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PROOF OF INSURANCE (2020 - 2020) CLOSED0 DATE(MMIDD/YYYY) �►G`+C REP CERTIFICATE OF LIABILITY INSURANCE �`, 08/2212019 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). y PRODUCER PHONE 979-4023 ( L all .............. --- FAX J _....P'.... CONTACT Ashbrook-Clevidence, Inc.AIC Nc 714 9......ITITITITITITIT NAME',Beverly 3000 W MacArthur Blvd, Suite 320 79-2609 Santa Ana, CA 92704 _AAPRESs: Berrerly!eac.!+ vi'd!TFe,com License #: 0188788 INSURED Mark Groh Mark Groh 5481 Vallecito Avenue Westminster, CA 92683 INSURERS/AFFORDING COVERAGE INSURER A.. : Fireman's Fund INSURER ScOtt 1s�le INSURER C INSURER D INs JRER E INSURER F : – NAIC.�#.... .- COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 6 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 AN_D CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY 'AID CLAIMS, ILTR TYPE OF INSURANCE ANDD �R ...... POLICY NUMBER PM0Df YY •, MWRD1Y r . ...... ......... rMMrDDrYY'YYY rMMrO LIMITS IGERAL IAILITY COMMERCIAL A XI Y AZC80896701 0710612019 07/0612020 EACH��� 04,000 OOCUR V � S� s ��� �.� ....... $ 1000,000 MED EXP (Any one person) $...................... 10.000 PERSONAL & ADV INJURY $ included — LIMIT.A.................L...L.........._. PLIES PER: ............... 2,000.000 G!EN'L AGGREGATE i GATE PRO- PRO- F q OP AGG.......$......... $ ... , w.I /POLICY JECT OC PRODUOTSGCOMP OTHER' A AUTOMOBILE LIABILITY AZC80896701 07/06/2019 07/06/2020 C'OMSINED SINGLE LIMIT a4ITIJ......... $ 1.000,000 ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED ent BODILY INJURYra $ AUTOS ONLY AUTOS NON -OWNED ,.. .... .............. PROP'FRTY �.Eacaa....... $ AHIREDUTOS ONLY' ... ^_...... AUTOS ONLY fFrfIfRq:?)) ...........( $ UMBRELLA LIAB OCCUR EA9!1299 C $ EXCESS LIAB CLAIMS -MADE AGGREGATE E ........ R...............REN.....E $ _.................-_ ....DED... V.R.,, ETENTION $ $ WORKERS COMPENSATION ETH AND EMPLOYERS' LIABILITY YIN ,TTE,,,•--,,,,mm,,,,,,,, ......_u $TAPER 1 , � ..........._ ANY EL EACH IDENT $ OFFICE IME ER EXCLUDED? El (Mandatory in H) EXCLUDED N / A EL SEASECEA EMP ............ ...... ........................."".'."......_ s, desce under If yyefkb DESCRIPTION OF OPERATIONS below E L, DISEASE - POLICY LIMIT $ B Professional Liab I EK13263035 07/11/2019 07111/2020 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of EI Segundo and its officers, employees, elected officials, volunteers, and members of boards and commissions are included as additional insureds, but only insofar as the operations under this agreement or contract are concerned per Endorsement ABC Multicover-AB91890807. This policy includes a Blanket Waiver of Subrogation. CERTIFICATE HOLDER CANCELLAt, I 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 EI Segundo, CA 90245 AUTHORIZED REPRESENTA IVE (BXL) , '7 98 15 AC RD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered ma A Printed by BXL on August 22, 2019 at 09:53AM ABC MuitiCover - AB 91 89 08 07 This endorsement modifies insurance provided under the following: American Business Coverage Your policy is broadened and clarified as follows: 1. Non Employment Discrimination Liability Unless Personal Injury or Advertising Injury is excluded from this policy: A. Section III - Definitions, Item 17. Personal Injury is amended to include: f. Discrimination B. Section III - Definitions, Item 2: Advertising Injury is amended to include: e. Discrimination C. Section III - Definitions is amended to in- clude: 30. Discrimination means the unlawful treat- ment of individuals based on race, color, ethnic origin, gender, religion, age, or sexual preference. D. Section H - Liability Coverage, Part H. Ex- clusions, Item Lp Personal Injury or Adver- tising Injury is amended to include: (11) Arising out of discrimination directly or indirectly related to the past employ- ment, employment or prospective em- ployment of any person or class of persons by any insured; or (12) Arising out of discrimination directly or indirectly related to the sale, rental, lease or sub -lease or prospective sale, rental, lease or sub -lease of any dwelling, permanent lodging, or premises by or at the direction of any insured; or (13) Arising out of discrimination, if insurance thereof is prohibited by law; or (14) Fines, penalties, specific performance, or injunctions levied or imposed by a go- vernmental entity, or governmental code, law, or statute because of discrimination. 2. Blanket Additional Insured Section It - Liability Coverage, Part L Who Is An Insured, Item 2. is amended to include: f. Any person or organization that you are re- quired by a written insured contract to include as an insured, subject to all of the following provisions: (1) Coverage is limited to their liability aris- ing out of: (a) the ownership, maintenance or use of that part of the premises, or land owned by, rented to, or leased to you; or (b) your ongoing operations performed for that insured; or (c) that insured's financial control of you; or (d) -the maintenance, operation or use by you of equipment leased to you by such person(s) or organization(s); or This Form must be attached to Change Endorsement when issued niter the policy is written. One of the Fireman's Fund lnsumn ce Companies as named in the policy ' 3 sect tary President AB9189 8.07 Page I of 6 t 0 0 go O 0 M 2 (e) a state or political subdivisioni per- assumption of Lability in a contract mit issued to you. or agreement. This exclusion does (2) Coverage does not apply to any occur- not apply to liability for damages rence or offense: that the vendor would have in the absence of the contract or agree - (a) which took place before the exe- ment; cution of, or subsequent to the cortpletion or expiration of, the b. Any express warranty unauthorized written insured contract, or by you; (b) which takes place after you cease to c. Any physical or chemical change in be a tenant in that premises. the product made intentionally by the vendor; (3) With respect to architects, engineers, or d, Repackaging, unless unpacked solely surveyors, coverage does not apply to Bodily Injury, Property Damage, Per- for the purpose of inspection, dem- sonal Injury or Advertising Injury arising onstration, testing, or the substi- out of the rendering or the failure to tution of parts under instructions render any professional services by or for from the manufacturer, and then re - you including: packaged in the original container. (a) 'Ile preparing, approving, or failing e. Any failure to make such in- to prepare or approve maps, draw- spections, adjustments, tests or ser- ings, opinions, reports, surveys, vicing as the vendor has agreed to change orders, designs or specifica- make or normally undertakes to tions; and make in the usual course of busi- ness, in connection with the distrib- (b) Supervisory, inspection, or engi- cation or sale of the products; neering services. If an Additional Insured endorsement is attached to this policy that specifically names a person or organization as an insured,* then this coverage does not apply to that person or organization, 3. Blanket Additional Insured for Vendors Unless the Products -Completed Operations Haz- ard is excluded from this policy, Section H - H - ability Coverage, Part I. Who Is an Insured, Item 2. is amended to include: g. Any vendor but only with respect to Bodily Injury or Property Damage arising out of your products which are distributed or sold in the regular course of the vendor's business, sub- ject to the following additional exclusions: N O AB9189 8-07 L The insurance afforded the vendor does not apply to: a. Bodily Injury or Property Damage for which the vendor is obligated to pay damages by reason of the f. Demonstration, installation, servic- ing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; g. Products which, after distribution or We by you, have been labeled or ,relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor. 2. This insurance does not apply to any in- sured person or organization, from whom you have acquired such products, or any ingredient, part or container, en- tering into, accompanying or containing such products. If an Additional Insured - Vendors endorsement is attached to this policy that specifically names a person or organization as an insured, then this coverage does not apply to that person or organ- ization. Page 2 of 6 4. Blanket Waiver of Subrogation Section H - Liability Coverage, Part K. Liability and Medical Payments General Conditions, is amended to include: 6. Transfer of Rights of Recovery Against Oth- ers to us and Blanket Waiver of Subrogation a. If the insured has rights to recover all or part of any payment we have made under this Coverage Part, those rights are transferred to us. The insured must do nothing after loss to impair those rights. At our request, the insured will bring suit or transfer those rights to us and help us enforce them. b. If required by a written insured contract, we waive any right of recovery we may have against any person or organization because of payments we make for injury or damage arising out of your operations or your work for that person or organ- ization. 5. Broadened Named Insured Section U - Liability Coverage, Part I. Who Is An Insured, Item 4. is replaced with: 4. All of your subsidiaries, companies, corpo- rations, firms, or organizations, as now or hereafter constituted, qualify as Named In- sured under this policy if: (a) you have the responsibility of placing in- surance for each such entity; and (b) coverage for the entity is not otherwise more specifically provided; and (c) the entity is incorporated or organized under the laws of the United States of America. But each entity is insured only while you own, duffing the policy'period, a controlling interest in such entity of greater than 50% of the stock or assets. However: (a) Coverage under this provision is afforded only until the end of the policy period, or the 12 month anniversary of the policy inception date, whichever is earlier; (b) Coverage C does not apply to bodily in- jury or property damage that occurred AB9189 8-07 before you acquired or formed the or- ganization; (c) Coverage C does not apply to personal injury or advertising injury arising out of an offense committed before you ac- quired or formed the organization. 6. Medical Payments Unless Coverage D. Medical Payments is excluded from this policy: A. Section H - Liability Coverage, Fart IL Ex clnsions, Item 21 is replaced with: E Included within the products -completed operations hazard. However, this exclu- sion does not apply to expenses for den- tal services. B. Section H - Liability Coverage, Part G. Cov- erage, Item 2., is amended to include: c. , Coverage D. Medical Payments is pri- mary and not contributing with any other insurance, even if that other insur- ance is primary also. 7. Tenant's Legal Liability A. Section III - Liability Coverage, Part J. Li- ability and Medical Payments Limits of In- surance, Item 3. is replaced with: 3. The most we will pay under Coverage C - Liability for damages because of prop- erty damage to premises while rented to you, temporarily occupied by you with the permission of the owner, or managed by you under a written agreement with the owner: a. arising out of any Covered Cause of Loss shall be the greater of - (1) f (1) $1,000,000; or (2) The Tenant's Legal Liability limit shown in the Declarations. 8. Chartered Aircraft Section H - Liability Coverage, Coverage C, Part H. Exclusions, Item l.g. is amended to include: (5) An aircraft in which you have no ownership interest and that you have chartered with crew. Page 3 of 6 9. Coverage Territory Broadened Payments Definitions, Items 17.b., d. and e. are replaced with: Section III - Definitions, Item 5.a. is replaced with b. Malicious prosecution or abuse of process; a. The United States of America (including its territories and possessions), Puerto Rico, Ca- d. Oral, written, televised or videotaped publica- nada, Bneawada, the Bahamas, the Cayman tio,� of rnate;ial t'iat slanders or libels a person Islands and the British Virgin Islands. or organization or disparages a person's or '—" 10. Broadened Advertising Injury organization's goods, products or services; Unless Advertising Injury is excluded from this e. Oral, written, televised or videotaped publica- tion of material that violates a persons right tion .__ policy: of privacy; A. Section III - Definitions, Item 2. is replaced 12. Broadened Personal or Advertising Injury With: 2. Advertising Injury means injury arising Unless Personal Injury or Advertising Injury is out of one or more of the following of- excluded from this policy, Section Ti - Liability fenses: Coverage, Coverage C, Part H, Exclusions, Item. Lp.(4) Exclusions is deleted in its entirety. a. Oral, written, televised or videotaped publication of material that slanders 13. Fellow Employees Coverage or libels a person or organization or Section II -Liability Coverage, Part I. Who Is an disparages a person's or organize- Insured, Item 2.a (1) is amended as fellows: tion's goods, products or services; a o b. Oral, written, televised or videotaped (1) Personal Injury to you or to a co'.employee g publication of material that violates while in the course of his or her employment, gor Q a persons right of privacy; the spouse, child, fetus, embryo, parent, o brother, sister or any member of the house - c. Misappropriation of advertising hold of that employee or co -employee as a ideas or Style of doing business; or consequence of such Personal Injury, or for any obligation to share damages with or repay d. Infringement of trademark, copy- someone else who must pay damages because night, title or slogan. of the injury; or B. Section H - Liability Coverage, Coverage C, 14. Mental Anguish Is Included in Bodily Injury Part H. Exclusions, Items 1.p.0) and (2) are replaced with: Section III - Definitions, Item 4. is replaced with: (1) Arising out of oral, written, televised or 4. Bodily injury means bodily injury, sickness or videotaped publication of material, if disease sustained by a person. It includes done by or at the direction of the insured death or mental anguish which result at any with knowledge of its falsity; time from such physical harm, physical sick - ness or physical disease. Mental anguish me - s (2) Arising out of oral written televised or ans any type of trental or emotional illness videotaped publication of material whose or disease. o first publication took place before the a beginning of the policy period; 15. Unintentional Failure to Disclose Hazards 11. Broadened Personal Injury Section H - Liability Coverage, Part K. Liability o Unless Personal Injury is excluded from this poI- and Medical Payments General Conditions, is N icy, Section III - Property, Liability and Medical amended to include: U AB9189 8-07 6. Unintentional Failure to Disclose Hazards If you unintentionally fail to disclose any ha- zards existing at the inception date of your policy, we will not deny coverage under this Coverage Form because of such failure. However, this provision does not affect our right to coded additional premium or exercise our right of cancellation or non -renewal. 16. Supplementary Payments, Increase Limits Section II - Liability Coverage, Part G. Coverage, Items Le. (2) and (4) are replaced with: (2) The cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds. (4) All reasonable expenses incurred by the in- sured at our request to assist us in the inves- tigation or defense of the claim or suit including substantiated loss of earnings up to 500 a day because of time off work. 17. Per Location Aggregate A. Section II - Liability Coverage, Part J. Limits of Insurance, Item 4. is amended to include: The Aggregate Limit of Insurance applies se- parately to each location owned by you, rented to you, or occupied by you with the permission of the owner. _ B. Section III - Property, Liability and Medical Payments Definitions, is amended to include: 31. Location means premises involving the same or connecting lots, or prernises whose connection is interrupted only by a street, roadway, waterway or right-of- way of railroad. 18. Amended Duties in the Event of an Occurrence, Offense Claim or Suit Section'll Liability Coverage, Part K. Liability and Medical Payments General Conditions, Items 2.a. and b. are, replaced with: a. In the event of an, occurrence, offense, claim, or suit, you must promptly notify us. Your duty to promptly notify us is effective when your executive officers, partners, members, or AB9189 8-07 legal representatives are aware of the General Liability occurrence, offense, claire, or suit. Knowledge of an occurrence, offense, claim, or suit by other employee(s) does not imply you also have such knowledge. b. To the extent possible, notice to us should include: (1) How, when and where the occurrence or offense took place; (2) The names, addresses, 'and telephone numbers of any injured persons and wit- nesses; and (3) The nature and location of any injury or damage arising out of the occurrence, of- fense, claim, or suit. 19. Common Policy Conditions (AB 00 09 A 01 S7), Part H. Other Insurance, Item 2. is replaced with: 2. Coverage C - Liability If other valid and collectible insurance is available to any insured for a loss we cover under Coverage C of this Coverage Part our obligations are limited as follows: a. The insurance provided under this policy is primary if you are required by a written insured contract to include any person or organization as an insured, but only with respect to that insured's liability arising out of the ownership, mainte- nance, or use of that part of the premises owned by or rented to you, or your work for that insured by or for you. Any other insurance available to that person or or- ganization is excess and noncontributory with this insurance, or; b. Except for the circumstance described in 2.a., above, the insurance provided under this policy is excess over any other l- ability insurance available to any insured whether such other insurance is written as primary, excess, contingent or any other basis: An exception applies when any insured specifically has purchased excess insurance to apply in excess of the limits of insurance shown in the Decla- rations of this Coverage Part for Cover- age C. Page 5of6 20. Damage to Invitees' Automobiles from Falling Trees or Tree Limbs - Limited Coverage The policy applies to direct physical damage to automobiles owned by invitees subject to all'of the —" following: e= 1. Provided such damage originates from. prem- ises owned, managed, leased or rented by an. insured; 2. Coverage applies only to invitees of an in- sured or an insured's tenant; 3. Such damage is directly caused by wind -driven falling trees or tree limbs; 4. The most we will pay for any one loss is the lesser of the actual cash value of the damaged automobile as of the time of the loss; or the cost of repairing or replacing the damaged automobile with another automobile of like a 7 N Z O N U AE9199 8.07 N ldnd and quality; subject to a limit of $25,000 in any one policy period; and 5. This coverage is not subject to the General Liability General Aggregate Limit. 21. Expected or Intended Injury - Amendment to Ex- clusion SECTION 1. - 2. EXCLUSIONS a. Expected or Intended Injury, is replaced by the following: a. Expected or Intended Injury Bodily injury or property damage expected or intended from the standpoint of the insured. This exclusion does not apply to bodily injury or property damage resulting from the use of reasonable force to protect persons or prop- erty. All other terms and conditions of the policy apply. Page 6 of 6 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 # ( I 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 those provisions or the agreement will automatically become void. blglnlly signed by M.,k Gwh Mur. -Mark Goh,—h,de d -Hearing Offl—,ou, Signature of Applicant ems. f,.�� k�,��„g.�Ma��.�,M Date NrOa'.4FAttMU WMJ"� un'M" " ^r Agreement for: �/1G;� �- �,hYWVA,,"" Dated: .. Reviewed b