PROOF OF INSURANCE (2019 - 2020) CLOSED'DATE (MM/DDIYYYY)
A� V CERTIFICATE OF LIABILITY INSURANCE
06/17/2019
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 11 is an ADDITIONAL INSURED, the policy(les) 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: Mary POJaf
ISU - Dunlap AgencyPHONE E tl, (714) 838-3158 LA/JNDI, (714) 922-6157
700 West 1st St., Suite 8EMAIL mary@dunlapins.com
ADDRESS:
Lake Forest CA 92630 I INSURER F:
COVERAGES CERTIFICATE NUMBER. 2018-2019 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 'ADOL SUBR - POLICYEFF POLICY EXP LIMITS
ITR TYPE OF INSUNICE I.— WVD POLICY NUMBER (MM/DD/YYYY) IMMIDDIYYYY) „
COMMERCIAL GENERAL LIABILITY $ 1,000,000
CLAIMS -MADE � OCCUR $ 1,000,000
$ 10,000
$ 1,000,000
$ 2,000,000
$ 2,000,000
$ 1,000,000
$ 1,000,000
AN
GRA, AGGREGATE LIMITAPPLIES PER:
PRO
POLICY 0 „)ECT LOC
OTHER
AUTOMOBILE LIABILITY
ANYAUTO
72SBABD3913 10/17/2018 1 10/17/2019
EACH OCCURRENCE
DAMAGE 10 RENTED
PREMISES (Ea occurrence)
MED EXP (Any one person)
PERSONAL BADV INJURY
GENERAL AGGREGATE
PRODUCTS - COMP/OPAGG
Employee Benefits
COMMNEID SINGLE LIMIT
tEaa acc.rdentl
BODILY INJURY (Per person)
A OWNED SCHEDULED 72SBABD3913 10/17/2018 10/17/2019 BODILY INJURY (Per accident)
AUTOS ONLY AUTOS
X HIRED NON -OWNED PROPERTY accident) ra^!w AUTOS ONLY AUTOS ONLY
X UMBRELLA LIAB OCCUR EACH OCCURRENCE
A EXCESS LIAR CLAIMS -MADE 72 SBABD3913 10/17/2018 10/17/2019 I AGGREGATE
$ 4,000,000
$ 4,000,000
DED I XI RETENTION $ 10,000
INSURERS) AFFORDING COVERAGE
NAIC #
Tustin
CA 92780INSURER A
Sentinel Insurance Co.
11000
INSURED
INSURER B:
Preferred Employers Ins, CO
10900
Matrix Imaging Products, Inc,
INSURER C :
Lloyds of London
AA1122000
20512 Crescent Bay,
I INSURER D:
If yes, describe under
DESCRIPTION OF OPERATIONS below
I E L DISEASE - POLICY LIMIT
Suite 100
I INSURER E:
Deductible: $1,000
a
Lake Forest CA 92630 I INSURER F:
COVERAGES CERTIFICATE NUMBER. 2018-2019 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 'ADOL SUBR - POLICYEFF POLICY EXP LIMITS
ITR TYPE OF INSUNICE I.— WVD POLICY NUMBER (MM/DD/YYYY) IMMIDDIYYYY) „
COMMERCIAL GENERAL LIABILITY $ 1,000,000
CLAIMS -MADE � OCCUR $ 1,000,000
$ 10,000
$ 1,000,000
$ 2,000,000
$ 2,000,000
$ 1,000,000
$ 1,000,000
AN
GRA, AGGREGATE LIMITAPPLIES PER:
PRO
POLICY 0 „)ECT LOC
OTHER
AUTOMOBILE LIABILITY
ANYAUTO
72SBABD3913 10/17/2018 1 10/17/2019
EACH OCCURRENCE
DAMAGE 10 RENTED
PREMISES (Ea occurrence)
MED EXP (Any one person)
PERSONAL BADV INJURY
GENERAL AGGREGATE
PRODUCTS - COMP/OPAGG
Employee Benefits
COMMNEID SINGLE LIMIT
tEaa acc.rdentl
BODILY INJURY (Per person)
A OWNED SCHEDULED 72SBABD3913 10/17/2018 10/17/2019 BODILY INJURY (Per accident)
AUTOS ONLY AUTOS
X HIRED NON -OWNED PROPERTY accident) ra^!w AUTOS ONLY AUTOS ONLY
X UMBRELLA LIAB OCCUR EACH OCCURRENCE
A EXCESS LIAR CLAIMS -MADE 72 SBABD3913 10/17/2018 10/17/2019 I AGGREGATE
$ 4,000,000
$ 4,000,000
DED I XI RETENTION $ 10,000
$
� --
WORKERSCOMPENSATION
-
k�j STATUTE I ORH-AND
EMPLOYERS' LIABILITY YIN
1,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE
B ❑ N/A WKN157011-5
EACH ACCIDENT
12/01/2018 12/01/2019
$
OFFICER/MEMBER EXCLUDED?
I
1,000,000
(Mandatory in NH)
E L DISEASE - EA EMPLOYEE
$
If yes, describe under
DESCRIPTION OF OPERATIONS below
I E L DISEASE - POLICY LIMIT
$ 1,000,000
Deductible: $1,000
$1,000,000
Professional Liaility
C Network Security MPL-0000265-02
06/1712019 06/17/2020 Deductible: $1,000
q
$250,000
DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule,
may be attached if more space is required)
The City of EI Segundo, its officials, and employees are named as additonal insured.
Insurance on the Certificate is Primary, Thirty (30) days notice of
Cancellation required.
CERTIFICATE HOLDER CANCELLATION
City of EI Segundo
350 Main St.
EI Segundo
ACORD 25 (2016/03)
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
CA 90245 oiq� D4-
1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
MATRIX IMAGING PRODUCTS, INC
7-OLICY NUMBER: 72SBABD3913 POMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY,
ADDITIONAL INSURED -OWNERS, LESSEES OR
CONTRACTORS (Form B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
qq,yl
Name of Person or Organization:
The City of El Segundo,, its officials and employees
(if no entry appears above, information required to complete this endorsement will be
shown in the Declaration as applicable to this endorsement.)
WHO IS AN INSURED (Section 11) is amended to include as an insured the person or
organization shown in the schedule, but only with respects to liability arising out of your
work preformed for that insured.
CG 24 10 07 04 Copyright, Insurance Services Office, Inc. 2004
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
WC 00 0313
(Ed, 4-84)
We have the right to recover our payments from anyone liabie for an 'injury covered by this policy. We will not enforce our
right against the person or organization named In the Schedule. (This agreement applies only to the extent that you
perform work under 9, written contract that requires you to obtain this agreement from us.)
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
Schedule
The City El Segundo,
Its officials and employees
This endorsement changes the policy to which It is attached and is effective on the date issued unless otherwise stated,
(The information below Is required only when this endorsement is Issued subsequent to preparation of the policy.)
Endorsement Effective: , Policy No. WKNI57011
Insured: MATRIX IMAGING PRODUCTS, INC.
Insurance Company; Employers Countersigned by Dean Duntso
WC 00 0313
(Ed. 4-84) Copyright 1983 National Council on Compensation Insurance,
Endorsement No, 1
Premium $0