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PROOF OF INSURANCE (2019) CLOSED AC CERTIFICATE OF LIABILITY INSURANCE I DATE(MMIDD/YYYY) 02/11/2019 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(ies) 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 does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT ttttE,?................................................._................,,,,........,. 1111. .. U FAx Hiscox Inc.d/b/a/Hiscox Insurance Agency in CA PHONE (888)t .y„p� m 202-3007 IA IC 520 Madison Avenue E-MAIL contact hlscoxxorn 32nd Floor AQDWSSs .,...,.... NANC New York,NY 10022 INSURERA: Hiscox Insurance Company Inc GE 10200#11 1111.._. �.... ___......__.1111.. INSURED INSURERS: IMGBSolutionsINSURER C: ................................................................................_.................................,.,. ... ............................................_............................................................ .. 9506 Karmont Ave South Gate,CA 90280 INSURER D INSURER E INSURER F: 1111 1111 , 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 30LICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ...--........TYPE.O........... m._..._.�,,.,..�........ ADDL�� ....................�.............................. POLICY EFF POLICY N.. ................................LIMITS ........�... LTR OF INSURANCE INS POLICYNUMBER IMMfDDr"YY'�1 WM0 X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE ..X....� OCCURaR, M�SES..Lia...?F41,CG4E.P.�r..1.............$...100,000 MED EXP(Any one person) $ 5,000 �.., ...... .....,,,,,,, 1111 1111,,, A N UDC-1506408-CGL-18 10/24/2018 10/24/2019URY $ 2,000,000 PERSONAL 8 ADV INJURY GEN'LAGGREGATELIMITAPPLIESPER: GENERAL AGGREGATE $ 2,000,000 ......._w.................................................................................................. RO- X] JlECT ...............0............................... „� ,, POLICY J,EC,T LOC PRODUCTS-COMP/OPAGG $ SIT Gen.Agq OTHER, AUTOMOBILE LIABILITY COrOBINEO SINGLE UMI T' ............................... ................ ANY AUTO ,BODILY INJURY(Per person) $ .......... ALL OWNED ��..,,,,' SCHEDULED ................................ .............. .. ............ - 111-1111111111­1111 .$ BODILY INJURY(Per accident) , AUTOS AUTOS NON-OWNED IPROI'ERd1"YDAduMAG ..�.$ .. HIREDAUTOS AUTOS ..A...gLarm::. nk)..... AB ------- .................�................... UMBRELLALI $ EXCESS ABCLAIMS-MADE AGGREGATE RENCE $ - i OCCUR $ DED I_I RETENTION$ WORKERS COMPENSATION PER I OTH- AND EMPLOYERS'LIABILITY YIN _m, STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E L,EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A __....................................... ........m""...._.._.. (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLAT'I'ON 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 EI Segundo Ca 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 0$9 HSCOX Hiscox Insurance Company Inc. Policy Number: UDC-1506408-CGL-18 Named Insured: IMGB Solutions Endorsement Number: 17 Endorsement Effective: October 24,2018 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - (DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) City of EL Segudo, its officers, employees, agents and volunteers 350 Main St EI Segundo,CA 90245 Information required to complete this Schedule, if not shown above, will be shown in the Declarations, Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s) or organi- zation(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omis- sions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 02/11/2019 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(ies) 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 does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Hiscox Inc.d/b/a/Hiscox Insurance Agency in CA PHS Nn E,xtti, (888)202-3007 FAXJ,ALNal, 520 Madison Avenue E•MAaL contaGf I1is'GL1'X.GodTa 32nd Floor a�DOREsS @ New York,NY 10022 NAIC# ............................ ....................................................................................... INSURER A: Hiscox Insurance Company Inc 10200 INSURED INSURER B IMGB Solutions INSURER C: 9506 Karmont Ave .._._....-........-..-.... .................................................................................................................................................................... �....................................... _ South Gate,CA 90280 INSURER D INSURER 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 BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INI POLICY NUMBER .....SIMM/DDI1/YYYI ...lMMdOOdYYYYg ..................................................._................_ .......LIML..,.,.,.,.,.,.,.,.,.,.....,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,............................. INSR 'ADD&.SUBRi III POLICY EPF PM1DD YY TS SD WYD. COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ .._._.__...... -C'7AIIl�i;• 'TIJ Fff�fU CLAIMS-MADE F7 OCCUR ,PF�MI�.�.�..G�?_Qcr�c4lrfenFi..�.)..........,.$...................................... MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PPOLICY� PRO. F LOC P,RO,DUCTS-COMP/OPAGG.... $,.............. AUTOMOBILE LIABILITY m COMBINED,SINGLE LIMP"R' ,,,,.....$..............................._ ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED BODILY INJURY(Per accident) $ AUTOS I AUTOS .... .m..,..... ..........................._ HIREDAUTOS NON-OWNED ..P,ca,O„ac �MA GE $ TOS � YUMBRELLA LIAB OCCUR , ..................... ..................... $ EXCESS CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PESTATUTE I I OERH __ wwwWw, AND EMPLOYERS'LIABILITY Y/N ••-"""-- ANYPROPRIETOR/PARTNER/EXECUTIVE E L,EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ If yes,describe under -� DESCRIPTION OF OPERATIONS below EX DISEASE-POLICY LIMIT $ A Professional Liability N UDC-1506408-EO-18 10/24/2018 10/24/2019 Each Claim:$1,000,000 Aggregate:$1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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 EI Segundo Ca 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE rd' ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD PROOF OF INSURANCE r______ _ W___--------PROOF OF INSURANCEVEHICLES--------------- -- POLICY------_-_____-__..___..__-__,_____----__,_ Interinsurance Exchange of the Automobile Club YEAR MAKE MODEL VEH I,D.# a W NAIC#:15598 2012 VLKS NEW JETTA SE 3VWDP7AJ1CM377075 d 2016 VLVO XC90 T5 MOMENTUM YV4102XKOG1073829 r , Named Insured Policy Number:CAM 07391418 2012 TYTA PRIUS PHEV JTDKN3DP2C3008610 m u GABRIEL BARRIENTOS a w r � , Lu w x o DRIVERS ON POLICY i' 0 BARRIENTOS,GABRIEL I Effective Date:06/16/2018 Expiration Date:06/16/2019 r , e This policy provides at least the minimum amounts of liability insurance required by the CA VEH CODE SECTION 16056 for the specified vehicles X and named insureds and may provide coverage for other persons and other vehicles as provided by the insurance policy. o t-----------------------------------,------------------------------------------.._..____,_____,_____,____,___,_______,_,_,____- j IF YOU HAVE AN ACCIDENT CALL OUR 24/7 AAA ACCIDENT ASSIST HOTLINE 1-800-67-CLAIM (1-800-672-5246) I After an accident,follow these 5 easy steps: Step 4: Call our AAA Accident Assist Hotline at 1-800-67-CLAIM (1-800-672-5246)to report the accident and,if necessary,have Step 1: Get the names and addresses of all persons I your vehicle towed to the repair shop or location of your Involved in the accident,e.g.,pedestrians,witnesses,other preference passengers,etc. w u = Step 5: Safely wait for the tow truck.Our independent service Step 2: Get the driver's license number and insurance o providers'tow trucks always display the AAA emblem information of the driver(s)of the other vehicle(s) u 1 Do not admit responsibility for or discuss the circumstances of the accident Step 3: Write down the vehicle(s)license plate,including with anyone other than the police or an authorized Auto Club claims state of registration representative.Do not disclose your policy limits to anyone. Coverage subject to policy terms and limits. ! I For questions or changes to your policy,call 1-877-422-2100,Monday through Friday from 7 a m,to 9 p.m.or Saturday from 8 a.m.to 5 p m, mmmm---_- Place the Proof of Insurance in each vehicle insured under your policy. In addition,we suggest that each listed driver carry a card. Under California law, drivers and owners of a motor vehicle must be able to establish financial responsibility at all times. These cards become invalid on the expiration or termination date of the policy. r--------------------------------------------------------------------------------------------------------------------, PROOF OF INSURANCE VEHICLES ON POLICY �a4 Interinsurance Exchange of the Automobile Club YEAR MAKE MODEL VEH I,D.# o NAIC#:15598 2012 VLKS NEW JETTA SE 3VWDP7AJ1CM377075 �" 2016 VLVO XC90 T5 MOMENTUM YV4102XKOG1073829 Named Insured Policy Number:CAM 07391418 2012 TYTA PRIUS PHEV JTDKN3DP2C3008610 w i GABRIEL BARRIENTOS , I w u � a w � n x I o DRIVERS ON POLICY ' 0 BARRIENTOS,GABRIEL N Effective Date:06/16/2018 Expiration Date:06/16/2019 w a A This policy provides at least the minimum amounts of liability insurance required by the CA VEH CODE SECTION 16056 for the specified vehicles and named insureds and may provide coverage for other persons and other vehicles as provided by the insurance policy, h-------------------------_.--------_...-----------------------------------------.....--------...7.___-_.._______..____-- IF YOU HAVE AN ACCIDENT CALL OUR 24/7 AAA ACCIDENT ASSIST HOTLINE s 1-800-67-CLAIM (1-800-672-5246) After an accident,follow these 5 easy steps: Step 4: Call our AAA Accident Assist Hotline at 1-800-67-CLAIM u (1-800-672-5246)to report the accident and,if necessary,have 1 Step 1: Get the names and addresses of all persons your vehicle towed to the repair shop or location of your Involved in the accident,e.g,,pedestrians,witnesses,other preference passengers,etc. w = Step 5: Safely wait for the tow truck.Our independent service %Step 2: Get the driver's license number and insurance o providers'tow trucks always display the AAA emblem a information of the driver(s)of the other vehicle(s) u;- 1 a w 1 Do not admit responsibility for or discuss the circumstances of the accident Step 3: Write down the vehicle(s)license plate,including with anyone other than the police or an authorized Auto Club claims w state of registration representative.Do not disclose your policy limits to anyone. Coverage subject to policy terms and limits. I 8 a For questions or changes to your policy,call 1-877-422-2100,Monday through Friday from 7 a m to 9 p.m or Saturday from 8 a m to 5 p,m ------------------------------------------------------------------------------------------------------------------------------A LWebPOI CAA 3E 04199 08165(8/10) 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. U 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# (_LX) I 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 California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with t se provisions or the agreement will automatically become void. Signature of Applicant Date 02/01/19 Agreement for: oti/I100'44ft'y 1 a- Dated: Reviewed by: 1