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PROOF OF INSURANCE (2019 - 2019) CLOSED DATE(MMIDD/YYYY) ,,. CERTIFICATE OF LIABILITY INSURANCE �I 12/10/2018 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 INSURERS), 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 CONTACT ..... " "' NAME: Lin D. Diaz PHONE 888.457.4426 m _FAX _._» .... D&C Insurance Solutions IAC N%Ext). 323.576.4552 EMAIL ackdci-insurance.com 300 S.Atlantic Blvd., Ste 201-B E-MAIL contact Monterey Park, CA 91754 I,NSURER(SI„AFFORDING COVERAGE INSURERA Maxum Indemnity Company 26743 !INSURED ....., ..... INSURER C _ ..,., ............_.,... .....................................................�. �..._,..._.._.._... Tillmann Forensic Investigations, LLC, '......... ....._ PO Box 4373 INSURER ......................_.... Covina CA 91723 INsu 11 RER 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. w,�n(WVn.,� .....................POLI ... 'POLICIYYYY»...-..............,,......EX-0.Y. ...........,.....LIMITS COMMERCIAL GENERAL LIABILITY A BDG 300842 _, 2117POLI/E EACH OCCURRENCE ._m.I s 1,000,0 L TO TYPE OF INSURANCE SUBRI 2-UM ER POIDDI EFF 1 (MMIDD/YYYYI U 12/17/2018 12/17/2019 EAcrlocc� OO Q __.. INYE.C.... ) AD CLAIMS-ME X OCCUR PREMISES Ea_. e, 100,000 Y..._ occurrent ».S L............. MED EX.P..(»A..)one person) ... 5,000 ! I PER ,.S..ON..A....L.....B..A V IN.J . G _.. 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GEf AGGREGATE s 2,000,000 POLICY PRO- JECT LOC PRoDCTPlOPAG $ 2,000,000 X11 ._.............s . s__ II r Omissions 1,000,000 L ) ...,..A._.�U-T MOBILE LIABILITY_ COMBINSF c` LI h . . BODILYANY AUTO URperson) OWNED SCHEDULED BODILY INJURY arsden AUTOS ONLY t) HIRED - NON-OWNED --0”iR » M .w.... .LSAUTOS ONLY LAUTOS ONLY $Ss UMBRELLA LIAB 1 OCCUR EACH OCCURRENCE S EXCESS LIAB "CLAIMS-MADE du ! .... ..........,._ AGGREGATE ._ ..... ., S DED I RETENTION$ ? $ AND EMPLOYERS'LIABILITY Y/N I EACH ACCIDENTL.' OTH- WORKERS COMPENSATION PER ITE I R OFFFICERIMEn BE EXCLUDED? ANYPROPRIETOR/PARTNER/EXECUTIVE $ Ify s,atony i e under DISEASE-EA EMPLOYEE S NIA El ..mm.... (Mandatory ) i DESCRIPTION OF OPERATIONS below I. ASE-POLICY LIMIT $ IY I i I II DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is requiredl REGARDING THE ABOVE REFERENCED GENERAL LIABILITY INSURANCE POLICY, THE CERTIFICATE HOLDER IS INCLUDED AS AN ADDITIONAL INSURED, BUT ONLY WITH RESPECT TO THE NEGLIGENT ACTS, ERRORS OR OMISSIONS OF THE NAMED INSURED. CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 348 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EI Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Lin Dau Diaz ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: BDG-3008422-05 COMMERCIAL GENERAL LIABILITY CG 2010 04 13 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 SCHEDULE Name Of Additional Insured Person(s) Location(s) Of Covered Operations Or Organization(s) City of EI Segundo, Various Locations 348 Main street, EI Segundo, CA 90245 Information required to complete this Schedule, if not shown above,will be shown in the Declarations N 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 However: 2. That portion of "your work" out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of the same project. 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_ CG 20 10 04 13 ©Insurance Services Office, Inc., 2012 Pagel of 2 C. With respect to the insurance afforded to these 2. Available under the applicable Limits of additional insureds, the following is added to Insurance shown in the Declarations; Section III—Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the most we applicable Limits of Insurance shown in the will pay on behalf of the additional insured is the Declarations. amount of insurance: 1. Required by the contract or agreement; or CG 20 10 04 13 ©Insurance Services Office, Inc., 2012 Page 2 of 2 CALIFORNIA INSURANCECARD ulual Automobile Insuran,ce Company 000 Old River Road Bakersfield,CA 93311 INSURED TfLLMANK STEVE&Aff A MIUTL VOL POLICY NUMBER EFFEC7WE YR 2017 MAKE FORD SEP 20 2019 WDEL F160 ViN IFTEWlCPXHKC29661 AGENT THOMPSON 1317- PH NE 317-PHUNE fflkO674-5577 NMC 25178 COVERAG P VIDEO BY THE POLICY MEETS THE MUMUM LIABILITY UMITIB I-W CAFE A C D'InI31000 H U 5011 00 EVAIG50 By ,E REVERM DEFORMEDt"TAI N. 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: (_) 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 forthe 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# ( I certify that, in the pearlormance of the work set forth in the agreement with the City of EI Segundo, I will not mploy 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 th 's provrsior or the agreement will automatically become void Signature of Applicant ��. _ a Date ' ��� Agreement for: , ` Dated: l Reviewed bY: ......._.. ._ _ _ I