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PROOF OF INSURANCE (2020) CLOSEDDONOGOL-01 MWOODS A�""^RIli7� `� CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 7/10/2019 ............ ............................wawa. 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 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 License # OD79613 C NTACT 1 LAME;..........____ .............. Bower'master & Associates Insurance Agency, Inc. ONE Fax 10805' Holder Street, Suite 350 �c, No, Ext): (714) 733-6200 �Alc, Nol:(714) 252 8253 Cypress, CA 90630 AI HS£ .. .............. .................... ... ....... ....................... ................ ..INSURERJsI,AFFORDINGC0VERA,GE NAIL.#................ _INSURER A: Phlladelp,h„I,a• I•nSU,rp,pp•„e,•,COm,parll@S INSURED INSURER B..9..A.llia,n,Z............................................................................... 21873 The Lakes at EI Segundo Lane Donovan Golf Partners, LLC wsuRERINSURER , D c,;, : ..........................._ 400 South Sepulveda Boulevard ••-•-••••••-••••• EI Segundo, CA 90245 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 3OLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN5R ADDL SUBR POLICY EFF POLVCY ExP _ ,TYPE OF INSURANCE INgp yyyD POLICY NUMBER LIMITS IMMUC YEFF tMMUCY EXPf- A X COMMERCIAL GENERAL LIABILITY I tAAMi E rORS'I ., .. 1,000,000 • EA4H CbCC4J,RIRENCE...., $ ..... CLAIMS -MADE W,X, I OCCUR X PHPK1844312 7/1/2019 7/1/2020 /'R .MGE'T RENTED � $ 100,000 �. MED, EXE. (Any ,.RQ.e.P.e,,,,,r„son)..w.w..._$,,,,,,,,,,,,,,, R EEN'L AG'GREG_ATE' LIMIT APPLIES PER: • ... NAI., � A,Dv Ir1�uRv $ I POLICY 0 JECQT F-1 LOC PIR.ODUIGTS COMP/OP AG $ 7 OTHE'R' A AUTOMOBILE LIABILITY 7/1/2019 7/1/2020 „B(JI]ILYInI,Iu,RY„IPer�arsan $ X ANY AUTO PHPK1844312 DAMAGE PR.��jPrL�al n;99 OWNEDSCHEDULED AUTOS ONLY OS ASUU(T�� $ ., ,OCCURRENCE 7/1/2019 7/1/2020 AGGREGATE X, ��yy X AUTOS ONLY �............. . AL/TO�/CY MBRELLA L X OCCUR .^^ �jTAT T Ex..LIAB k...::::, CESS LIABCLAIMS-MADE SSE15357296 .,..,............... _E L DISEASE EA EM,PLOYE.Em 5 ............... E L DISEASE_- POLICY LIMIT DED RETENTION $ 7/1/2019 7/1/2020 Each Occur/Aggregate WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE P416EMME'MBER EXCLUDED? N I A ❑ atoryIn NH) If yes, describe under DESCRIPTION OF OPERATIONS below A Liquor Liability PHPK1844312 �. MED, EXE. (Any ,.RQ.e.P.e,,,,,r„son)..w.w..._$,,,,,,,,,,,,,,, • ... NAI., � A,Dv Ir1�uRv $ PIR.ODUIGTS COMP/OP AG $ 'm COMBINED SINGLE LIMIT _�iE�R.�aco,gpP11 $ 7/1/2019 7/1/2020 „B(JI]ILYInI,Iu,RY„IPer�arsan $ (Peral�ident) NJURY $ DAMAGE PR.��jPrL�al n;99 $ EACH $ ., ,OCCURRENCE 7/1/2019 7/1/2020 AGGREGATE $„,.,•,,,,,,,,,,,, OTH- .^^ �jTAT T E.L .,..,............... _E L DISEASE EA EM,PLOYE.Em 5 ............... E L DISEASE_- POLICY LIMIT $ 7/1/2019 7/1/2020 Each Occur/Aggregate DESCRIPTION OF OPERATIONS / LOCATIONS / VEH'ICLESACORD 101, Additional Remarks Schedule, may be attached If more space is required) RE: 400 S. Sepulveda Blvd., EI Segundo, CA 90245. City of EI Segundo is named Additional Insured per attached endorsement form. _- a 1w Ir City of EI Segundo Attn: Recreations and Parks 350 Main Street EI Segundo, CA 90245-3895 I ACORD 25 (2016/03) CANCELLATION 5,000 1,000,000 3,000,000 3,000,000 1,000,000 20,0.00,000 1,000,000 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 9-T.v''6”- ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PHPK1844312 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): City of EI Segundo Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include 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: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 ^= EVIDENCE OF PROPERTY INSURANCE DATE (MM/DDIYYYY) ''�` .� I 8/16/2018 THIS EVIDENCE OF PROPERTY INSURANCE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ADDITIONAL INTEREST NAMED BELOW. THIS EVIDENCE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS EVIDENCE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE ADDITIONAL INTEREST. ................................................. A ENCYIPHONE LIP. C -Q-9xW 714-733-6200 COMPANY Ph'Idlh' I C Bowermaster & Associates 10805 Holder St Ste 350 Cypress, CA 90630 714-252-8253...ADO �E ;.WOodSt ?, werrra st room IG .IW.a)....._...._...... _._.. _. I a e p la nsurance ompanles 26300 La Alameda Suite 470 Mission Viejo CA 92691 . CTE::OD ______......_.........._............_...."'q .. ASEN.CY -.CUSITVMER Ip.p.................____.........____....._...................,.,.,................................................... a (NSURED NUMBER LOANEFFECTIVE The Lakes at El Segundo E""POLICYNUMBER PHPK1844312 Lane Donovan GolfPartners, LLC DATE EXPIRATION DAT ...................... .............. 400 South Sepulveda Boulevard 7/1/2019 7/1/2020 CONTINUED UNTIL TERMINATED IF CHECKED EI Segundo, CA 90245 — a ......... ...... ._...... ............. THIS REPLACES PRIOR EVIDENCE DATED: The Lakes at EI Segundo Golf Course - 400 South Sepulveda Blvd, EI Segundo, CA 90245 ............... 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 EVIDENCE OF PROPERTY INSURANCE 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. COVERAGE INFORMATION PERILS INSURIED I I BASIC I U BROAD II I SPECIAL. COVERAGE/PERILS/FORMS Blanket Building, Special (Including Theft), Agreed Value Blanket Business Personal Propperty/ Special (Including Theft), Agreed Value Blanket Inland Marine/Golf Caris/Equipment, Replacement Cost REMARKS (including Special Conditions) Evidence CANCELLATION AMOUNT OF INSURANCE DEDUCTIBLE 17,962,002 10,000 4,501,021 2,500 4,419,000 1,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ADDITIONAL INTEREST NAME AND ADDRESS ADDITIONAL INSURED �� LENDER'S LOSS PAYABLE u LOSS PAYEE MORTGAGEE City of EI Segundo LOAN # Attn: Recreations and Parks 350 Main Street AUTH'ORIZEDREPRESENTATIVE EI Segundo CA 902453895 USA of. ACORD 27 (2016/03) ©1993-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ,--1*1 0 I DATE (MM/DD/YYYY) A�Ra CERTIFICATE OF LIABILITY INSURANCE 01/02/2019 V 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: INT: If the certificate f such endorsement older is an ADDITIONAL q NSURED, the policy(ies) must be endorsed. If SUBROG STIONcIIS WAIVED, subject to the terms and conditions of the olic , certain policies may require an endorsement. A statement on this certificate doe nfer rights to the certificate O PRODUCER (CONTACT NAME: Self Insured Solutions PHONE FAX (800) 592-0047 (aC,No,E■t): (800) 592-2541 Administrator, California Restaurant Mutual Benefit Corp. E-MAIL siscerts@selfinsuredsolutions.comADDRESS: 430 N Vineyard Ave.. #102 INSURER(S) AFFORDING COVERAGE NAIC# Ontario, CA 91764 INSURERA: California Restaurant Mutual Benefit Corp.* INSURED INSURER R: State National Insurance Company 12831 Donovan Golf Courses Management, Inc. INSURER C: Affiliate of California Restaurant Mutual Benefit Corp. INSURERD: c/o Bowermaster & Associates P. O. Box 6026 INSURER E: Cypress, CA 90630 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 EQUIREMENT, TERM, OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO 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 SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE I INSR WVD POLICY NUMBER (MM/DD1YYYYI MM DDM'YY1 LIMITS I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ � CLAIMS -MADE OCCUR DAMAGEs O RENTED PREMISE $ (Ea occurrence) . MED EXP (Any one person) $ PERSONAL &.ADV INJURY $. ... ... ., GEN1. AGGREGA'T'E LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY, PROJECT F7 LOC PRODUCTS - COMP/OP AGG $ OTHER COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ ANYOWNED SCHEDULED �YII BODILY INJURY (P AUTOS AUTOS of accident) $ HIRED AUTOS NON -OWNED PROPERTY DAMAGE $ AUTO (Per accident, ,,$, UMBRELLA LIAR .OCCUR , H OCCURRENCE ...,, $ EXCESS LIAB CLAIMS -MADE IF AGGREGATE $ IDED RETENTION $ $ WORKERS COMPENSATION X I WCSTATU- OTH-' AND EMPLOYERS' LIABILITYV/N❑ TORY LIMITS ER A ANY PROPRIETOR/PARTNER/EXECUTIVE I N/A OFFICE/MEMBER EXCLUDED? N 4517-1682 01/01/2019 01/01/2020 E.L. EACH ACC(DE NT $1,000,000.00 (Mandatory in NH) E.L. DISEASE- EA EMPLOYEE $1,000,000.00 Ifyes, describe under - DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT $1,000,000.00I B EXCESS WORKERS COMPENSATION ( NDE -093 7598-18 01/01/2019 01/01/2020 + Limits. AND EMPLOYERS LIABILITY I Applicable to WC Statutory Limits and Employers Liabilit DESCRIPTION OF OPERATIONS / LOCATION / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Re: Golf Course: The Lakes at EI Segundo -400 S. Sepulveda Blvd. ** Waiver of Subrogation applies - see attached ** *Complies with the requirements of the Director of Industrial Relations under the provisions of Sections 3700 to 3705, inclusive, of the Labor Code of the State of California, holder of Master Certificate of Consent to Self -Insure No. 4517 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Recreations and Parks ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street,••. EI Segundo, CA 90245-3895 AUTHORIZED REPRESENTATIVE L. Bell _......... Q 1988-2010 ACORD CORPORATION. All rights reserved ACORD 2S (2014/01) The ACCORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY California Restaurant Mutual Benefit Corp. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS We have the right to recover our payments from anyone liable for a covered injury. 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 a 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 Name of Person or Organization: City of EI Segundo Attn: Recreations and Parks 350 Main Street El Segundo CA 90245-3895 Insured: Donovan Golf Courses Management, Inc. Policy No.: 4517-1682