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PROOF OF INSURANCE (2019 - 2020) CLOSED2281189 Mainstream Unlimited Certificate Of Insurance 7/18/2019 5:08:12 PM a DATE(MMIDD/YYYY) ACC>R" CERTIFICATE OF LIABILITY INSURANCE 7/18/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON' 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 CONTACT NAME: rw1 PHONE 800 688 1,984 I FAX 877-826-967 1 (91q_N9_w): ( ) ANP. Npl. 0 insureon E-MAIL Insureon (BIN Insurance Holdings LLC.) ADDRESS 30 N. LaSalle, 25th Floor, Chicago, IL 60602 INSURER(S) AFFORDING COVERAGE NAIC # DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is named as Additional Insured as their interests may appear in regards to general liability. This insurance is primary and non-contributory to any other insurance provided as respects general liability coverage. CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street EI Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. attn:Liana Osborne AUTHORIZED REPRESENTATIVE I � ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD INSURERA: Philadelphia Indemnitv Insurance Company,. ......... 18058 _ INSURED INSURER B : HiSCOX 10.200 _ Mainstream Unlimited INSURER C: 37159 Galena Cir, Burney, CA, 96013 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 iA6G�L'" Ubk POt•q' y',. .. ... E,'� OBDDt"Y"V"Y"M1 TR TYPE OF INSURANCE JN POLICY NUMBER ..L.,,...,..,. IMMIDDPYYYYI ''4iWIMLt LIMITS MME LIABILITY �II EACH OCCURRENCE $2 000,000 ✓ ED 0 CLAIMS -MADE OCCUR $ „PREMISES (Ea occurrence,) . • MED EXP (Any one person) $ 5,000 BYes �I UDC -1694215 -CGL -19 2/3/2019 2/3/2020 PERSONAL 8 ADV INJURY $ 2.000,000 .... ... ... GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 J'EC7 ❑ LOC OHECd FRO- ,000 0 PRODUCTS-COMP/OPAGG $ 2 00 �OT . AUTOMOBILE LIABILITYCOM BUIh@ED SINGLE LI.�.l..�... ............ �a awda'nl ),,,,,,,,,,,,,,,,",,,,,,,,,, $ ANY AUTO BODILY INJURY Per ars ( person) $ ALL OWNED �pI SCHEDULED accident) DILYINJ R erac _AUTOS fl NON�OWNED PPROEI11M DAMAGE HIREDAUTOS AUTOS cr acc+ejynl .. ) ( .... I $ UMBRELLA LIAB OCCUR EACH OCCURRENCE B CLAIMS -MADE I AGGREGATE $ DE.DE.SS..LI- ...................I, N ...T RETENTIO WORKERS COMPENSATION PER OTE RH STAT0 AND EMPLOYERS' LIABILITY YIN II ........ ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N / A E ,EACH ACCIDENT L $ OFFICER/MEMBER EXCLUDED? i Mandato in NH (Mandatory ) _ EA EMPLOYE E L DISEASE O $ � If yes, describe under DESCRIPTION OF OPERATIONS below E1 DISEASE -POLICY LIMIT $ A Professional Liability (Errors and Omissions) PHSD1393194 2/4/2019 2/4/2020 Occurrence/Aggregate $1,000,000 / $2,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is named as Additional Insured as their interests may appear in regards to general liability. This insurance is primary and non-contributory to any other insurance provided as respects general liability coverage. CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street EI Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. attn:Liana Osborne AUTHORIZED REPRESENTATIVE I � ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD A HISCOX GET THE RIGHT INSURANCE, RIGHT NOW err f Policy Number: Named Insured: Endorsement Number: Endorsement Effective UDC -1694215 -CGL -19 Mainstream Unlimited 16 February 03, 2019 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Ilt IN • A 1 ,, •le • • • This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) 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 organi- zations) 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 omis- sions 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 Policy Number: Named Insured: Endorsement Number: Endorsement Effective UDC -1694215 -CGL -19 Mainstream Unlimited 8 February 03, 2019 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any per- sons) or organization(s) for whom you are performing operations or leasing a premises when you and such person(s) or organiza- tion(s) have agreed in writing in a contract or agreement that such person(s) or organiza- tions) be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to lia- bility 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 opera- tions; or 2. In connection with your premises owned by or rented to you. A person's or organization's status as an addi- tional insured under this endorsement ends when your operations or lease agreement for that additional insured are completed. G.. CGL E5421 CW (02/14) Includes copyrighted material of Insurance Services Office, Inc., with its Page 1 of 1 permission. Policy Number: UDC -1694215 -CGL -19 Named Insured: Mainstream Unlimited Endorsement Number: 10 Endorsement Effective: February 03, 2019 Hiscox Insurance Company Inc. COMMON" POLICY CONDITIONS All Coverage Parts included in this policy are subject to the following conditions. A. Cancellation 1. The first Named Insured shown in the Declara- tions may cancel this policy by mailing or deli- vering to us advance written notice of cancella- tion. 2. We may cancel this policy by mailing or deliver- ing to the first Named Insured written notice of cancellation at least: a. 10 days before the effective date of cancel- lation if we cancel for nonpayment of pre- mium; or b. 30 days before the effective date of cancel- lation if we cancel for any other reason. 3. We will mail or deliver our notice to the first Named Insured's last mailing address known to us. 4. Notice of cancellation will state the effective date of cancellation. The policy period will end on that date. 5. If this policy is cancelled, we will send the first Named Insured any premium refund due. If we cancel, the refund will be pro rata. If the first Named Insured cancels, the refund may be less than pro rata. The cancellation will be ef- fective even if we have not made or offered a refund. 6. If notice is mailed, proof of mailing will be suffi- cient proof of notice. B. Changes This policy contains all the agreements between you and us concerning the insurance afforded. The first Named Insured shown in the Declarations is authorized to make changes in the terms of this policy with our consent. This policy's terms can be amended or waived only by endorsement issued by us and made a part of this policy. C. Examination Of Your Books And Records We may examine and audit your books and records as they relate to this policy at any time dur- ing the policy period and up to three years after- ward. D. Inspections And Surveys 1. We have the right to: a. Make inspections and surveys at any time; b. Give you reports on the conditions we find; and c. Recommend changes. 2. We are not obligated to make any inspections, surveys, reports or recommendations and any such actions we do undertake relate only to in- surability and the premiums to be charged. We do not make safety inspections. We do not un- dertake to perform the duty of any person or organization to provide for the health or safety of workers or the public. And we do not warrant that conditions: a. Are safe or healthful; or b. Comply with laws, regulations, codes or standards. 3. Paragraphs 1. and 2. of this condition apply not only to us, but also to any rating, advisory, rate service or similar organization which makes in- surance inspections, surveys, reports or rec- ommendations. 4. Paragraph 2. of this condition does not apply to any inspections, surveys, reports or recom- mendations we may make relative to certifica- tion, under state or municipal statutes, ordin- ances or regulations, of boilers, pressure ves- sels or elevators. E. Premiums The first Named Insured shown in the Declara- tions: 1. Is responsible for the payment of all premiums; and 2. Will be the payee for any return premiums we pay. IL 00 17 11 98 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 2 F. Transfer Of Your Rights And Duties Under This Policy Your rights and duties under this policy may not be transferred without our written consent except in the case of death of an individual named insured. If you die, your rights and duties will be transferred to your legal representative but only while acting within the scope of duties as your legal representa- tive. Until your legal representative is appointed, anyone having proper temporary custody of your property will have your rights and duties but only with respect to that property. Page 2 of 2 Copyright, Insurance Services Office, Inc., 1982, 1983 IL 00 17 11 98 I Hiscox Insurance Company Inc. Policy Number: UDC -1694215 -CGL -19 Named Insured: Mainstream Unlimited Endorsement Number: 1 Endorsement Effective: February 03, 2019 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DEFINITION OF IEMUPLOYIEE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART In Section V — DEFINITIONS, Definition 5. "Employee" is deleted and replaced with the following: 5. "Employee" includes a "leased worker" and a "temporary worker". CGL E5401 CW (03110) Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1 Policy Number: UDC -1694215 -CGL -19 Named Insured: Mainstream Unlimited Endorsement Number: 3 Endorsement Effective: February 03, 2019 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EXCLUSION - PERSONAL INFORMATION. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Paragraph 2. Exclusions under Section I — COV- ERAGE A — BODILY INJURY AND PROPERTY DAMAGE LIABILITY, COVERAGE B — PERSONAL AND ADVERTISING INJURY LIABILITY, and COVERAGE C — MEDICAL PAYMENTS is amended to include the following exclusion: Personal Information "Bodily injury", "property damage" or "personal and advertising injury' caused by the insured's failure to protect any non-public, personally identifiable infor- mation in the insured's care, custody or control. CGL E5404 CW (03/10) Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1 :SAA insurance Exclirlange: Automobile Policy Declarations � .r' 110 1. oA 221? 1 " W-inura Oaklami, (J)+ 94023 222 I Please keep with your policy. See Important Notice on reverse For questions or changes call: (800) 922-8228 Page 1of1 I Name and Address of Insured IIIII��nI��II�iInIII�IIiI�nIIrII�I�Ii��rIIIrIIIIiI�IJ�nll�lr ROBERT MAY IRENE MAY 37159 GALENA CIR BURNEY. CA 96013-4255 Alternate Address Item Make %A 1 u 1 2 GMC ,_„ 3 GMC >I Model Yr Body Type 2017 SUV 2019 PICKUP Occupation Retired Z Declarations Process Amended Declarations 07-02-2019 0 Type (530)335-4288 Date P: 1 Dedu�ole Premium Name Q PolicyCAA5102097536 Number � Insured 2007 Since z 1 GKKVSKD4HJ224873 U.11 0 From 12 01 A M Standard Time at the address of the W. z Z correspond Named Insured, but not prior to the time applied Your 06-06-2019 for or, if this is a replacement declarations, no: Policy Comprehensive Actual :ash Value Less Deductible prior to the time coverage change was reques:ed. Period J TO 12:01 A M Standard Time at the address of the 60 10-19-2019 Named Insured, Alternate Number Telephone Number Coverage _..N,l' imis e mt .. Item � ..Prmu (530)335-4288 Vehicle Identification No Deductible ble Prmum 1 Dedu�ole Premium Name Item Eliminated � vers ddo not not Irene 1 GKKVSKD4HJ224873 U.11 necessarily Robert Uninsured Motorists 1,000,000 1,000, 000 y correspond $92 1 GT42VCYl KF159281 . $139 to principa+ly $117 Comprehensive Actual :ash Value Less Deductible p operated 1,000 i $100 i Full Comprehensive Safety Glass Endorsement vehicles Coverage _..N,l' imis e mt .. Item � ..Prmu rem� 3 ... .��-- �.... nc.. E PersonEach Occurrence Deductible ble Prmum 1 Dedu�ole Premium r". blePremium Deductible Pemium Bodily Injury 1 OOO,00000 $174 $196 $130 Medical Payments 25,000 $33 $57 $36 Uninsured Motorists 1,000,000 1,000, 000 $96 $102 $92 Property Damage.. _.,.. ..... ..... .........1,000,000.... . $139 ; $177 $117 Comprehensive Actual :ash Value Less Deductible $20 1,000 $143 1,000 i $100 i Full Comprehensive Safety Glass Endorsement i ...........,($0 deductible)............................. ..... ............. ............ NO COV NO COV i , Collision Actual Cash Value Less Deductible $99 1,000 i' $594 1,000 y $428 ........... Transportation rtation Ex ense Enhanced .......spo p No 1E,ov ,rage ! $17 $21 $25 per aggregate p r All Risks Actual Cash Value Less Deductible No Cov2rage No Coverage No Coverage Vehicle Loan/Lease Protection Endorsement No Coverage No Cn�erage No Coverage New Car Added Protection Endorsement No Coverage No Coverage No Coverage Original Equipment Manufacturer Parts (OEM) Endorsement No Coverage No Coverage No Coverage Ride -sharing Coverage Endorsement No Coverage No Cobrerage No Coverage TOTAL PREMIUM PER VEHICLE $569 $1,286 $924 * Automobile Death Benefits $15,000 per deceased insured person p Premium $6 Premium Summary This is not a bill CA Surcharge: $0 Total Return Premium: $287.00 - Total Premium shown is for the Member Advantage m Program. EXCLUSIONS There is no coverage provided by this Policy while the following individual(s) operate a motor vehicle: None Schedule or Changes LA Maintain Vehicle(s) L9 z Q x u 55 1500 12 15 07-02-2019 01034 0100 (Continued on back) 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 for the 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 # () 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 tvisions or the agreement will automatically become void. �i Signature of Ap is nt � f=- �+' � Date ?/Z � Print Name I C/ - Agreement for: Dated: Reviewed by:� �- _ _ �....�......�.._.� _�...