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PROOF OF INSURANCE (2020 - 2020) CLOSEDDATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 05/30/2019 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(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 Alis Maynard NAME:' Insurance Solutions PHONE (949) 348-7400 FAX(949) 348-2373 AM1" , Na, Ext): (AIC,. No). License #0746539 ' AIL' AlisM@ins-solutions.com ADDRESS: 33302 Valle Rd, Suite 200 INSURERS) AFFORDING COVERAGE NAIC it San Juan Capistrano CA 92675 INSURERA: Hiscox Insurance Company Inc. 10200 INSURED INSURER B: California Automobile Insurance Co. 38342 Counterrisk, Inc., DBA: Michael T Little INSURER C: 18000 Studerbaker Road, Suite 700 INSURER D : INSURER E: I Cerritos CA 90703 INSURER F: II V COVERAGE'S C RTIFICATE NUMBER: 19-20 E 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. ILiR I TYPE OF INSURANCE INSO WVD POLICY NUMBER IMMIDDIYYYY) lM /DD7 YY1PfM1 LIMITS " COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE x OCCUR PREM SESLM oc,curra nce$ $ 100,000 MED EXP (Any one person) V $ 5,000 A Y UDC -1993098 -CGL -19 06/07/2019 06/07/2020 PERSONAL&ADV INJURY p $ 1,000,000 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ XPOLICY [__j PRO- LOC JECT IPRODUCTS-COMP/OPAGG $ 2,000,000 OTHER. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 4Es accJdentl $ 1,000,000 X ANYAUTO BODILY INJURY (Per person) I $ B OWNED SCHEDULED Y BA040000034276 06/06/2019 06/06/2020 BODILY INJURY (Per accident) $ I— AUTOSONLY HIRED AUTOS NON -OWNED ( PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY f Per aerJd'ant) UMBRELLA LIABOCCUR —Td EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE I AGGREGATE $ DED J, I, RETENTION $ $ WORKERS COMPENSATION IPER STATUTE I I ETH AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE ENIA EL EACH ACCIDENT - $ OFFICER/MEMBER EXCLUDED? (Mandatoryin NH) E,L. DISEASE - EA EMPLOYEE $ IF yes, describe under DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT $ Each Claim $1,000,000 Professional Liability A Y UDC -1993098 -CGL -19 06/07/2019 06/07/2020 Aggregate $1,000,000 ' DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) City of EI Segundo its officials, and employees as "additional insureds" under said insurance coverage and to state that such insurance will be deemed "primary" such that any other insurance that may be carried the City of EI Segundo will be excess thereto. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 314 Main Street AUTHORIZED REPRESENTATIVE EI Segundo I CA 90245,E ©1988 2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Policy Number: Named Insured: Endorsement Number: Endorsement Effective UDC -1993098 -CGL -19 Michael Little 8 June 7, 2019 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - AUTOMATIC STATES 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- son(s) 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. CGL E5421 CW (02/14) Includes copyrighted material of Insurance Services Office, Inc., with its Page 1 of 1 permission. 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. 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 # ( &I 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 ,•o as to become subject to the workers' compensation laws of California, and agree that, if I should become 1 1 Ject la, the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those pr sioot, or the agreement will automatically become void. a , . a of Applican(;.... � ... � . r Signature Date A Agreement for; 4F p4vk 9*% Dated; �0- Reviewed b--` 1