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PROOF OF INSURANCE (2020) CLOSEDDATE I CERTIFICATE OF LIABILITY INSURANCE6/2 6/2018 MmorcYYY) THIS CERTIFICATE IS ISSUED AS A MATTER O FN ORMATION ONLY AND CONFERS NO RIGHTS UPON T 11 H 11 E 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. to the terms andlf the cond conditicate holder is an ons the policy, certain pTo'OesLmay requirethe an endorsee ent mustA e endorsed. If statement on this UcBROGate do s WAIVED, subject o certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAM"E U I Chad Lakey Central Washington Insurance Inc. *11DRESS: (509) 697-4871 q PAX (509)697-4600 g c. Esd1: (APC" N.Y: 410 S First 3t. chadl@centralwainsurance.com P.O. BOX 100 I INSURER(S) AFFORDING COVERAGE NAIC # SELAH, WA 98942 INSURER A: Hartford Casualtv Insurance Company 29424 INSURED INSURER B; Wiland Associates, LLC INSURER C: X1651 Collins Rd �INSURER D: IIy INSURER E; Selah WA 98942 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1753002649 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. HNSR ADOL SUBR POLICY EFF POLICY EXP LIMITS i LTR TYPE OF INSURANCE ISP POLICY NUMBER IMMIDD/YYYY) (MMIDDIYY'YY) X COMMERCIAL GENERAL LIABILITY A =CLAIMS—MADE OCCUR X Y :52SEAVW2897 GEN'LAGGREGATE LIMITAPPLIES PER: X POLICY 7 JEC F—]LOC OTHER, AUTOMOBILE LIABILITY A ANY AUTO ALL OWNED SCHEDULED 52SBAVW2897 AUTOS AUTOS X Y NON -OWNED X HIREDAUTOS X AUTOS EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES 4Ea cccurrenca),,,,,,,,, $ 1/12/2019 1/12/2020 MED EXP (Any one person) $ PERSONAL & ADV INJURY S �GENERAL AGGREGATE $ N PRODUCTS -COMP/OPAGG $ tl Stopgap $ COMBINED SINGLE LIMIT' $ REa a�cci�danll BODILY INJURY (Per person) $ 1/12/2019 1/12/2020 I BODILY INJURY (Per accident) $ rf PROPERTY DAMAGE $ Par atcddenlI$ ....... UMBRELLA qqq, OCCUR ADE, EACH OCCURRENCE X UMBRELLA LIAB � CI $ A EXCESS LIAB V AGGREGATE I S DED RETENTION $ X Y 52SEAVW2897 1/12/2019 1/12/2020 I,$ PER: A ANY EMPLOETOR/PA BILITYEXECUTIVE YIN 52SHAVW2897 01/12/2019 01/12/2020 E.LIEACHIITF. ACCIDENT OTH- WORKERS COMPENSATION 9 PROPRI AND EMPLOYERS' LIABILITY � FORT �R ' $ OFFICERIMEMBER EXCLUDED? NIA (Mandatory in NH) Y E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESC'RIP'TION OF OPERATIONS below E . DISEASE - POLICY Uh 1 $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached of more space is required) City of Elsugundo, its officers, officials, employees and volunteers are named as additionlas insureds. Coverage is Primary and Non -Contributory with waiver of subrogation. 1,000,000 300,000 1 10,000 1,000,000 2,000,000 2,000,000 1,000,000 1,000,000 , 2,000,000 2,000,000 1.000.000 1,000,000 1,000 000 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE Chad Lakey/CDL ©19'58-2014 ACORO CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 (201401) i POLICY NUMBER: 52 SSA VW2897 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED _ OWNERS, LESSEES OR. CONTRACTORS - COMPLETED, OPERATIONS This endorsement modifies insurance provided under the following: BUSINESS LIABILITY COVERAGE FORM SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): CITY OF EL SEGUNDO Location And Description Of Completed Operations: 350 MAIN ST EL SEGUNDO., CA 90245 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section C. -- 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" or "property damage" caused, in whole or in part, by "your work" at the - location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products - completed operations hazard". Form SS 41 7106 11 Process Date: 11/26/18 Page 1 of 1 Policy Expiration Date: 81012/20 © 2011, The Hartford (Includes copyrighted material of Insurance Services Office, Inc., with its permission) � , ICCORLY CERTIFICATE OF LIABILITY INSURANCE DATE(MMJDDIYWY) „02/22120, „ THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOTAFFIRMATIVELY 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 ADDITION AL 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 endorsement(s). PRODUCER 4 �A6Y I w4 NAME, Central Wash. Ins. Agency, Inc (a("/c°No. Extl; Laic. No):' PO Box 100 AODRESS': INSURER(S) AFFORDING COVERAGE NAIC it Selah WA 98942 INSURERA: Underwriters at Lloyds, London - CFC 100001 INSURED INSURER B : Wiland Associates LLC INSURERC : 1651 Collins Road INSURERD: INSURER E : Selah WA 98942 INSURERF: 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. LIM ITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSD�UkD POLICY NUMBER PMLICNEFF' POLICY YYEXP LIMITS (NSO WYO 4'MMIDDYYYYY) (MMJDD/YWY�) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE. TO RENTED CLAIMS -MADE F70CCUR PP:.MISE•S (Ee occurran,0 $ �MED EXP (Anu one oomonl $ I PERSONAL &ADV INJURY $ ;•', 't.A;GGREGATELIMITAPPLIESPER GENERALAGGREGATE PRO - L: 1 li ®JECT1:1 LOC PPOr&I%T$ C01h4P(OPA(ir $ ..I AUTOMOBILE LIABILITY C'OGw1B'NED 5ING,LE LIMIT $ IEa aUldfjot i BODILY INJURY (Per arson} It _ AN'vAUTO ALL r)VVNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS H AUTOS UMBRELLA LIABHC0L'-Ac,U',-,,ADE EXCESS LIAB LVED l YIP RF7ENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVEN JA OFFICER/MEMBER EXCLUDED? N (Mandatory in NH) If yes, de?, cr,be under DESCRIPTK N OF OPERATIONS below A Professional Liability PSH031115133 02/15/2019 02/15/2020 P BODILY INJURY (Per acodenl) $ PRd.',e.P'R.RT Y E'rAaN1J' G E BPer $n�. z urYva�l V $ EACH OCCURRENCE AGC,REGATE 4TATLITE � „L„ERH EL EACH ACCIDENT $ EL DISEASE - EAEMPLOYEE�, $ EL DISEASE- POLICYLIMIT $ $1,000,000 /$1,000,000 - PL DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of Insurance CERTIFICATE H'OLDE'R 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. 350 Main Street AUTHORIZED REPRESENTATIVE B Segundo CA 90245 deo . ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 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 El Segundo. Policy No. (_) 1 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 Policy Number Expiration Date Name of Agent Phone # '6 1 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 mu t - immediately comply with th ions or the egreernent wild automatically become void. Signature of Applicant �� Date Print Name`'' Agreement for: Dated: 1>--i -oz. - 19 Reviewed by�,/-fi