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PROOF OF INSURANCE (2019 - 2020) CLOSED�DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE MARKEL` 1/29/2019 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 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 Stephanie Weiss Specialty Performers nsurance of the U.S. AgencyPHONEN Ext)- 715-246-8908 aat 715-246-4257 A1C. Nag; P.O. Box 24 piea°ss- Cealsa spun„aly„ns„UrarlCea gency.com New Richmond, W1 54017 INSURER(S)AFFORDINGCOVERAGE NAIC# INsuRERA: Evanston Insurance Company 35378 INSURED Dan Stevens INSURERB: .................................................................... dba 4 Alarm Band ...... INSURER C : 18871 Pinto Lane - Santa Ana, CA 92705 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. INSIZAtal'J�,....P - TYPE OF INSURANCE fit$ wvn OLICYNUMBER I't�MlpD Y�YI lMWOYJbb�Y`r"WR .... ...... LIMITS X COMMERCIAL GENERAL LIABILITY 1EACH OCCURRENCE $ 1,000,000 X X OAAMAO�T(EutlicaLirr0on,ce/ CLAIMS -MADE OCCUR $ ..300,000........ MED EXP (Any one person) $ 5,000 A X X 2CN0162-20050 01/28/2019 01/27/2020 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X EGPRO- T LOC 2,000,000 f OW PER AUTOMOBILE LIABILITY ..q...d... DS9NGLE LIMIT (ga .gt.....,$ ANY AUTO BODILY INJURY (Per person) $ OWNED 1 SCHEDULED BODIY INJURY (Pe BODILYrr accident) $ ,_ AUTOS ONLY AUTOS HIRED NON -OWNED kdOERTYU," $ AUTOS ONLY AUTOS ONLY ..... ptIpntb $ UMBRELLA LIAB I OCCUR EACH OCCURRENCE $ ..... EXCESS LIAB.... CLAIMS -MADE AGGREGATE $ . IR..... DED ETENTION $ $ ..., RKERS COMPENSATION PER STATAC OTH ER EMPLOYERS' LIABILITY Y❑ ANYPROPRIETOR/PARTNER/EXECUTIVE ANYPR PRIET E.L. EACH ACCIDENT EREXCLUDEDX NIA E,$ ... ... ( Mandatory ) - EMPLOYE �� $ $E EA ................................ If es, describeunder DESCRIPTION OF OPERATIONS below EL DISEASE SE - POLICY LIMIT $ A BUSINESS PERSONAL PROPERTY., INLAND MARINE AGGREGATE DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) PERFORMER IS A NAMED INSURED AS A MEMBER OF PERFORMERS OF THE U.S.: Dan Stevens dba 4 Alarm Band Additional Insured: City of EI Segundo, its officers, officials, employees, agents and volunteers Attn: Morse Palacios Event Date: July 28, 2019 CERTIFICATE HOLDER City of EI Segundo 111 W. Mariposa Avenue EI Segundo, CA 90245 [1IYA11110741III.F 111 IIILolkl SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY POLICY NUMBER: III 2CN0162-20050 MARKEL' EVANSTON INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE FORM PRODUCTS/COMPLETED OPERATIONS COVERAGE FORM LIQUOR LIABILITY COVERAGE FORM PROFESSIONAL LIABILITY COVERAGE FORM Please refer to each coverage form to determine which terms are defined. Words shown in quotations on this endorse- ment may or may not be defined in all coverage forms. SCHEDULE Person or Entity: Any person or organization to whom you are obligated by valid written contract to provide such coverage. Additional Premium: $ (Check box if fully earned.®) Included WHO IS AN INSURED is amended to include the person or entity shown in the Schedule above as an Additional Insured under this insurance, but only as respects negligent acts or omissions of the Named Insured and only as respects any coverage not otherwise excluded in the policy. Our agreement to accept an Additional Insured provision in a contract is not an acceptance of any other provisions of the contract or the contract in total. When coverage does not apply for the Named Insured, no coverage or defense shall be afforded to the Additional In- sured. No coverage shall be afforded to the Additional Insured for injury or damage of any type to any "employee" of the Named Insured or to any obligation of the Additional Insured to indemnify another because of damages arising out of such injury or damage. All other terms and conditions remain unchanged.. MEGL 0009-01 04 11 Includes copyrighted material of Insurance Services Office, Inc. Page 1 of 1 with its permission. COMMERCIAL GENERAL LIABILITY POLICY NUMBER: III 2CN0162-20050 A K LEVANSTON INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Additional Premium: $ 0 Name of Person or Organization: Any person(s) or organization(s) to whom the Named Insured agrees to waive rights of recovery in a written contract. The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above as respects written contracts that exist between you and such person or entity, provided you have agreed in writing to furnish this waiver. This waiver applies only to the person or organization shown in the Schedule above. All other terms and conditions remain unchanged. MEGL 0241.01 04 11 Includes copyrighted material of Insurance Services Office, Inc. with its Page 1 of 1 permission. POLICY NUMBER: 2CN0162-20050 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 Evidence of Insurance Here are your Evidence of Liability Insurance Cards Two cards have been provided for each vehicle insured. One card must be carried in the proper insured vehicle. Proof of insurance is required to register or renew the registration of your vehicle. A law enforcement officer can ask you to prove that you have liability insurance meeting the basic requirements of California law. A violation of these requirements can result in a fine of up to: $1,000 for the first time $2,000 for additional times Also, a judge can have your vehicle impounded. False proof of insurance may result in a fine up to $750 and 30 days in prison. Due to space limitations on the ID card, only the Named Insured and the Co-insured are listed. For a full list of drivers covered under this policy, please reference the Drivers section of your Declarations Page, which is included with your insurance packet. If you would like additional ID cards you can go online to geico.com or call us at 1-800-841-3000. GEICOCalifornia Evidence of Liability Insurance gei'co.com 1-800-841-3000 GEICO GENERAL INSURANCE COMPANY P.O. Box 509090 - San Diego, CA 92150-9090 NAIC Code: 35882 Policy Number Effective Date 4482-04-20-92 03-22-19 Year Make Model 2013 TOYOTA PRIUS C Insured: Daniel Paul Stevens Viennie Tran Vu 18871 Pinto Ln Santa Ana CA 92705-2265 Expiration Date 09-22-19 Vehicle ID No. JTDKDTB31 D1543105 The coverage provided by this policy meets the minimum requirements of sections 16056 & 16500.5 of the California Vehicle Code, minimum liability limits prescribed by the law, DANIEL P STEVENS AND VIENNIE T VU 18871 PINTO LN SANTA ANA CA 92705-2265 GEICOi California Evidence of Liability Insurance geico.com 1-800-841-3000 GEICO GENERAL INSURANCE COMPANY P.O. Box 509090 - San Diego, CA`92150L9090 NAIC Code: 35882 Policy Number Effective Date 4482-04-20-92 03-22-19 Year Make Model 2013 TOYOTA PRIUS C Insured: Daniel Paul Stevens Viennie Tran Vu 18871 Pinto Ln Santa Ana CA 92705-2265 Expiration Date 09-22-19 Vehicle ID No. JTDKDTB31D1543105 The coverage provided by this policy meets the minimum requirements of sections 16056 & 165005 of the California Vehicle Code, minimum liability limits prescribed by the law. Evidence of Insurance Here are your Evidence of Liability Insurance Cards, Two cards have been provided for each vehicle insured. One card must be carried in the proper insured vehicle. Proof of insurance is required to register or renew the registration of your vehicle. A law enforcement officer can ask you to prove that you have liability insurance meeting the basic requirements of California law. A violation of these requirements can result in a fine of up to: $1,000 for the first time $2,000 for additional times Also, a judge can have your vehicle impounded. False proof of insurance may result in a fine up to $750 and 30 days in prison. Due to space limitations on the ID card, only the Named Insured and the Co-insured are listed. For a full list of drivers covered under this policy, please reference the Drivers section of your Declarations Page, which is included with your insurance packet. If you would like additional ID cards you can go online to geico.com or call us at 1-800-841-3000. ���� California Evidence of Liability Insurance elco.co 1-800.841-3000 GICO GENERAL INSURANCE COMPANY P.O. Box 509090 • San Diego, CA 92150-9090 NAIC Code: 35882 Policy Number 4482-04-20-92 Year Make 2011 TOYOTA Insured: Effective Date 03-22-19 Daniel Paul Stevens Viennie Tran Vu 18871 Pinto Ln Santa Ana CA 92705-2265 Model SIENNA LE Expiration Date 09-22-19 Vehicle ID No. 5TDKK3DC9BS067818 The coverage provided by this policy meets the minimum requirements of sections 16056 & 16500.5 of the California Vehicle Code, minimum liability limits prescribed by the law. DANIEL P STEVENS AND VIENNIE T VU 18871 PINTO LN SANTA ANA CA 92705-2265 C31=-1CO3California. Evidence of Liability Insurance g,e lca. am 1-800-841-3000 GEICO GENERAL INSURANCE COMPANY P.O. Box 509090 • San Diego, CA 92150=9090 NAIC Code: 35882 Policy Number Effective Date 4482-04-20-92 03-22-19 Year Make Model 2011 TOYOTA SIENNA LE Insured: Daniel Paul Stevens Viennie Tran Vu 18871 Pinto Ln Santa Ana CA 92705-2265 Expiration Date 09-22-19 Vehicle ID No. 5TDKK3DC9BS067818 The coverage provided by this policy meets the minimum requirements of sections 16056 & 16500.5 of the California Vehicle Code, minimum liability limits prescribed by the law. Evidence of Insurance Here are your Evidence of Liability Insurance Cards. Two cards have been provided for each vehicle insured. One card must be carried in the proper insured vehicle. Proof of insurance is required to register or renew the registration of your vehicle. A law enforcement officer can ask you to prove that you have liability insurance meeting the basic requirements of California law. A violation of these requirements can result in a fine of up to: $1,000 for the first time $2,000 for additional times Also, a judge can have your vehicle impounded. False proof of insurance may result in a fine up to $750 and 30 days in prison. Due to space limitations on the ID card, only the Named Insured and the Co-insured are listed. For a full list of drivers covered under this policy, please reference the Drivers section of your Declarations Page, which is included with your insurance packet. If you would like additional ID cards you can go online to geico.com or call us at 1-800-841-3000. California Evidence of Liability Insurance GEICO eicoccm 1.800-841-3000 GEICO GENERAL INSURANCE COMPANY P.O. Box 509090 • San Diego, CA 92150-9090 NAIC Code: 35882 Policy Number Effective Date Expiration Date 4482-04-20-92 03-22-19 09-22-19 Year Make Model 2010 M BENZ E350 Insured: Daniel Paul Stevens Viennie Tran Vu 18871 Pinto Ln Santa Ana CA 92705-2265 Vehicle ID No. WDDHF5GB4AA239686 The coverage provided by this policy meets the minimum requirements of sections 16056 & 16500.5 of the California Vehicle Code, minimum liability limits prescribed by the law. DANIEL P STEVENS AND VIENNIE T VU 18871 PINTO LN SANTA ANA CA 92705-2265 MEMO California Evidence of Liability Insurance gelco.com 1-800-841-3000 GEICO GENERAL INSURANCE COMPANY P.O. Box 509090 • San Diego, CA 92150-9090 NAIC Code: 35882 Policy Number Effective Date Expiration Date 4482-04-20-92 03-22-19 09-22-19 Year Make Model 2010 M BENZ E350 Insured: Daniel Paul Stevens Viennie Tran Vu 18871 Pinto Ln Santa Ana CA 92705-2265 Vehicle ID No. WDDHF5GB4AA239686 The coverage provided by this policy meets the minimum requirements of sections 16056 & 16500.5 of the California Vehicle Code, minimum liability limits prescribed by the law. Evidence of Insurance Here are your Evidence of Liability Insurance Cards. Two cards have been provided for each vehicle insured. One card must be carried in the proper insured vehicle. Proof of insurance is required to register or renew the registration of your vehicle. A law enforcement officer can ask you to prove that you have liability insurance meeting the basic requirements of California law. A violation of these requirements can result in a fine of up to: $1,000 for the first time $2,000 for additional times Also, a judge can have your vehicle impounded. False proof of insurance may result in a fine up to $750 and 30 days in prison. Due to space limitations on the ID card, only the Named Insured and the Co-insured are listed. For a full list of drivers covered under this policy, please reference the Drivers section of your Declarations Page, which is included with your insurance packet. If you would like additional ID cards you can go online to geico.com or call us at 1-800-841-3000. ��� California Evidence of Liability Insurance e�cc ccs 1.800-841-3000 GPICO GENERAL INSURANCE COMPANY P.O. Box 509090 • San Diego, CA 92150-9090 NAIC Code: 35882 Policy Number Effective Date Expiration Date 4482-04-20-92 03-22-19 09-22-19 Year Make Model 2010 LEXS RX 350 Insured: Daniel Paul Stevens Viennie Tran Vu 18871 Pinto Ln Santa Ana CA 92705-2265 Vehicle ID No. JTJZK1BA5A2001323 The coverage provided by this policy meets the minimum requirements of sections 16056 & 16500.5 of the California Vehicle Code, minimum liability limits prescribed by the law, DANIEL P STEVENS AND VIENNIE T VU 18871 PINTO LN SANTA ANA CA 92705-2265 ��CC) California Evidence of Liability Insurance gelco.com 1-800-841-3000 GEICO GENERAL INSURANCE COMPANY P.O. Box 509090 • San Diego, CA 92150-9090 NAIC Code: 35882 Policy Number Effective Date 4482-04-20-92 03-22-19 Year Make Model 2010 LEXS RX 350 Insured: Daniel Paul Stevens Viennie Tran Vu 18871 Pinto Ln Santa Ana CA 92705-2265 Expiration Date 09-22-19 Vehicle ID No. JTJZK1BA5A2001323 The coverage provided by this policy meets the minimum requirements of sections 16056 & 16500.5 of the California Vehicle Code, minimum liability limits prescribed by the law. Evidence of Insurance Here are your Evidence of Liability Insurance Cards Two cards have been provided for each vehicle insured. One card must be carried in the proper insured vehicle. Proof of insurance is required to register or renew the registration of your vehicle. A law enforcement officer can ask you to prove that you have liability insurance meeting the basic requirements of California law. A violation of these requirements can result in a fine of up to: $1,000 for the first time $2,000 for additional times Also, a judge can have your vehicle impounded. False proof of insurance may result in a fine up to $750 and 30 days in prison. Due to space limitations on the ID card, only the Named Insured and the Co-insured are listed. For a full list of drivers covered under this policy, please reference the Drivers section of your Declarations Page, which is included with your insurance packet. If you would like additional ID cards you can go online to geico.com or call us at 1-800-841-3000. ����� California Evidence of Liability Insurance e�cla.com 1-800-841-3000 GIGO GENERAL INSURANCE COMPANY P.O. Box 509090 - San Diego, CA 92150-9090 NAIC Code: 35882 Policy Number Effective Date Expiration Date 4482-04-20-92 03-22-19 09-22-19 Year Make Model 2017 SUBARU IMPREZA Insured: Daniel Paul Stevens Viennie Tran Vu 18871 Pinto Ln Santa Ana CA 92705-2265 Vehicle ID No. 4S3GTAA65H3706972 The coverage provided by this policy meets the minimum requirements of sections 16056 & 16500,5 of the California Vehicle Code, minimum liability limits prescribed by the law, DANIEL P STEVENS AND VIENNIE T VU 18871 PINTO LN SANTA ANA CA 92705-2265 CaEICC), California Evidence of Liability Insurance geico.com 1-800-841-3000 GEICO GENERAL INSURANCE COMPANY P.O. Box 509090 • San Diego, CA 92150=9090 NAIC Code: 35882 Policy Number Effective Date 4482-04-20-92 03-22-19 Year Make Model 2017 SUBARU IMPREZA Insured: Daniel Paul Stevens Viennie Tran Vu 18871 Pinto Ln Santa Ana CA 92705-2265 Expiration Date 09-22-19 Vehicle ID No. 4S3GTAA65H3706972 The coverage provided by this policy meets the minimum requirements of sections 16056 & 16500.5 of the California Vehicle Code, minimum liability limits prescribed by the few. CITY OF EL SEGUNDO WOTRU ERS'COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORIKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMIPL OYERTO CRIMINAL PENALTIES AND CIVIL FINES UIPTO ONE HUNDRED THOUSAND DOLLARS ($100,000), IIN ADDITION TOTHE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3-706, INTEREST, AINS ATTORNEY'S FIEES.. I affirrn under penalty of periury under the laws of California one of the following declarations: l 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 El Segundo. (___y 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 El Segundo is executed. My workers' compensation insurance carrier and policy number are: fame of Agent Policy Number Expiration Date . ........ Phone# 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 imirnediately comply with those rft`S�ision Siof j a ,Q, agreement wiilll autornatically become void gnature Da tre Print Name ........ . . ... ....... . . . . . . . ................................ ... . . . ..... - - - - - --------- Agreement for: + Mom b uI -I PDA4 5V4-57 Dated: Reviewed by: _70 --Jo