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PROOF OF INSURANCE (2019 - 2020) CLOSEDOP ID: MN TE (MMIDD/YYYY) „..�- CERTIFICATE OF LIABILITY INSURANCE DA03/22/2019 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(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 certificate holder in lieu of such endorsement(s). CONTACT All'iance'M t. & Insurance Sery FAX 3°� PRODUCER Vera Cruz #7 R=Z6MeNL � ,_�5: 78 5 Vla Ve rAlcN 760-471-93PRCA A� gent/Broker Lic# 0737966 iscor com San Marcos, CA 92078 PR/ituCER WYEN-1'.........................._....................................................... Michelle A. Nowell gUA19MER Ip #: INSURERS) AFFORDING COVERAGE NAIC # INSURED Wyenn & Associates INSURER A:Acceptance CasualtyIns Com 10349 JoelWyenn...........................����������������......................._., p 815 S Central Ave #20 INSURER B Glendale, CA 91204 INSURERC: INSURER D : & .........SUR......,. ... ..................................................................... IN ERE: 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. I N R . .........._........"""""",,,,,,,,, ................4DDL $Ube.,..............................-.LICY ..........""""'"""" POEf"F .._10dUdY EXRY........................................,,,,,,,,,,,................................ ILTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDDIYYYYi iMMIDDIYYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 — DAMA6 TO fi"ENTER...................... _.,..... A .X......COMMERCIAL GENERAL X LIABILITY PREMISES (Ea_occurren,pe X CP00960505 0310612019 03/06/2020 100,000 .I vi - CLAIMS -MADE OCCUR MED EXP (Any one person) $ .�............. 5,000 $ X Errors & Omission PERSONAL & ADV INJURY $ ,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X ( POLICY PRJECO�T ( ( LOC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS -MADE DEDUCTIBLE RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below O SCRIPT'ION OF P RATIONS I LOCATIONS I V, HICLES (At coo ACORD 10'1, Addltlonat Remarks Schedule, It more space Is required) ElrSegundo F r' ice Department o�icials, otic rs, a nts nd employ es are named as additional insured with respect to Me we r� pei orme(. by tae named insred. a'oTlonn'ellelse undo.org Investigate n, CI -- CERTIFICATE HOLDER CANCELLATION EI Segundo Police Department GENERAL AGGREGATE $ 5,00_0,000 PRODUCTS - COMP/OP AGG $ 1,000, 000 COMBINED SINGLE LIMIT $ (Ea accident) ............... BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (PER ACCIDENT) C EACH OCCURRENCE $ AGGREGATE $ (WC STATU- H- TORY LIMITSI I°,"",,,,,,,,,... E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ p E.L. DISEASE -POLICY LIMIT $ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Assistant to the Captains Amanda O'Donnell AUTHORIZED REPRESENTATIVE 345 Main Street lNow%(ti ,EI Segundo, CA 90245 O ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: CP00960505 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 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 Perso n(s) Or Organization(s) Automatic Status Included Where Required by Written Contract. All Where Required by Written Contract. Section II - Who Is An Insured is amended to in- clude as an additional insured the person(s) or organization(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 omissions 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 202607 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ Thank you for choosing Allstate Al state A You're in good hands. Proof of Insurance Card . .. ... Page 1 of 2 For your convenlenck two insurance cards have been included for each vehicle. State law requires that one of these cards be kept in each vehicle. Please place them in your vehicles by the effective date. . ......... . ......... ............ .......... .......... . ...... . .......... -- ----- ...... ..... ...... .. . ...... ...... - ----- ....... Allstate. Allstate.: Yawrr in &OW hands. fto*re in Row Please use the Plated Insurance Cards below. Please use the printed Insurance Cards below .................... . . . . . . . . . . .. . ................ . ........................ ....... . .. . ..... .. . ....... .. . ..... ............. ........ Allstate. hft (waram fxd hft tosavane Cud You reingw0wWs. AW *&hmW"TI Kqr#36455 POGO 6600MMOTOX� FO Box 66059t S.MM 'Odndft*pmh 238W =tL1CA9W-Z42Z Tba=wd*akCAVG*24W This Pormy nw--es the reWsirtmnts of the WNUMC Cbliftmla fiftw-bl This poky rata ts " mquirawwas of do appfimble MW NUMBER VEAR/MAKEIMOM MMNMM YEAK/W 934U69SI ZDt6ii f4aebrs M4269A 2MOP EFFMWEDAH EFFECTIVE DATE VEHaEl ONUM0#J2D/19 OMTIDNOATE EXPIRAIM DATE 0900M OW" Thbcard must boCM7iodinftvebideataU times asovidencoofM=rwwa Tftowdfiwf bCWr*d& the n*A*atail firm Allstate. YoWre in grid nwft. NOX# 36455 KE/MODEL 'NUMBER: as evidence of ftoo nce- 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 of self -insure for workers' compensation, issued by the Director of Industrial Relations as provided for by ode § 3700 forthe performance of the work set forth the agreement with the City of EI Segundo. Policy No. (_) I have and will maintain workers' Cor�pen tion irusura s required by Labor Code § 3700 forthe performance of the work for which the agreement with e f egundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone # �certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not mplo any person in any ma er o as to become subject to the workers' compensation laws of California, and agree that, if I should beco a su ject to the worke"mpensation provisions of Labor Code § 3700 1 must immediately comply with tho a pro isions or thea9fegIfnent will automatically become void. Signature of Applicant - Date l Agreement for: Dated: Reviewed by:�