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PROOF OF INSURANCE (2020 - 2020) CLOSEDOP ID: MN CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 06/11/2019 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 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 endorsemellt(s)" PRODUCER CONTACT Michelle A Nowell AllianceAgent/Broker oker Lic# 073 966 E44AIL..................'nowell amiscorp.com )' 760FAX -471-9378 - - 355 V' , No, Ext): 760-471-7116 ARL;, Na) . CA A' E44AIL San Marcos, CA 92078 PRODUCERm Michelle A. Nowell cusT'ol ID r,, MESSI-1 INSIARER{Sy AFFORDING COVERAGE NAIC # INSURED Messina & Associates,lnc INSURER A: Acceptance Casualty Ins Comp 10349 814 Forbes Drive INSURER B Brea, CA 92821 INSURER C 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 INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE I�!S!VD POLICY NUP«MBERkI'P«9MYfllDP'MYY�'�,"_(PrvdryPV9lD0/YYXYj LIMITS ...... �„ .......... GENERAL LIABILITY EACH OCCURRENCE a 1,0'00,000 A X w,l ;I r.ul 1>,),I I oiii'I ii, X CP00961045 06/01/2019 06/01/2020 DAMAGE 1Q RENTED 100,000 X Errors & Omission 61 IN'I (1 ;''Pl IC II 1101 ),I'll I. If.,; I"P..I X POLICYLOC .Ira ,,.ry AUTOMOBILE LIABILITY I I o, \NI[III II7 ”%AV1^O', . I III IPS III I' II 111 7+1: I) Adl I 1 ,,''r II'M61;teLll..>a, IL.IImMlli:r' ........ :.od'I'I:Uk XCESS IL.IIAIB r;Yl,AIP,/d::', I'VIP'llI'11: ,I', I''HIP, II fll I II WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTh1ER/E>.ECLJ"FIVE I. "p OF=FICER/MEMBER EXCLUDED? N ( A (Mandatory in NN) Ii y a, ­Jcl DESCRIPTION OF OPERATIONS below .... ....... ......................_,.,_ ..,_.......... DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) City of Ei Segundo its officers, volunteers,emploees and representatives are named as additional insured with re)ect towort/ performed by the named s insured with, and 30 Days Notice of anceil'ation Investigation, CA -- canderson elsequndo.org CERTIFICATE HOLDER CANCELLATION City of EI Segundo hristopher Donovan 314 Main Street EI Segundo, CA ACORD 25 (2009/09) N[l ID I. %11 IF',r„; , I I,, I„,I',,,I I 5«000 ro,111n1 1,000,000 I"III P?II^, "I+1 .,.,'I'I. 5,000,000 1,000,000 COMBINED SINGLE LIMIT (FIER ACCIDENT) L II i1i'hp il��'o I!4'IRI.II11:II ii q``R'vl'CV' I,.IIiII l ; I d Ito,, 1 1 IIM11Il .' 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 OL © 1988-2009 ACORD CORPORATION. All rights reserved, The ACORD name and logo are registered marks of ACORD POLICY NUMBER: CP00961045 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 Pers on(s) Or Organizat'ion(�) Automatic Status Included Where Required by Written Contract. All Where Required by Written Contract. "It is agreed, as respects the Policy, thirty (30) days notice of cancellation, except as respects non- payment of premium, for which ten (10) days notice will apply, or other regulatory requirements that may apply, will be given as respects the indicated certificate holder." Information required to complete this Schedule, if not shown above„ will be shown in the Declarations. Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s) or organ- ization(s) shown in the Schedule, but only with re- spect 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 20 26 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 11 a 111LGII I1 IJlll A$ ILrG L—ALr11AI lyG VI LI IG P%ULV111%J J11G VIIU J ,! Automobile Insurance Policy Coverages and Limits Renewal Declarations We are pleased to offer you a renewal for your automobile insurance policy. To renew your policy, send at least the minimum payment on or before the due date. Insurance is in effect only for the vehicles, coverages, and limits of liability shown on this declarations page and as set forth in the insurance policy and endorsements. These declarations, together with the contract and the endorsements in effect, complete your policy. If any change to your policy or to the information we have on file results in a premium decrease during the policy period, the Interinsurance Exchange reserves the right to apply any refund due to your outstanding balance. NAMED INSURED (item I� ertlrn 1.) MESSINA, MICHAEL AND CAROLYNA 814 FORBES DR BREA CA 92821-7306 VEHICLES AUTO POLICY NUMBER: CAA 065044011 POLICY PERIOD (PACIFIC STANDARD TIME) POLICY EFFECTIVE DATE: 03-25-19 12:01 A.M. POLICY EXPIRATION DATE: 03-25-20 12:01 A.M. VEH. Vehicle 5 Vehicle 7 IDENTIFICATION VEHICLE GARAGE ANNUAL"' VERIFIED NO, YEAR MAKE MODEL NUMBER USE ZIP CODE MILES MILEAGE 5 2012 KIA SOUL SW/!/SPORT KNDJT2A65C7474113 PLEASURE 92821 12,501 -15,000 VERIFIED 7 2009 JEEP WRANGLER UNLIMITED 1J4GA39159L745955 PLEASURE 92821 5,501 - 7,500 VERIFIED 8 2016 MBNZ E CLASS 550 WDDKJ7DBOGF314383 PLEASURE 92821 5,501 - 7,500 VERIFIED 9 2016 CHEV SLVRDO 1500 CR NEW 3GCUKSEC3GG285230 PLEASURE 92821 7,501 -10,000 VERIFIED 10 2017 HYUN ELANTRA SE KMHD84LFOHU299328 COMMUTE 92821 3,501 - 4,500 VERIFIED COVERAGES AND LIMITS Coverage is not in effect unless a premium or the word "included" is shown. COVERAGES LIMITS OF LIABILITY Liability Bodily Injury $100,000 each person/ -$300,000 each occurrence Property Damage $50,000 each occurrence Medical Physical Damage (Actual Cash Value unless otherwise stated, less deductible) Car Rental Expense (Per Day) $35 $35 Uninsured Motorist Bodily Injury - $30,000 each person/ Uninsured & Underinsured Vehicles Uninsured Deductible Waiver Uninsured Collision Total Premium ANNUAL PREMIUMS SALVAGE NO NO NO NO NO Vehicle 5 Vehicle 5 Vehicle 7 Vehicle 8 Vehicle 9 Comprehensive ACV ACV ACV ACV (Less Deductible) $1000 $1000 $1000 $1000 Collision ACV ACV ACV ACV (Less Deductible) $1000 $1000 $1000 $1000 Car Rental Expense (Per Day) $35 $35 Uninsured Motorist Bodily Injury - $30,000 each person/ Uninsured & Underinsured Vehicles Uninsured Deductible Waiver Uninsured Collision Total Premium ANNUAL PREMIUMS SALVAGE NO NO NO NO NO Vehicle 5 Vehicle 7 Vehicle 8 Vehicle 9 Vehicle 10 $ 362 $ 346 $ 197 $ 286 $ 166 $ 274 $ 241 $ 150 $ 246 $ 120 No Coverage; No Coverage No Coverage', No Coverage No Coverag Vehicle 10 ACV $ 71 $ 35 $ 97 $ 58 $ 57 $1000 ACV $ 478 $ 199 $ 698 $ 448 $ 352 $1000 $35 $35 $35 $ 67 $60,000 each accident $ 82 $ 45 $ 34 $ 28 $ 27 $71 $65 $36 $46 Included Included Included Included Included No Cove'ragle i No Coverage No Coverage No Coverage ; No C'overag. $ 1334 $ 937 $ 1241 $ 1101 $ 768 PREMIUM DISCOUNTS "No Coverage" indicates coverage not purchased. Please refer to the enclosed document entitled "Premium Discounts Applied to Your Automobile Policy." If at any time you choose to pay less than the full balance outstanding, finance charges of up to 1.5% per month of the balance outstanding will apply as explained in your billing statements, which are part of these declarations. ** To see the annual mileage for your expiring policy, please refer to the "Notice of Annual Mileage" page contained in your renewal package, Total Annual Premium* (Includes all applicable discounts.) Less Policyholder Savings Dividend Net Premium* $ 5381 $ 717 $ 4664 CAA0200A PROCESS DATE 02-13-19 PLEASE ATTACH TO YOUR POLICY (SEE REVERSE) E20190107 021419 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 LaborCode § 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 # (__g 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 v i ^ P),—Date 7/12/2016 I" Agreement for 5 tpj Dated: Reviewed by:, ,�"e2-