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PROOF OF INSURANCE (2020 - 2021) CLOSED
�,..•r OP ID: MN ,4c�►Rc CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 10/01/2020 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 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 Michelle Nowell Alliance Mgt. & Insurance Sery PHONE """""""""" 6 � FAX CAAggent/Broker Lie# 0737966 11-MAf�ss: mnowel �amiscor ) 71-9378 San Ma cos, CA 92078 EssR ...-............1�.. !� ................... IAdC... .;.... •6.. .............................. _____— Michelle A. Nowell ..q.0T1.P A CAPEN-1 _ .. „ wsuRee Casual Ins INSURER A : A AFFORDING COVE INSURED Capen Profession COVERAGE NAIC# ...... al Services cce tan....... P�............................ Comp ..................................010349 .. John CapenINSURER B :.. 8502 E Chap man Ave #449 Orange, CA 92869 INsuRER.D.°........,,., u ................. ................._. . ................................. INSURER ... ............................. V I INSURER F: I 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. (LTR .................. dII'DI L'SU'S' " ..............................................rVPd _................................... TYPE OF INSURANCE POLICY NUMBER l]6 YYY POLICY EXP' YY'YI 6MM!'OD/YYY'YN I'., LIMITS GENERAL LIABILITY A X COMMERCIAL GENERAL LIABILITY lCLAIMS -MADE �� OCCUR X Errors & Omission —................................... GGE IN'L AGGREGATE LIMIT APPLIES PER: JL POLICY JEC3 ILOC AUTOMOBILE LIABILITY ANY AUTO .............. ALL OWNED AUTOS ............. SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS — UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS -MADE DEDUCTIBLE EACH OCCURRENCE $ 1,000,000„ CP00961198 09/06/2020 09/06/2021 � S ( cagy ) $ 100,000 X PRE'MiVSES' (Ea o�c�i¢�;en;, �. , ....... , Q P 5, 000 PE D EXP (Any one arson) $........... .....................�-........... . . M... PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 5,000,000 PRODUCTS - COMP/OP AGG $ 1,000,000 RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE F7 N / A OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below A Professional Liab CP00961198 COMBINED SINGLE LIMIT $ (Ea accident) BODILY.INJURY (Per person) $ .......................................................... BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (PER ACCIDENT) .............................. EACH AGGREGATE RENCE$ ... — WC STATU I OTH- T RY LIMITS �....FR E L, EACH ACCIDENT $ E L DISEASE - EA EMPLOYEE $ E L. DISEASE - POLICY LIMIT $ 09/06/2020 09/06/2021 Prof Liab 1,000,000; DESCRIPTION OF OPERATIONS 1 LOCATIONS P VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) City of El Segundo is named as additional insured with respect to the work performed by the named insured. Investigation, CA -- CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of EI Segundo Director of Human Resources AUTHORIZED REPRESENTATIVE David Serrano 350 Main Street (� IEI Segundo. CA 90245 O ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: CP00961198 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 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) Automatic Status Included Where Required by Written Contract. All Where Required by Written Contract. Section 11 - Who Is An Insured is amended to in- clude 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 41personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of thoseactingon your behalf: A. In the performance of your ongoing operations; or B. in connection with your premises owned by or rented to you. CG 202607 04 C ISO Properties, Inc., 2004 Page 1 of 1 ❑ AC " VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE DATEIMMIDDIYYYY) 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. This form is used to report coverages provided to a single specific vehicle or equipment. Do not use this form to report liability coverage provided to multiple vehicles under a single policy. Use ACORD 25 for that purpose. PRODUCER NAME Ta3tfiriy RUCk@T ar __.... 877 629 0644.IT........ $�tBe. � TEXTRAPEEPAT AGENCY TEX RAPEEPAT AGENCY 22461,.1 94dgd858 640�t bitclxrn►c F„ N,�y k ADDRESS y tucker 12 "fit. 11RODUC�R............................................. 22461 ANTONIO PKWY STE 8120 CUSTOMER ID A RANCHO SANTA MARGARITA CA 92688 INSURER(S) AFFORDING COVERAGE NAIC it INSURED INSURER A State Farm Mutual Automobile Insurance Company 25178 _................ . ............... CAPEN, � & JOHN INSURER B INSURER C INSURER D INSURER E DESCRIPTION OF VEHICLE OR EQUIPMENT YEAR MAKE / MANUFACTURER MODEL BODY TYPE VEHICLE IDENTIFICATION NUMBER 2017 FORD EXPLORER SPORT WG 1FM5K7D88HGC55308 DESCRIPTION VEHICLE/EQUIPMENT VALUE SERIAL NUMBER COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICY(IES) OF INSURANCE LISTED BELOW HAS/HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD(S) 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 POLICY(IES) DESCRIBED HEREIN IS/ARE SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES). INSR A00„L LTR MRn TYPE OF INSURANCE +. U VEHICLE LIABILITY GENERAL LIABILITY OCCURRENCE .................w......ww.....................CLA MS MADE INSR Loss LTR i'AYEE TYPE OF INSURANCE X VEH COLLISION LOSS �{I............. VEH COMP VEH OTC EQUIPMENT BASIC BROAD m��mm I SPECIAL N { J REMARKS (INCLUDING SPECIAL CONDITIONS I OTHER COVERAGES) (Attach ACORD 101, Additional Remarks Schedule, if more space is required) ADDITIONAL INTEREST CANCELLATION Select one of the following: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Ire ed iem BEFORE EXPIRATION DATE THEREOF, CE WILL BE ftsled q ealigl lacer^ subaN to add the add monak nleresl y( S. Tbdr&iCunma4y�nr adonen below�Ypas lseeaw ;�aldea0l�edtwscortl Fulr� G �erakq�VeSalicy numbers) .. DELIVERED IN ACCORDANCE WITH THE POLICYIPROVISION ................... VEHICLE / EQUIPMENT INTEREST LEASED FINANCED DESCRIPTION OF THE ADDITIONAINSURED L INTEREST INTEREST NAME AND ADDRESS OF ADDITIONAL INTEREST !! ADDITIONAL PAYEE I I LOSS PAYEE LEND LOAN / LEASE NUMBER . R ......... PRIa, f; T TX 78263 Ata'Trt Rt.� NT /� IVpQ/� ©1997-2015 ACORD CORPORATION. All rights reserved. ACORD 23 (2016/03) The ACORD name and logo are registered marks of ACORD 1004361 142987 4 04-24-2020 POLICY EFFECTIVE POLICY EXPIRATION POLICY NUMBER DATE (MMIDDIYYYY) DATE (MMIDDIYYYY) LIMITS ._.......................................................... ........................................................... COMB NED S NGLE L MIT $ BOD LY INJURY (Per person) .S 100,000 L39 4930 -E23 -75H 05/23/2020 11/23/2020 BOD LY INJURY (Per accident) S 300,000 PROPERTY DAMAGE $ 50,00 EACH OCCURENCE $ ...................... ... GENERAL AGGREGATE S POLICY EFFECTIVE POLICY EXPIRATION POLICY NUMBER DATE (MMIDDIYYYY) DATE (MMIDD/YYYY) LIMITS / DEDUCTIBLE Acv ❑AGREED AMT ! S LIMIT L39 4930 -E23 -75H 05/23/20 11/23/20 STATED AMT ❑ ❑ $ 250.00 DED .............................._.____ ❑Acv E] AGREED AMT S LIMIT L39 4930 -E23 -75H 05/23/20 11/23/20 ❑ ❑ STATED AMT S DED ....,,........._____.__....._......._..._.....,..._.,................... [:]ACV ❑ AGREED AMT $ LIMB ❑ RC ❑ STATED AMT S50000 DED REMARKS (INCLUDING SPECIAL CONDITIONS I OTHER COVERAGES) (Attach ACORD 101, Additional Remarks Schedule, if more space is required) ADDITIONAL INTEREST CANCELLATION Select one of the following: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Ire ed iem BEFORE EXPIRATION DATE THEREOF, CE WILL BE ftsled q ealigl lacer^ subaN to add the add monak nleresl y( S. Tbdr&iCunma4y�nr adonen below�Ypas lseeaw ;�aldea0l�edtwscortl Fulr� G �erakq�VeSalicy numbers) .. DELIVERED IN ACCORDANCE WITH THE POLICYIPROVISION ................... VEHICLE / EQUIPMENT INTEREST LEASED FINANCED DESCRIPTION OF THE ADDITIONAINSURED L INTEREST INTEREST NAME AND ADDRESS OF ADDITIONAL INTEREST !! ADDITIONAL PAYEE I I LOSS PAYEE LEND LOAN / LEASE NUMBER . R ......... PRIa, f; T TX 78263 Ata'Trt Rt.� NT /� IVpQ/� ©1997-2015 ACORD CORPORATION. All rights reserved. ACORD 23 (2016/03) The ACORD name and logo are registered marks of ACORD 1004361 142987 4 04-24-2020 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 # (Z) 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 manne so as to become subject to the workers' compensation laws of California, and agree that, if I should become a fect to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those o ion the agreement will automatically become void. Signature of Araiclicant Date cv�o Print Name Agreement for: n m Dated: Reviewed by: