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PROOF OF INSURANCE (2019 - 2019) CLOSED (2) AeC>R& �✓" CERTIFICATE OI DATE / Y)ITY INSURANCE 12110/2018 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 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 If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on n this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Lin D. Diaz Epps ._...._. -...._- .IAXiA .NP......323.576.4552 300 S. Atlantic Blvd., Ste 201-B E-MAIL tt contact nsu N D&C Insurance Solutions 888 457.4426 � m dcl rance.co.... l Monterey Park, CA 91754 INSURE R(S)AFFORDING COVERAGE NAIC# NSURER A: Indemnity Company 26743 INSUREDmm INSURER B: i Tillmann Forensic Investigations, LLC. INSURER C: PO Box 4373 INSURERD: INSURER E Covina CA 91723 I INSURER F J..,,,,,,, ......................,„.... ..J.LL. COVERAGES CERTIFICATE NUMBER: REVISION NUIMBER: 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. INSRi .... .... nir� 4uvo POLI. .... TYPE OF INSURANCE(ABILITY A BDG 30 /'Y"YI (MM/DDIYYYY4 EACH OCCURRENCE LIMITS LTR 08422 05 ER 11-2/1D7)POLICY EFF POLICY EXP CLAIMS-MADE M $ 1,000,000 COMMERCIALGENERA L�occuR 01 8 12/17/2019 PREM sEs�a ac�u�nceY �$ 100,000 MED EXP(Any one person) $ 5,000 _ ................. $ ..,000,000 N ERSONAL&ADV INJURY N'L AGGREGATE LIMIT APPLIES PER: $ 2,666,000 PR'('7- Errors&Omissions X POLICY JE,C,1f LOC 2,000,000 OTHER' $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LWI't' (Ea accoent) $ ANY AUTO BODILY INJURYp OWNED SCHEDULED PROPYRTY D M Pe accident) $ HIRED S ONLY NON OWNED (.. E .........'....... _ e accident)f$ AUTOS ONLY AUTOS ONLY Percc,i rr,t $ $ UMBRELLALIAB ....., EXCESS LIAB .II { ..DE.,� AGGR GATE OCCURRENCE $................................................. OCCUR E CLAIMS-MA DED � i R ETENTION$ $..................................................,,, WORKERS COMPENSATION PEROTH_ AND EMPLOYERS'LIABILITY YIN _ STATUTE,,,,,,,,,,,,, ER CIDENT (MandatMEMBE)XCLUDED?ECUTIVE NIA ------DISEASE EMP $ _ LOYEE,l$ . If yes,describe under _E.L.EACH AC DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT I $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It more space is requlredl 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 CANCELLA'TIO'N 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 wy,, Lin Dau Diaz • ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: BDG-3008422-05 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 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, El Segundo, CA 90245 Information required to complete this Schedule, if not shown above, will be shown in the Declarations 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 C Insurance Services Office, Inc., 2012 Page 1 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 0413 0 Insurance Services Office, Inc., 2012 Page 2 of 2 INSURANCE CARD Stato Form Mutual Automobile Insurance company SOO 0I4 Rivor ReedBakersfield,CA MIT INa SUMED TILLMANN,ST'E VIE 9.R'Il"A NIUfL VOL PDUff NUMBER 342 SS?7•C29,-?6E EFfECI'IVE YR WIT MiAKE FORD MAR 29 1I919'TO SEP go 2019 MODEL F160 VtN iFTEWICPXHKC2WI AGENT OMPSON PHONE HV E�taq �R VIIDEO BY THE{POLICY pOL CYIMEETS 1b� 'r�dlr�IMUM LIABILITY LIMITS COMWE Y I 0000' 'EVIDIEFes'SII'EBCI AIN TIg1 . mllri, Afiq S till ........... Principal Driver&Assigned Drivers Your prerblum may be influenced by the Information shown For each awornobile, the Principal Driver is the individual for'1hese fters, who rnost frequentW 1-drives it, Each driver is,designated as an Assi�gneld Driver ori dhe househola aiutoriablllie that he cx she most frequently drives. C,•0 VE,KA I(J!Iii N0111 t 11' 8as)0Ui`P0fiCyfqrQ"qApli of these covii A Liability y PropertyQarrmge 100,000 $263.51 C Medical Payments 5,000 $12,12 D 1000 DO Coni pph;mqiVe $30,62 G 1000 Deductible Collision $18108 ............. .............I— H Emergency Road Svvica $3.10 U Uninsured Motor Vehicle Bodily Irl 100,000K100,000 $35.38 ............ Ul Uninsured Motor Vehicle P:,Dpecly Darnage $3,91 If any coverage you carry is changed to give broader ymi r�he r,M,add it protactmn without msWrq! a new pohill protection with no additional premium charge, we will give slillfling on The date Ne adopt'the bruaderpwteoflon, !I! These adftmli have afteady been 41q)h: d to your pir ,ginium, Multiple Line Multicar Vehicle Solely Driving S, Hteiiy Record California Good Driver Loyalty ToW Disoriunts, Other Available Discount(s) You may be eligible for additional discounts See the enclosed insert for more information, Mature Driver JC%�, OAw L, a piMM %iVq�`J! Driving Safety Record' Rating Plain deteurliine�,s what y()u pay tor. Liability,Med(6al i'layments, iftir drivhig safetyrecoid, e.kng with other rating factors, Conipr0enswo, ("IoN,,4:ioin, and Uninsured Motor Vehida 11oaftnuo 0 on next p aup) Poll*Number:342 5877-C29-75D Page number 3 of 5 Prepared August 23,2018 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# 1 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 ject to the workers" compensation provisions of Labor Code § 3700 1 must immediately comply with tor �e a eement will automatically become void.. Signature of Applicant Date - j Print Name Agreement for: p.� � '�Y? ' I" i NM(JOh JAS a L — I Dated: Reviewed by: :� ,