12 . 01 A.M ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME COMMERCIAL TRANSPORTATION SERVICES 142 E BONITA AVE # 107 SAN DIMAS, CA 91773 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, City of E1 Segundo WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, COMMERCIAL TRANSPORTATION SERVICES 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 CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 2570 AIIEIIO1121zD RE1II SE:NI IVE PRESIDENT AND CEO SCIF FORM 10217 {REV.7-20141 OLD DP 217 e�tearttrxr�ta COMMERCIAL TRANSPORTATION SERVICES INC. 142 E. BONITA AVE. #107 SAN DIMAS, CA. TELEPHONE/FAX (626) 966-1509 dino-cts@verizon.net RE: PROFESSIONAL SERVICES AGREEMENT January 2, 2019 To whom it may concern, We request that you consider waiving the insurance requirements for CTS/Dino Perugino for the following reasons: C.T.S has no exposure and the insurance does not apply. C.T.S works on the city premises and does not provide any equipment other than his expertise. C.T.S. is providing a certificate of the General Liability Insurance, E. & O., again, no exposure here in regards to the services C.T.S provides. Additional Insured Endorsement: The current insurance provider does not provide this coverage because C.T.S once again has no exposure or liability in this area. Auto: C.T.S does not have a commercial auto exposure with regard to the services he provides the city. In fact C.T.S does not own a commercial vehicle. In the past C.T.S has provided a copy of his personal auto insurance policy. We have provided a copy of said insurance. In regards to Workers Compensation Insurance, we have provided a copy the State Fund Compensation Insurance Certificate. Please feel free to contact Diane Stamm with any questions at Supple-Merrill & Driscoll. He can be reached at 626-795-9921 Monday — Friday 9-5. Sincerely, DINO PERUGINO Consultant/Instructor .................................... ..... "A well informed driver can provide a safer working environment for all." w W1 I " . ��v wu�r^n.'��"rraN;ro COMMERCIALION SERVICES INC. 142 E. BONITAAVE. #107 SAN DIMAS, . TELEPHONE/F966-1509 dino-cts@verizon.net RE: PROFESSIONAL SERVICES AGREEMENT January 2, 2019 To whom it may concern, We request that you consider waiving the insurance requirements for CTS/Dino Perugino for the following reasons: C.T.S has no exposure and the insurance does not apply. C.T.S works on the city premises and does not provide any equipment other than his expertise. C.T.S. is providing a certificate of the General Liability Insurance, E. & O., again, no exposure here in regards to the services C.T.S provides. Additional Insured Endorsement: The current insurance provider does not provide this coverage because C.T.S once again has no exposure or liability in this area. Auto: C.T.S does not have a commercial auto exposure with regard to the services he provides the city. In fact C.T.S does not own a commercial vehicle. In the past C.T.S has provided a copy of his personal auto insurance policy. We have provided a copy of said insurance. In regards to Workers Compensation Insurance, we have provided a copy the State Fund Compensation Insurance Certificate. Please feel free to contact Diane Stamm with any questions at Supple-Merrill & Driscoll. He can be reached at 626-795-9921 Monday — Friday 9-5. Sincerely, DINO PERUGINO Consultant/Instructor "A well informed driver car7 provide a safer working nv roar ent for all.""