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PROOF OF INSURANCE (2020 - 2020) CLOSEDAC<>RV CERTIFICATE OF LIABILITY INSURANCE I °AT 8/27/2019
OBI27I2019
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
Extl; I (Ax. No):
License #0746539E -NIHIL AlisM@ins-solutions.com
ADDRESS:
33302 Valle Rd, Suite 200 INSURER(S) AFFORDING COVERAGE I NAIC $
San Juan Capistrano CA 92675 INSURERA, Hiscox Insurance Company Inc, �i 10200
INSURED
INSURER B
Emergency Management Consulting Solutions Inc.
INSURER C:
21520 Yorba Linda Blvd. Ste. G560
INSURER D:
I INSURER E:
Yorba Linda CA 92887 INSURER F:
COVERAGES CERTIFICATE NUMBER: 19-20 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.
1LTR TYPE OF INSURANCE NSD WVD POLICY NUMBER (PMM.D"IY�YY'�I (MMIDDYIYYYPYI LIMITS
`"X" COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 3,000,000
CLAIMS -MADE X OCCUR
DAMAGE'rO RENTED
PREMISES (Ea occurrence)
$ 100,000
MED EXP (Any one person)
$ 5,000
A UDC -1487197 -CGL -19
08/26/2019 08/28/2020 PERSONALBADV INJURY
$ 3,000,000
GGEENI(''LAGGREGATELIMIT APPLIES PER:
GENERALAGGREGATE
$ 3,000,000
'''
.01NPOLICY J'ECT PRO- LOC
PRODUCTS - COMPIOPAGG
s 3,000,000
OTHER:
$
AUTOMOBILE LIABILITY
COMBI'N'ED SINGLE UMI'T
4Ea aucr dau tl
$
ANYAUTO
BODILY INJURY (Per person)
$
OWNED SCHEDULED
I BODILY INJURY (Per accident)
$
AUTOS ONLY AUTOS
HIRED NON -OWNED
PROPERTY DAMAGE.
$
AUTOS ONLY AUTOS ONLY
_GPer accident)
$
UMBRELLA LIAR OCCUR
EACH OCCURRENCE
$
EXCESS LIAB HCLAIMS-MADE
AGGREGATE
$
DED I I RETENTION $
$
WORKERS COMPENSATION
ry p H
� STATUTE II II ER
'
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETO"ARTNERIEXECUTIVE I"—'j N /A
I E L EACH ACCIDENT
$
OFFICEWMEMBE;R EXCLUDED? l�f!
(Mandatory in NH)
EL DISEASE -EA EMPLOYEE
$
H yes, describe under
DESCRIPTION' OF OPERATION'S below I
EL DISEASE- POLICY LIMIT
Is
Limit: $1,000,000
Ded: $500
Errors and Omissions
I
A UDC -1487197 -EO -19
08/28/2019 08/28/2020 Aggregate: $1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
RE: Management Consulting @ City of EI Segundo
Certificate Holder is included as additional insured.
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 St, EI Segundo AUTHORIZED REPRESENTATIVE
EI Segundo CA 90245
I
©1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
Policy Number: UDC -1487197 -CGL -19
Named Insured: Emergency Management Consulting Solutions Inc.
Endorsement Number: 9
Endorsement Effective: August 28, 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-
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-
tion(s) 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 (02114) Includes copyrighted material of Insurance Services Office, Inc., with its Page 1 of 1
permission.
Proprietary Information
Not for Publication
t lnterinsurance Exchange of the Automobile Club
Automobile Insurance Policy Coverages and Limits
Policy Change Declarations
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.
NAMED INSURED (item 1.)
"MiLL, JAMES
CLOVERD
YORBA LINDA CA 92886-1948
SUBJECT OF POLICY CHANGE
CANCEL VEHICLE
AUTO - CORRECTION
ANNUAL MILEAGE CHG
AUTO POLICY NUMBER: CAA 087664017
POLICY PERIOD (PACIFIC STANDARD TIME)
POLICY EFFECTIVE DATE: 01-25-19 12:01 A.M.
POLICY EXPIRATION DATE: 01-25-20 12:01 A.M.
POLICY CHANGE EFFECTIVE DATE: 04-02-19 12:01 A.M.
THIS
IS NOT A BILL
This policy change will decrease your premium by $398.00.
VEHICLES
VEH. %=AM K.- IDENTIFICATION VEHICLE GARAGE ANNUAL VFRIFIFn
COVERAGES AND OMITS
Coverage Is not in effect unless a premium or the word "included" Is shown.
COVERAGES LIMITS OF LIABILITY
Liability
Bodily Injury $500,000 each person/ $1,000,000 each occurrence
Property Damage $1,000,000 each occurrence
Medical
Physical Damage Value unless oMarkze toted„ lees deductible)
Vehicle 8 Vehicle
Comprehensive ACV
(Less Deductible) $500
Collision ACV
(Less Deductible) $500
Car Rental Expense on
(Per Darr) No Coverage No Coverage No Coverage No Coverage
l ninsu and Motorist
Bodily Injury - $500,ODD each person/ $1,000,000 each accident
Uninsured & Underinsured Vehicles
Uninsured Deductible Waiver
Uninsured Collision
Total Premium
ANNUAL PREMIUMS
Vehicle 7 Vehicle 8 Vehicle 9 Vehicle 10 Vehicle
6
No Coverage No Coverage `No Coverage No Coverage:
u z a
i
8
,-No Coverage No Coverage; No CoverageNo Cover'ag'e
PREMIUM DISCOUNTS
Please refer to the enclosed document entitled "Premium Discounts Applied to Your Automobile Policy."
t If at any time you choose to Pay less than the full l ba'lan'ce outstanding,
finance charges of up to 1.6% per month of the balance outstanding will apply
as explained in your billing statements, which are part of these- declarations.
Adjusted Total Annual Premium*
(Includes all appliicatde discounts.)
Less Policyholder Savings Dividend
(Previously applied a to your premium balance)
Adjusted Net Annual Premium`
(Balance atter previous dividend)
m p PROCESS DATE 04.03-19 PLEASE ATTACH TO YOUR POLICY (SEE REVERSE)
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 (#700,000),
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 pequry under ft laws of California one of the following declarationw.
(_) I have and will maintain a certificate of consent of selfLinsure for workers!
with of . ••
(_) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance
of the work far which the agreement with the City of El Segundo is executed. My workers' compensation insurance
carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone #
(JL/) I certify that, in the performance of the work set forth in the agreement with the City of El 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 I must
immediately comply with those provisions or the agreement will automatically become void. //
Signature of Applicar� Date 111.0 /(,e
'ak"Agreement for:
Dated: 68 • 11 • cv
Reviewed by . -"-I r'� �