PROOF OF INSURANCE (2020 - 2020) CLOSEDACC)Ra h
CERTIFICATE OF LIABILITY INSURANCE DATE (MMlDD1YYYY)05l07l19 II
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
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s),
PRODUCER CONTACT
NArAE
COMPLETE EQUITY MARKETS INC PHO,.,�1v.Etitk (i (__ � 444
a�i�oNE
1190 Flex Court E•MAII
{64 �1 00...,_ 84? 541-0.. �.....�
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Lake Zurich, IL 60047
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AFFORDING COVERAGE ...,., „ ..__
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INSURER A'Underwriters atLlovd�,�opdon
INSURED
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MAK Fire Protection Engineering
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& Consulting, Inc.
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12130 Rahn Avenue
Granada Hills, CA 91344
INSURER F:
q
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
NDICATED. NOTWITHSTANDING ANY REOU REMENT„ TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, I -HE INSURANCE AFFORDED
BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO
ALL THE TERMS,
EXCLUSIONS AND TIONS OF SUCH POLICIES. LIMITS SHOWN MAY H AVE BEEN REDUCED
CED BY PAID CLAIMS.
lies R Nsu
ITR TYPE, of i R
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I diw�MrD OFrYrYI d4N4a[NDDFY F^ "'v'q LIMITS
a...URANCE
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EACH CCCU R M'E
2400 000
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5.000
A 1701021
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03!16(19 03!16!20 & ADV INJURY I;
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2,000,000
. r�t°�F��rC� LIMIT APPLIES PER: I
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POLICY ...C,1'I PRO- ,
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AUTOMOBILE
ANY TOIABILITY
I
BODILY INJURY (Per person)
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OWNEDSCHEDULED
AUTOS ONLY AUTOS
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(Per accident)
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I HIRED NON-OWNEDq,,—
AUTOS ONLY I, AUTOS ONLY
PROPERTY -'h i1
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UMBRELLA LIABI IOCCUR Y
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II EXCESS LIAB
EACH OCCURRENCE M
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WORKERS COMPENSATION
AND
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PERPTATWO7F I
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ER
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BNEEDE7 ECUTIVE ,;Y'N
ANY OFFICER
OPRIETOR EX N i A
/MEMBE
F L EACH ACCIDENT
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(Mandatory m NH)
E.L. DISEASE . EA c, P GYr_
Iles, describe under
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D SCRIPT*N OF OPERATIONS below
E. L DISEASE - POLICY LIMI4' �
Professional Liability
A 94690
06/01/19 06/01/20 Each Claim
$1,000,000
Aggregate I
$1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Please see pages 2, 3 and 4 for additional information.
CERTIFICATE HOLDER CANCELLATION:
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of EI Segundo, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Its officers, offlolals, employees, agents and volunteers ACCORDANCE WITH THE POLICY PROVISIONS.
Attn: Carol Lynn Anderson AUTHORIZED REPRESENTATIVE
314 Main Street
El Segundo, CA 90245
(O 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
AMENDATORY ENDORSEMENT NO.: 1701021
INSURED: MAK FIRE PROTECTION ENGINEERING & ADDITIONAL PREMIUM: (Included)
CONSULTING, INC_
EFFECTIVE: March 16, 2019 to March 16, 2020
(Primary)
It is hereby agree(] and understood that the person(s) or entity(ies) listed 'below is/are included as
Additional Insured(s) under the policy number referenced above, but only with resix-cl to claims or
damages arising, solely out of actions of the Named Insured:
City of Segundo, its officers, officials, employees, agents and volunteers
314 Main Street
El Segundo CA 90245
The coverage provided hereunder to the above-named Additional Insured shall be primary and
non-contributory to any insurance or self-insurance maintained by the Additional Insured.
All other terms, conditions, limits and exclusions remain unchanged.
Attached to and forming part of Certificate No.: NI 9023
Dated: March 27, 2019 UNDERWRITERS AT LLOYD'S, LONDON
LII 442-3 (04/12) Complete 1°. uity Markets, Inc.,.
WMR) B0429 BA1901027 d1m Complete Eq Aty Markets Irmir7ame A esiq, Inc
P14"353 I'tw'ASUOD44077'I
By
Lawrence T.P. Molloy
Endorsement #12
AMENDATORY ENDORSEMENT NO.: 1701021
INSURED: MAK FUZE PROTECTION ENGINEERING & ADDITIONAL PREMIUM: Included
CONSULTING, INC- RETURN PREMIUM: N/A
EFFECTIVE: March 16, 2019 to March 16, 2020
F1,1041:01.4 W11 -101R, 9,
In consideration of the additional premium paid as shown above, it is
hereby understood and agreed that UnderNvriters shall provide, a
30 -day written notice of' cancellation regarding this policy of
insurance to:
Ms. Carol Lynn Anderson
City of El Segundo
314 Main Street
El Segundo CA 90245
All other terms, conditions, limits and exclusions remain unchanged.
Attached to and forming part of
Cover Note/Certificate/Policy No.: NI 9023
Dated: March 27, 2019
AUTHORIZATION NO.: (UMR) B0429 BA1901027
AIF 23911 (06/99)
(UMR) B0429 BA1901027
P14'*34
Endorsement #13
UNDERWRITERS AT LLOYD'S, LONDON
Complete L(' ulty Markets, Inc.
dba Uity Markets Insuranre Agency, Inc.
(CASLOD44077)
AMENDATORY ENDORSEMENT NO.: 94690
ASSURED: MAK FUZE PROTECTION ENGINEERING & ADDITIONAL PREMIUM:
CONSULTING, INC.
EFFECTIVE: June 1, 2019 to June 1, 2020
FXTFNSION OF COVERAU,
BAR IMS-LLOD --11X
(Primary)
'It is hereby agreed and understood that Underwriters will pay Damages and Claims
Expenses on behalf of the entity/entities listed below for its/their vicarious or imputed
liability
it; which arises from Claims caused by the negligent errors or omissions of the Named
Assureds identified in the Declarations, in the performance of their Professional Services for
the below identified Additional Assureds:
The City of El Segundo, its officers, officials, employees, agents and
volunteers
It is further understood and agreed that such liability stated above shall apply only to the
listed entity/entities and its/their employees.
ployees, This extension of coverage does not increase
the Limits of' Insurance nor amend any other provision in the Certificate which shall remain
the same.
It is further agreed that the coverage provided hereunder to the above-named Additional
Assured(s) shall be primary and non-contributory to any insurance or self-insurance
mainlained by the Additional Assured(s).
(Included)
All other terms, conditions, limits and exclusions remain unchanged.
Attached to and forming part of Certificate No.: CEM 58 - 19
Dated: May 7, 2019 UNDERWRITERS AT LLOYD'S, LONDON
LII 197-3 (08/15) Complete E Ult� Market,s, Inc.
V
(UMR) B0429BA1901026 dba C y Markets Insurancv Agwicy, In -, (CASL#OD44077)
Lib**504
By
Lawrence T.P. Molloy
Endorsement #13
AMENDATORY ENDORSEMENT NO.: 94690 ADDITIONAL PREMIUM: Included
ASSURED: MAK FIRE PROTECTION ENGINEERING &
CONSULTING, INC_
EFFECTIVE: June 1, 2019 to June 1, 2020
NOTICE OF CANCELLATION
In consideration of the additional premium paid as shown above, it is hereby
understood and agreed that if Underwriters cancel this insurance for any
reason other than non-payment of premitun, Underwriters shall provide a
30 -day written notice of cancellation to tile following:
Ms. Carol Lynn Anderson
City of El Segundo
314 Main Street
El Segundo CA 90245
All other terms, conditions, limits and exclusions remain unchanged.
Attached to and forming part of Certificate No.: CEM 58 -19
Dated: May 7, 2019 UNDERWRITERS AT LLOYD'S, LONDON
AIF 2119 (09/08) Complete ESjuity Markets, I'nc.
dba Cumplete Equity Markets Insurance Agency, 7 In - CCASL#01)44077)
(UMR) B0429BA1901026
Lib*023 revised 7/04 8/04 9/08 By lk6�"-
Lawrence T.P. Molloy
Endorsement #14
Certificate of Insurance
MAK FIRE PROTECTION ENGINEERING & CONSULTING, INC,
Policy Number: 94690/1701021
Subject to all policy ternis, canditions, exciusions and endorseinents of �each respective policy. The City of El
Segaindo, its officers, officials, ernployees, agents and volunteers H an additional insured but only per the ternis &
conditions of' the endorsernent gener;ted f'4 each respective policy and subject to all policy terms, conditions,
exclusions and endorsements.
***Primary/Non-Contributory and a 30 -Day Notice of Cancellation only applies to the General Liability Policy.
SURPLUS LINES NOTICE TO POLICYHOLDER - PLEASE SEE ATTACHED
Lawrence T.P. Molloy
binders't'M
NOTICE:
1. THE INSURANCE POLICY THAT YOU HAVE PURCHASED IS
BEING ISSUED BY AN INSURER THAT IS NOT LICENSED BY
THE STATE OF CALIFORNIA. THESE COMPANIES ARE
CALLED "NONADMITTED" OR "SURPLUS LINE" INSURERS.
2. THE INSURER IS NOT SUBJECT TO THE FINANCIAL
SOLVENCY REGULATION AND ENFORCEMENT THAT APPLY
TO CALIFORNIA LICENSED INSURERS.
3. THE INSURER DOES NOT PARTICIPATE IN ANY OF THE
INSURANCE GUARANTEE FUNDS CREATED BY CALIFORNIA
LAW. THEREFORE, THESE FUNDS WILL NOT PAY YOUR
CLAIMS OR PROTECT YOUR ASSETS IF THE INSURER
BECOMES INSOLVENT AND IS UNABLE TO MAKE
PAYMENTS AS PROMISED.
4. THE INSURER SHOULD BE LICENSED EITHER AS A FOREIGN
INSURER IN ANOTHER STATE IN THE UNITED STATES OR AS
A NON-UNITED STATES (ALIEN) INSURER. YOU SHOULD
ASK QUESTIONS OF YOUR INSURANCE AGENT, BROKER, OR
"SURPLUS LINE" BROKER OR CONTACT THE CALIFORNIA
DEPARTMENT OF INSURANCE AT THE FOLLOWING
TOLL-FREE TELEPHONE NUMBER: 1-800-927-4357 OR
INTERNET WEB SITE VIWW.INSURANCE.CA.GOV. ASK
WHETHER OR NOT THE INSURER IS LICENSED AS A
FOREIGN OR NON-UNITED STATES (ALIEN) INSURER AND
FOR ADDITIONAL INFORMATION ABOUT THE INSURER.
YOU MAY ALSO CONTACT THE NAIC'S INTERNET WEB SITE
AT WWW.NAIC.ORG.
5. FOREIGN INSURERS SHOULD BE LICENSED BY A STATE IN
THE UNITED STATES AND YOU MAY CONTACT THAT
STATE'S DEPARTMENT OF INSURANCE TO OBTAIN MORE
INFORMATION ABOUT THAT INSURER.
6. FOR NON-UNITED STATES (ALIEN) INSURERS, THE INSURER
SHOULD BE LICENSED BY A COUNTRY OUTSIDE OF THE
UNITED STATES AND SHOULD BE ON THE NAIC'S
INTERNATIONAL INSURERS DEPARTMENT (IID) LISTING OF
APPROVED NONADMITTED NON-UNITED STATES INSURERS.
ASK YOUR AGENT, BROKER OR "SURPLUS LINE" BROKER TO
OBTAIN MORE INFORMATION ABOUT THAT INSURER.
7. CALIFORNIA MAINTAINS A LIST OF APPROVED SURPLUS
LINE INSURERS. ASK YOUR AGENT OR BROKER IF THE
INSURER IS ON THAT LIST, OR VIEW THAT LIST AT THE
INTERNET WEB SITE OF THE CALIFORNIA DEPARTMENT OF
INSURANCE: W`WW.INSURANCE.CA.GOV.
8. IF YOU, AS THE APPLICANT, REQUIRED
THAT THE
INSURANCE POLICY YOU HAVE PURCHASED
BE BOUND
IMMEDIATELY, EITHER BECAUSE EXISTING
COVERAGE
WAS GOING TO LAPSE WITHIN TWO BUSINESS DAYS OR
BECAUSE YOU WERE REQUIRED TO HAVE
COVERAGE
WITHIN TWO BUSINESS DAYS, AND YOU DID NOT RECEIVE
THIS DISCLOSURE FORM AND A REQUEST
FOR YOUR
SIGNATURE UNTIL AFTER COVERAGE BECAME
EFFECTIVE,
YOU HAVE THE RIGHT TO CANCEL THIS POLICY WITHIN
FIVE DAYS OF RECEIVING THIS DISCLOSURE. IF YOU
CANCEL COVERAGE, THE PREMIUM WILL BE
PRORATED
AND ANY BROKER'S FEE CHARGED FOR THIS
INSURANCE
WILL BE RETURNED TO YOU.
LMA9098A
04 May 2017
D-2 (Effective January 1, 2017)
bindersx138
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 #
41 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 Califomia, and
agree that, if I should become ubject to tile e workers' compensation provisions of labor Code § 370 1 must
immediately comply with thos islons agreernent will automatically become void.
Signature of Applicant Date
Agreement for: °� t ' m"� � %" )112�YI i'I,� �' �dh�l t �• n'
i
Dated:AV
Reviewed by: 11>