PROOF OF INSURANCE (2020 - 2020) CLOSEDATE (MMIC)Dff"
�� CERTIFICATE {JF LIABILITY INSURANCE i 0§/2812019
O INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
THIS CERTIFICATE !S ISSUED AS A MATTER F
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{Sl, AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If tho certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be ondorsad.
If SUBROGATION IS WAIVED, subject t0 the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this cartlflcate does not confer rights to the certificate holder In lieu of such endorsoment(sj
PRODUCER NCAy
A pROT JERRY MACIAS
Na Hassle Insurance Agency PH }�(888144 -4094
1400 E. Cooley Dr. Ste. 202-A I maclas nolaaeelelne,net
Colton, CA 92324 IRSURERIS1 AFFORaINO COVERAGE NAIL u
License f#: OE74924 INSURERA: Unitad 3't III �(tt ____m
INSURED INSURERS:
Christpher Heppell INSURER 0:
DBA• Precision Reef Systems
7712 Goddard Ave. IN>}SPRERD:
Los Angeles, CA 90045 IHse.
INSURER F,
,
NUMBED: 00000000.10094.
COVERAGESTSs
REVISION NUMBER: 6
IES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
IS TCERTIFY THAT THE POLICIES
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
eUaA'
TYPE OF INSURANCE naiDi3;� PCIJOY NUM8FR TAIM10,OR MW"tl'1 rMI rPDa1Y1M'Y'i
LiruiTs$
A X COMMERCIAL GENERAL L1A�LrfY CL 17578850 0611912019 0 11112020
EACHf1Ql �i'Oi��
UMNCE 1.0' .0. _.�
CLAWS -MADE OCCUR
o, REN
PB¢�„IEaema�s moi_ _,..$ 1,�DG}I.....
_iAED EXD (Any We Imo) s 6,000 ,
PERSONAL S ADV I'NJ'URY $ 1.000-.000
w
OrF N'L AsRECI%? LIMIT APPLIES PER;
I
2000 000 -
POLICY JECT E LOC
PRODUC7S�COPVIPIOPAid3 $ 00'00
OTHER'
C�OMaINED INOLLUMIT $
AUT OMOBILE LIABILITY ,I
Abbe arctd®n91 „
ANY AUTO
INJURY
$
OWNED
ONLY
SCHEDULED
AUTOS
`Perperson)
SODINJURY Peracclaom}
AUTOS
HIRED
_.,.....
NON -OWNED
RD s
AUTOS ONLY
AUTOS ONLY
RILL ALIARLI
ItpI SUR
v`I OCCURRENCE $
EXCESS
8 CLAIMS -SIA
AGGREGATE $
p
DED I RETENTION S
$
.. I.
VdoR'Kr.RS COMPENSATION
AND FNIPLOYERS'LlABILITYYIN
ANY PROPRIVORIPARTNERIEXECUTIVE r `j NIA_EL.
EXCLU0902
EACH HS _......
OFFICERIMlIMSER'
(Mzndalory to NH)
E L. DISEASE- EMPLOYEE _ _.
II descrIbe0dor
0 InOF OPERATIONSbrAow
I
E.L.DtSEASE-POLICYLIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD tat, Additional Remarks Schedule, may be aNaohed N more space is required)
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
The City of El Segundo and Its employees ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
El Segundo, CA 90245 AUTHORI%ED EPRESI NTATIve
i (JMAL;
01988-.2095 ACORD CORPORATION. All rights reserved.
ACORD 25 (209$103) The ACORD name and logo are registered marks of ACORD
Printed by JMA on May 28, 2099 at 02:05PM
POLICY NUMBM. CIL 17578850 t;OCJIMSMALARNORAL LIABILI7lr
0020100704
TH10 ]INDORSEMENT CHANOf;S TH9 POLICY. PLEASE FIS rr CAREFUU.Y.
ADDITIONAL INSURED OWNERS LESSEES OR
CONTRACTORS SCHEDULED ERSON OR
ORGANIZATION
This onftsoftrdnl tllad&e Inxinranoo provided under Ilia following,
COMMEKOIAL GUNERAL (- MILrry COVERAGE PMT �
SCHEDULE
nlanoa of Addltlana3 Insaretl Persara(s}
or q gMnl ttlorll� . � Io Ids) f ra�rsr �t t�rsrot�dons
—J���u y v4ten con10I Q.C. meA%I ggto'f „at„!o„n.tt ed Insurad
The City of El Segundo and ifs employees
350 Main Street
P -I Segundo, CA 90246
Winiatton �sciulrod ca a tris a Iadtrls” ft not shown pove will far n I li
�,.. �� or�fluwwn l�rrtlara 00tslraa'stlpgao, .�
A”. Rootlon 11 — Who Is An iraourod 14 urnanded io
Inclttaie as an odditlottal lnatrred Ilts persons} or
ortlrtni atfon(s) s wum M the •ledulaa, but oily
wwaI h respsnt to fitrbddtty for °°t oOlty hjwy", "property
drxrrraat; or '"i raona,l end a4vorilsIng InJ!ery"
caused, in whole or Irr poet, by:
1. Your rujta or raraaissions3 or
2. Tho ants or arnlsmIcho of those noting all yapr
behalt; . . ._ . .
in the perfrarrlanett Of yraur onooln0 aapttl�tlorta for
the asddttinnaal hourod(s) at tite tart on(a) dos ,
hated Htwo.
M With resat tar the Insumoroa arrorded to thoets
addition Insureds, the taliowino atdditlwaf excltt-
olons apilyt
This Instrtome dr»aorr not uppty to "bvdlly Injury" or
"proparty 4rarr eg " oar urrlcr0 edict
4, All wo*, IWuding moterlolo, parts or equip,
Mani A mMed in aonttsation with augb work,
on the pro001 ottior then service, mafntdnance
or rspsdts, to o parforntad by or v),bohalf of
the a,d'dliltrr l Insurod{$at the location or Die
cover d oporatdotre taps soon Completed, or
2. That portfnn of "your work* out cat ^whl h the
Injury or damage artaos hail baon put to Its In•
trarfdacd use by tthy peruon or 0r0artixratlorn oliv,
e r than another raontrootor or atr'beentractor
cognood in performing opsrotlonrp for p p4n.
o1,pal as a Pak of Itis samo project,
C0,20 10 07' 04 6 160 Propertleas, than 2004 Pagel 4 at 3 Ct
i
ENDORSEMENT
Slus�Y, NIS, � 7
�6
t� aer�erval
I
* "R
IT IS AGREED, FOR AN ADDMQNAL PRSMIUM OF $ THAT THO TRANSFER OF
IIIIS WAIVE ANY RIGHT OF RSCOVSIRY WS MANY HAVE AGAINST ANY PERSON OR
ORGANIZATION THAT QLIALJFIE%9 AS AN ADDITIONAL IN'SURS.0 PURSUANT TO THE TERMS OF
ENDORSEMENT NUMBOR 1 IMAM OF PAY' EES WE MAKE FOR BODILY INJURY OR
PROPERTY DAME ARISING OUTQFg 'YOUR WORK PS RFORM90 OURIhNO TIHI POLICY
PeAI �ro UNDER AN INSURED RED Cd�I�1 R�1 TWITH THAT POR sON OR ORGANIZATION, ',ATION, P1RMOED
THAT TWO SCiL&Y INJU Nei' OR PROPERTY OAMAGO OCCURS SUBSSQUSNT TO TEAS
VXE~OtJTItN-OI*' Met'INSU O1<,TRACT;OR-(te-YOVR-PlgO "I-MANIJP,FCTURSD-OR-SOLtl--_.®_.--
C)URM THE POLICY PERIOD UNDER AN INSURED 10ONTIRAOT WiTIR THAT PERSON OR
ORGANIZATION, PROVIDED THAT TICS OODILY INJURY OMR PJROPSrR`I'Y DgMAOS 00GURS
SMEOVENT TO THE FASCUTION OF THE IIS DURED DONT RAC T.
'A
I»'L QTH9R TERMS AN'O C'Cwl°IOIIILI of TNpp P0I,1 Y AWMI UNCHANGED,
pollqNumbor 100=4 6IIa t
CL 1767885C Christophor Heppeii DBA; precision Reef Systems 06/11/2019
Vo,AWO'WO'flTCAP
I
ACS CERTIFICATE OF LIABILITY INSURANCE I DATE Il1
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON Inc 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 P'RODUCER'. AND THE CERTIFICATE HOLDER.
IMPORTANT: If thecert]Acate 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 holder in lieu of such endorsement(s).
PRODUCER
Sly Brent K Whitlock Insurance Age PHONE CONTACT ._ Melissa Sanders - NI ,
ce tate does not con his to e �
Agency Inc IAfC. N, E�It..310-821-0864 FAX
_ .... .
(4e-. 310 541-6199
28441 Highridge Rd Ste 503 E-MAILS&melissa.sanders.isak@matefarm.com
ADORRolling (fills Estates, CA 90274 INSURE_R(S)AFFORDING COVERAGE NAIL 4''
.... �. .....�.
INSURER mobile Insurance Company 25178
� _ State Farm Mutual Auto
INSURED
INSURER 10 - ...... ......, _.. ......... .�. � , .....,
Christopher Heppell
7712 Goddard Ave
pllllW 1URER D'
Los Angeles, CA 90045
IT,twURES IL m. _
INSURER F
COVERAGE'S CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAI 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.
INsEXCLUSIONS AND CONDITIONS OF SUCH
POLICIES,LIMITS SHOIHAVE BEEN RED BY PAID 'ID CLAI
MS
AODL�POUCYLkFF PEXP
"'PE OF IwSURANNCPOLICY M RfkYYNwwwYI
LIMITS
COMMERCIAL GENERAL LIABILITY EACHMCIMArN.r s,....
w= 70 RENTED I
�.� C S OCCUR I*id'Cd7a,a I'4't' Cay+�TM11 P'1
GF.N'L AGGREGATE LIMIT APPLIES PER
VI iN'n na' IIu'", I1
VIPUI!,mil
ih'1ii' V Lft'.dN
I' M1,'II�99'rl�"
AUTOMORMEUAMLITY
p ANY AUTO
A ONtIED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON-OYKFEU
AUTOS ONLY AUTOS ONLY
UMBRELLA LUM OCCUR
EXCESS L1AB WILTS
OC,O N'1'K?N'!
VAORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
YIN
ANY PC,!f''7,C"'AFI'FM�'ENWo"E,'WIwU,9,p'k'k ElN!A
�Ir r it FRA Vr MCC R CXCI..PC
IM01041+t M NH)
Har �Jra�Liam �t tet
I1 '�FI,C iP' t rT N ''IIF OPrRATICNS W'+v
V..�I tl$ONA4 8 AU'V INJUH'V $
or-ArRAI AGGREGATE S
PRODUCTS • COMPIOP AGG : 3
S
612 9574-C14-75 09114!2019 W 03114)2020S
,En S
BODILY INJURY {Por parwnl S 1,000„000
BODILY INJURY (Par MCMV%) L...,
s V
s 1,000.0W
II
::ua 1 .000,000
iJI•a.u� B i u Ma; n �'� it d
I S
EACH OCCURRENCE 4
AGGREGATr „m
S
4
Prn 070
STATUTE W4 -
rvELEACHA= E.NI, 5 '
r L OBSEAsa= FA MMPI oYrr1
. C L• 04E.ASE - PULII;:Y LPN(+k' S
DESCRIPTION OF OPERATIONS I LOCATIONS J VEHICLES (ACORD 701. AOaUoW R”"I Schad^ mW Im III N mme rpm Is r" d"
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
The City of EI Segundo and its employees ACCORDANCE WITH THE (POLICY PROVISIONS.
350 Main Street
EAUTHORIZED REPRESENT
I Segundo, CA 90245
- 0�AC ROOAPRATIOM All rights reserved.
ACORD 2b (2016103) 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 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 Policy Number Expiration Date
Name of Agent Phone #
(XI 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 must
immediately comply with thus , rovisions or the reemen 'ill automatically become void.
Signature of Applicant � Date
Print Name L ��(_' . .
J
Agreement for:
Dated:
Reviewed by: (��e