Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
PROOF OF INSURANCE (2020 - 2020) CLOSED
® DATE / A Y) CERTIFICATE OF LIABILITY INSURANCE ' 12/1/1 3/20192019 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 NAME: Lin D. Diaz D&C Insurance Solutions (A//C.Nr; . Ext): 888.457.4426 FAX No): 323.576.4552 300 S. Atlantic Blvd., Ste 201-B E-MAIL ADDRESS: contact@dci-insurance.com Monterey Park, CA 91754 INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: Western World Insurance Company 13196 INSURED INSURER B: Tillmann Forensic Investigations, LLC. PO Box 4373 Covina INSURER C: INSURER D: INSURER E: CA 91723 INSURER F 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 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR LTR TYPE OF INSURANCE INc,vn POLICY NUMBER POLICY EFF POLICY EXP (MM/DDYYY) (MM/DD/YYYY) /Y LIMITS X COMMERCIAL GENERAL LIABILITY An w NPP8622407 12/17/201912/17/2020 EACH OCCURRENCE $ 1,000,000 FN/71 DAMAGE O(Ea 100,000 CLAIMS -MADE OCCUR PREMISES occurrence) $ MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER : GENERALAGGREGATE $ 2,000,000 PRO - POLICY � POLICY ❑ LOC PRODUCTS - COMP/OPAGG $ Included OTHER: Errors & Omissions $ Included AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLALIAB OCCUR EXCESS LIAB HCLAIMS-MADE DED I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRI ETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Per accident) EACH OCCURRENCE AGGREGATE PER STATUTE EERH E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) REGARDING THE ABOVE REFERENCED GENERAL LIABILITY INSURANCE POLICY, THE CERTIFICATE HOLDER IS INCLUDED AS AN ADDITIONAL INSURED, BUT ONLY WITH RESPECT TO THE NEGLIGENT ACTS, ERRORS OR OMISSIONS OF THE NAMED INSURED. CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 348 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EI Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Lin Dau Diaz" ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: NPP8622407 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: X011VAI►VAI=11Zia] /_\111110e]=11 11111=11:7_1Na/_1 IaIWK6101V/=1:7_Te3Zecy-11X49 SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): City of EI Segundo 348 Main Street EI Segundo, CA 90245 Location(s) Of Covered Operations Various Locations Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage" or "personal and advertising injury" "property damage" occurring after: caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. 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. 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 04 13 Copyright, Insurance Services Office, Inc., 2012 Page 1 of 2 C. 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. Page 2 of 2 Copyright, Insurance Services Office, Inc., 2012 CG 20 10 04 13 1!�", " uil 4 .... . .. . .... 11 12,11, 1'! 1 ",to 11 W M I W I'll! w, I " Al: P 0: ;" M11,011H, �,, , . .....II 11 ;Vll, � 11 I'll , 11 I'll I "I '' 11 I'll ", N d;" I " a io,, 4" 4 Illi"" 1, q, om1 CALIFORNIA Stall INSI-YRANCE CARD S"tate Farm Mutual Autonilobile Insuraince Company RO Box,853919, is ISI, TX 75085-39,19 161 'S ( I R F: 0 TILLMANN, s-rEVE & RITA MUTL VIOL POLICY NUMBER r-TFECTIVE, YR 2019 MAKE.` JEEP MAR 29 21020,"i "1 11 99 2020 M, E L WFIANGLEIR VIN A GE "r - I'll, I v 1'13,17-AED MPSON 11 JONE NAI(o 25178 -11E PO,t.11(.',' Y -JE MINIMUM LIABILITY LIMITS ME ETS Tl ,0VERAG, I "' I PRES('0331BED, BY COV'ERAGF."',S,A 0 D'1001() G1000 11 ()'U'l SEE REVERSE WE FOR AN UVIANAll ON. 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: U 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 # 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 ject to the workers" compensation provisions of Labor Code § 3700 1 must immediately comply with tor �e a eement will automatically become void.. Signature of Applicant Date - j Print Name Agreement for: p.� � '�Y? ' I" i hVM(JVh JAS a L — I Dated: Reviewed by: