PROOF OF INSURANCE (2019 - 2020) CLOSED ACi�?REY CERTIFICATE OF LIABILITY INSURANCE DA3�6i201 9Y )
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 GUN'IACI `
( NAME: Maile Jeppesen
Brennan and Associates Risk Mgmt & Insurance Svc PHONE 714-509-1073 FAX 714-975-89 r 66
.E'rr'rh WC,Nol,
License # 0649629 �,EWIAL
DDRESS
1551 N. Tustin Ave., Ste 500 INSURER(S)AFFORDING COVERAGE NAIC p
Santa Ana CA 92705 INSURERA:COlony Insurance Com a�
INSURED INSURER B:Berkshire Hathawav Homestate Ins Ca
Krause ACT, Inc. INSURERC:Ohio Security Insurance Companv
.................. -
DBA: Air Cleaning Technology INSURER D:
411 Rowland Ave INSURER E
Santa Ana CA 92707 INSURER F;
COVERAGES CERTIFICATE NUMBER:2019 PKG & xs Renewal 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,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR 57DI.SUBR' POLICY EFF POLICY EXP
LTRTYPE OF INSURANCE
,,,�,_, '(NCD WVn POLICY NUMBER IMMIpDIYYYYI (MMI00IYYYI'1 I LIMITS
X COMMERCIAL GENERAL--LIABILITY EACH OCCURRENCE $ 1,000,000
A =CLAIMS-MADEAMAGE I i u OCCUR ( y D 300,000
PREM SES�Ea oc RENTur?encel $
X $2,500 Deductible X PACE4245133 3/7/2019 3/7/2020 MED EXP An one person) g 50,000
each occurence PERSONAL&ADV INJURY IS 1,000,000
GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY JLRCO"7 E LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: 3
AUTOMOBILE LIABILITY T;OM Ell 0 SINGLE I.WiT S
Ea aoCidonr'V
ANYAUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY Per accident $
I � AUTOS AUTOS ( )
NON-OWNED PROP'BRT'Y'IDAMAGE --- -
HIRED AUTOS
AUTOS fPec oCoidcn9l $
UMBRELLA LIAR X OCCUR �.... �I EACH OCCURRENCE I $ 4,000,000
A X EXCESS LIAB CLAIMS-MADE AGGREGATE — $ 4,000,000
,OED I RETENTION S EXC4245134 3/7/2019 3/7/2020 $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITYY/N x m STATUTE I I ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E EACH ACCIDENT $ 1,000,000 .
OFFICER/MEMBER EXCLUDED? NIA
B .....
(Mandatory in NH) Y KRWC016856 1/1/2019 1/1/2020 I EL.DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E DISEASE-POLICY LIMIT S 1,000,000
C Contractors Equip/Tools IBKS57761799 2/1/2019 2/1/2020 U'dte $10,000/$1000
A Errors & Omissions PACE4245133 3/7/2019 3/7/2020 LI It $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
RE: E1 Segundo Fire Department, 314 Main Street, E1 Segundo, CA 90245. The City of E1 Segundo is included
as Additional Insured with regard to General Liability per attached forms EPACE100-0814 & EPACE101-0814.
(Waiver of Subrogation applies to Workers' Compensation per attached form WC990410B.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of El Segundo THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Attn: City Clerk ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE
Grog l[H�ri
1988-2014 ACORD CORPORATION. All(rights reserved,
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025(201401)
CERTIFICATE OF LIABILITY INSURANCE D 03111120D 9)
THCERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,'AND THE CERTIFICATE HOLDER.
IMPORTANT:if the certificate holder is an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the
PRODUCER
holder in lieu of such endorsement(s). NAME!
Kathy Perry -35 -„w,
Dan Rickabus !AX 1836
State Farm insurance F 949-363-7104 iAlc �;
( �Tkatherine,peny,ittt( statefarm,Com
~'� 30131 Town Center Drive, Suite 275
w, Laguna Niguel,GA 92677 INSURERIS)AFFORDING COVERAGE NAIC$
INSURER A_.State Farm Mutual Automobile Insurance Company 26176
INSURED Krause A C T INSURER B: � .........,.,
DBA Air Cleaning Technology INSURER C:
411 Rowland Ave INSURERD:
Santa Ana, CA 927073445 INSURER E.
INSURER F:
CERTIFICATE NUMBER: REVISION NUMBER:
COVERAGES THIS 13S 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,
POLICY NUMBER REDUCED BY 'AID CLAIMS.
EXCLUSIONS ,....,__.. ... __
LIMITS SHOWN MAY BEEN
... TYPE OF INSURANCE ADDLSUeR' - FOLICY E'FF POLICY EXP
. POLICIES.AND CONDITIONS OF SUCH
10.T I 4M�hWDO�YYY'Yi tMM0DdYYYY'1 LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
fCLAIMS-MADE F.m]OCCUR PREMISESIE,aI ccumsnr�i $
MED EXP(Any one Person) $ .................”.
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LI........
MIT APPLIES PER:
GENERAL AGGREGATE $
POLICY JET 0 LOC PRODUCTS-COMPIOPAGG 1 $
G OTi1ER: $
A AUTOMDBtLELWBiLiTY y 5458874-001-75 03!0112019 09/01/2019 I COMBiNEDsiNKaLELtMiT $ 1,000,000
..{.,r-�,ae_a idM a ........
ANYAUTO 6191539-001-75 0310112019 09101/2019 BODILY INJURY(Per parson) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
5451763-C01-75 0310112019 0910112019 PR�tNERTY DAMAGE' $
GPorrrcEdRdT ru
HIREDAUTOS AUTOS 4971093-C01-75 03101/2019 0910112019 $
EXCESS A LLIASI J_d OCCUR RCG OCCURRENCE
C U RENCE $
pp pp CLAIMS-MADE $
TE
DED 9 1 RETENTION$ ^^ S
WORKERS COMPENSATION I PER LITE
9 ER"
AND EMPLOYERS'LIABILITY Y t N
ANY PROPRIETORMARTNEWEXECUTIVE ❑NIA E.L.EACH ACCIDENT
OFFICER/MEMBER EXCLUDED?
E LDISEASE-POLICY LIMIT $
..
!Mandatory in NH)
DISEASE-EA
If yes,describe under
E.L. EMPLOYEE tCY ..
DESCRIPTION OF OPERATIONS below .,
A ENOL Y $,txro,twO c:s�
507 2152-C01-75 0310112019 0910112019 131250 Ptry l Damage deductible
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,AddRionai Remarks Schedule,may be attached it more apace is required)
City of EI Segundo,its officials and employees are named additional insured
Location:EI Segundo Fire Department
u !
CERTIFICATE.HOLDER CANCELLATION
EI Segundo Fire Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
350 Main St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
EI Segundo,CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REFRESENTATn E J w "'
01988 r
-2014 ACOCORPORATION,. � rights reserved.
ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD 1001481t=49.9 02-04-2014
POLICY NUMBER: PACE4245133
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INA►L INSI RED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
EnviroPACE Insurance Policy
SCHEDULE
Y Name Of Additional Insured Person(s) Location And Description Of Completed
Or Organization(s) Operations
Where Required By Written Contract Where Required By Written Contract
A. Section XX. WHO IS AN INSURED, Coverage Part 1 and Part 2 is amended to include as an
additional insured the person(s) or organization(s) shown in the SCHEDULE above, but only with
respect to liability for bodily injury, property damage, environmental damage, or cleanup costs
caused, in whole or in part, by your work at the location designated and described in the SCHEDULE
of this endorsement performed for that additional insured and included in the products-completed
operations hazard.
However:
1. The insurance afforded to such additional insured only applies to the extent permitted by law; and
2. If coverage provided to the additional insured is required by a contract or agreement, the insurance
afforded to such additional insured will not be broader than that which you are required by the
contract or agreement to provide for such additional insured.
B. With respect to the insurance afforded to these additional insureds, the following is added to section
XXI. LIMITS OF LIABILITY AND DEDUCTIBLE:
If coverage provided to the additional insured is required by a contract or agreement, the most we will
pay on behalf of the additional insured is the amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits of Liability shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits of Liability shown in the Declarations.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
EPACE100-0814 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1
with its permission.
POLICY NUMBER: PACE4245133
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - O'WNERS, LESSEES
OR CONTRACTORS - SCHEDULED
PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
EnviroPACE Insurance Policy
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s) Location(s) Of Covered Operations
Where Required By Written Contract Where Required By Written Contract
A. Section XX. WHO IS AN INSURED, Coverage Part 1 and Part 2 is amended to include as an
additional insured the person(s) or organization(s) shown in the SCHEDULE above, but only with
respect to liability for bodily injury, property damage, personal and advertising injury,
environmental damage, or cleanup costs caused, in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your behalf;
in the performance of your ongoing operations for the additional insured(s) at the location(s)
designated above.
However:
1. The insurance afforded to such additional insured only applies to the extent permitted by law; and
2. If coverage provided to the additional insured is required by a contract or agreement, the insurance
afforded to such additional insured will not be broader than that which you are required by the
contract or agreement to provide for such additional insured.
B. With respect to the insurance afforded to these additional insureds, the following additional exclusions
apply:
This insurance does not apply to bodily injury or property damage occurring after:
1. All work, including materials, parts or equipment furnished in connection with such work, on the
project (other than service, maintenance or repairs) to be performed by or on behalf of the
additional insured(s) at the location of the covered operations has been 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.
EPACE101-0814 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 2
with its permission.
C. With respect to the insurance afforded to these additional insureds, the following is added to section
XXI. LIMITS OF LIABILITY AND DEDUCTIBLE:
If coverage provided to the additional insured is required by a contract or agreement, the most we will
pay on behalf of the additional insured is the amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits of Liability shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits of Liability shown in the Declarations.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
EPACE1 01-0814 Includes copyrighted material of Insurance Services Office, Inc., Page 2 of 2
with its permission.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 04 10B
(Ed.9-14)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA
BLANKET BASIS
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. (This agreement applies only to the extent that you
perform work under a written contract that requires you to obtain this agreement from us.)
The additional premium for this endorsement shall be 2% of the total manual premium otherwise due on such
remuneration. The minimum premium for this endorsement is $350.
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
SCHEDULE
BLANKET WAIVER
Person/Organization Blanket Waiver—Any person or organization for whom the Named Insured has
agreed by written contract to furnish this waiver.
Job Description All California Operations
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information
below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective 01/01/2019 Policy No. KRWC016856 Endorsement No. 001
Insured Krause ACT, Inc. Premium$
Insurance Company Berkshire Hathaway Homestate Ins. Co.
WC 99 04 10B Countersigned by
(Ed.9-14)