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PROOF OF INSURANCE (2020 - 2020) CLOSEDTIFFHOM-01 _KGOURLEY" DATE (MMIDDIYYYY) TY INSURANCE 6/20/2019 ........... _.......... CERTIFICATE......O..F.. LIABILL.................. _............................ �����_ 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(ies) 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 in lieu of such eyndorsement(s). PRODUCER .. g' NE'-.................................. ........ ...... ,...._._... this certificate does not confer rights to the certificate holder License # 0757776 c� TACT Karen Gourley HUB International Insurance Services Inc. PHO,NI , E tI,: (9p9) 912 6438 FAX 3390 UniversityAvenue, Suite 300 Keren.G tlubint IFVC,No): A` ''AEI ernational.Corn Riverside, CA 92501 AD ourVey IN.SURERIS) AFF°PJR4iING COVERAGE „NAM q .... INSURER A Philadelphia Indemnity Insurance Company 18068 INSURED INSURER „e' ...., ....,..,,,, .,.. Tiffany Home Care INSURER C; DBA: Always Right Home Care 9700 Reseda Blvd., Ste 105 „MSURERD. Northridge, CA 91324-5516 INSURER E . ENSURER F ............... .........................IT................................... _ _... C_TTHISRIS GTOSCERTIFY THAT THE POLICIES REQUIREMENT, OR LISTED BELOW ANY ISSUED COT THE OTHER INSURED NAMED ABBOT FOR T ER R THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY O SPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, C BY PAID CLAIMS INAEXCLUSIONS AND CONDITIONS ENOFr3UCH ADDL SIU POLICY NUMBER POLICY EFF POLICY EXP LIMITS LIMITS SHOWN MAY HAVE BEEN RED Y _ 1^ SR TYPE OF INSURANCE VNS„"dD iMhWCD I COMMERCIAL G ,,.I.,ACH OCCURRENCE a pl}ti"gyp X CLAIMS -MADE OCCUR PHPK1997981 6/15/2019 6/15/2020 S m 100,000 MED EXP Any onp prson'I �' DAMAGE TO R& N I ED X Retro Date 6/15103 i I' � / W 5,000 FIE RSO NAL s A0V, uN.EURY s 1,,000,000 X r AGGPOLiREGATE LIMIT APPLIES PER: GENERAL ,AGGREGAT E' 5 3 000,000 E rARODUr,rs •COP�Fc.ron �O , S „000000 1 PEL�r LOG A Au$��MNNDSVChE LIMT 1,000,001 romoelLEunelurY t, ANY AUTO PHPK1997981 6/15/2019 5 BO'LTE L!I100LIR (Pcrperson)S' „ (' r 1 ' OWNED SCHEDULED AUONL AUTOS ONLY AUTOS Pg'u�rRE FAYVI Iri° �r.I�aen, ����CC �Ory BM1JIDILY,I�+E.ILJRY I•, X,.,RITC)' ONLY X., NONfi ;M,IEY rM?r'r&s[R Y04xmbAC.iL. 5 UMBRELLA LIAB OCCUR EACH 0C=RRENCE ., 5 EXCESS LIAB CLAIMS -MADE .,,AGGREGATE 5 DED RETENTION$ '5 $T FI° WORCOMPENSATION AND EMPLOYERS' LIABILITY YFN A I)LL R ANY PROPRIETOR/PARTNER/EXECUTIVE EI ACICENE 5 OFFICER/MEMBER EXCLUDED? N I A (Mandatory ) E,A,EMP'L()YEE; 5 I Mandato In NH I= IL DISEASE , lI yes, ondor _-A—pi-of L' bOTRDF6115103" r/a' t lcv PHPK1997981 611'512019 6...1 .....�_�t... _......_..0 w E,I_ DE'EASF FCdt,ICY'I. 01T i ��-mmmd15/2020 'IEa Incidnt 1,000,,000 A Prof Liab RD 6/15/03 !PH'PK1997981 6/1512019 6/15/2020 ',Aggregate 3,000,000 DESCRIPTION OF OP'E'RATIONS I LOCATIONS I VEHICLES EACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Hotder'is included as Additional Insured as respects to the General Liability when required by written contract per policy terms and conditions as respects Senior In Home Care Project for the City CERTIFICATE HOLDER City of EI Segundo 350 Main Street EI Segundo, CA 90245 ACORD 25 (2016/03) CANCELLATION 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 ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PHPK1997981 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION 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 E1 Segundo Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section li — 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 0413 © Insurance Services Office, Inc., 2012 Page 2 of 6 '.. 6, �- IDATY)"R" CERTIFICATE OF LIABILITY INSURANCE 09/2512019 PRODUCER THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION Douglas J Carlson ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1820 S Elena Avenue, Suite H HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Redondo Beach, CA 90277 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Cypress Insurance Company Tiffany Homecare Inc. INSURER e. dba Always Right Home Care INSURER C: 9700 Reseda Blvd. Ste 105 INSURER D: Northridge, CA 91324 INSURER E I COVERAGES 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 AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR ADD'L. POLICY NUMBER POLICY EFFECTIVE I POLICY EXPIRATION LIMITS LTR':INSRD TYPE OF INSURANCE DATE IMM/DD/YY) DATE (MM/DD/YYI GENERAL LIABILITY EACH OCCURRENCE $ WWAGQ'D g4EN1 :I,) COMMERCIAL GENERAL LIABILITY ; PREMISE tlLe d3CC.J,!drrroce)$ CLAIMS MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ E LIMIT APPLIES PER GEN'L AGGREGATE R: I PRODUCTS -COMP/OP AGG $ POLICY PRO - JE 'a° LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIREDAUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Peraccident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT . $ ANY AUTO A OTHER THAN E ,ACC $ AUTO ONLY AGO $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE S OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $................ RETENTION S $ VVC ST'A'T'U- 0111- WORKERS COMPENSATION AND a4 TIWC016345 03/01/2019 03/01/2020 TORY LIMITS ER EMPLOYERS' LIABILITY E L EACH ACCIDENT $ 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE EMPLOYEE $ 1,000,000 If yes, describeBunderXCLUDED? SPECIAL PROVISIONS below E L DISEASE - POLICY LIMIT S 1,000,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS City of EI Segundo 350 Main Street EI Segundo, CA 90245 CERTIFICATE MOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of EI Segundo DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN 350 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL EI Segundo, CA 90245 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE haw .ra amPv:v,„�,,�,,, , ACORD 26 (2001/08)�” ORATION 1988 Important Information Insured Tiffany HomeCare, Inc. 9700 Reseda Blvd Ste 105 Northridge, CA 91324-5516 .. IIII iiull�� �JIIII III IIII C V' h w 1..;I 141 E S III II l iii, t 01 11111 111 F 1i r IIII' 1° i IIII ` Agency R -T SPECIALTY INSURANCE SERVICES, LLC 500 S Grand Avenue Suite 2100 Los Angeles, CA 90071 Changes to Your Workers' Compensation Policy with Cypress Insurance Company Policy Number TIWC016345 Policy Period From March 1, 2019 to March 1, 2020, 12:01 AM, standard time at the insure s mailing address, Type of Endorsement Added CA CIGA Adjustment - 0% on 2019 Premium Transactions effective 03/01/2019 State: CA; New: 0,0000 Added Forms effective 03/01/2019 WC990402C - CA Waiver Of Right To Recover - Specific Added Waiver of Subrogation effective 03/01/2019 Name: City of EI Segundo; Job Description: Per written contract Added Waiver of Subrogation Class Code effective 03/01/2019 State: CA; Code: 8827 Home Care Services Premium change. $ This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective See Above Insured Tiffany HomeCare, Inc. Insurance Company Cypress Insurance Company WC 99 00 13 (Ed. 11-14) Policy No, TIWC016345 Endorsement No 1 Premium Countersigned by 330.00 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 04 02 C (Ed 9-14) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy 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 ) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 5% of the applicable manual premium otherwise due on such remuneration subject to a policy maximum charge for all such waivers of 5% of total manual premium. The minimum premium for this endorsement is $350. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule Schedule Specific Waiver Person/Organization: City of EI Segundo Job Description: Per written contract Waiver Premium: 350.00 Payroll Subject Class State to Waiver 8827 CA 9,144.00 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: 03/01/2019 Policy No.: TIWC016345 Endorsement No. Insured: Insurance Company: Cypress Insurance Company WC 99 04 02C (Ed. 9-14) Countersigned by Premium $