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PROOF OF INSURANCE (2019) CLOSED.......... n� DATE (MMIDD/YYYY) * CERTIFICATE OF LIABILITY INSURANCE 05/24/2019 .......... 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 be endorsed. If SUBROGATIONIS 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•••••••••••• ISU-SADLER & COMPANY/PHS/FAST BUS NAME: PHONE 866 467-8730 FAX � "m""'2 22291933 ( ) (888) 4 13-6112 (A/C, No, Ext): (AIC, No): The Hartford Business Service Center 3600 Wiseman Blvd E-MAIL San Antonio, TX 78265 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURER A: The Sentinel Insurance Company 11000 ES PRESS INC INSURER B 8340 N THORNYDALE RD STE 110-314 I(.. ............ --• .................. TUCSON AZ 85741-1162 INSURER C: INSURER D : INSURER E: II 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. INSR TYPE OF INSURANCE ADDL SUBR I POLICY NUMBER POLICY'EFF POLICY EXP LIMITS �,..••,..,INSR WVD fMMIDD/YYYXZ,,„-•,((�A„�}/,�i)o1,1„�',.V,�„� — COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 C�I.AIM'SWADE p y;• OCCUR A .ff' DAMAGE TO RENTED $1,000,000 vl� ....... X neral Liability �nre) yns:cuperson) MED EXP An one erson _m..., . $10,000 A X 22 SBM ZG9713 08/09/2018 08/09/2019 PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY PRO-LOC X PRODUCTS - COMP/OP AGG $2,000,000JECT .....-... OTHER• ..._ ..............._....r AUTOMOBILE LIABILITY COMBINED SINGLE "LIMIT $1,000,000 ... fFa accident) ANY AUTO ............•.• BODILY INJURY (Per person) A m” ALL OWNED SCHEDULED 22 SBM ZG9713 AUTOS AUTOS 08/09/2018 08/09/2019 BODILY INJURY (Per accident) HIRED NON -OWNED X X PROPERTY DAMAGE AUTOS AUTOS (Per accident) ................. -. UMBRELLA LIAB ..............------.---............ OCCUR ........ ° .............................................. .........—.. EACH OCCURRENCE _ ............. {Iv.._... EXCESS LIAB CLAIMS - .. AGGREGATE MADE DEDI IRETENTION $ Ory N _.._.._.._.• ISTATUTE I PI. AND EMPLOY RS' LIABI . •.•.........._ BH ANY YIN E.L. EACH ACCIDENT PRO PRIETOR/PARTNER/EXECUTIVE............. NIA OFFICERIMEMBER EXCLUDED? F E L. DISEASE -EA EMPLOYEE (Mandatory in NH) ."""""""'11 •• If yes, describe under E1, DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS below A EMPLOYMENT PRACTICES $10,000 22 SBM ZG9713 LIABILITY 08/09/2018 08/09/2019 DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Those usual to the Insured's Operations. Certificate holder is an additional insured per the Business Liability Coverage Form SS0008 attached to this policy. ..................... CERTIFICATE 'FOLDER .. CANCELLATION _._................ CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED CITY CLERK BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 350 MAIN ST RM 5 IN ACCORDANCE WITH THE POLICY PROVISIONS. ................. EL SEGUNDO CA 90245-3813 AUTHORIZED REPRESENTATIVE —,d 1:�Fueall of © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD THE HARTFORD BUSINESS SERVICE CENTER THE 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 CITY OF EL SEGUNDO CITY CLERK 350 MAIN ST RM 5 EL SEGUNDO CA 90245-3813 Account Information: 0 Policy Holder Details: O ES PRESS INC May 24, 2019 Contact Us Business Service Center Business Hours: Monday - Friday (7AM - 7PM Central Standard Time) Phone: (866) 467-8730 Fax: (888) 443-6112 Email: ggenicy.service s( thehartford.cam Website: httos:I/business,thehartford.com Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team hJl � �:i�Z�f•� 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 Name of Agent Policy Number Expiration Date Phone # (max} 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 immediately comply with those provisions or the agreement will automatically become void. Signature of Applicant Agreement for: Dated: Reviewed by. _ �� Date 6/12/19