Loading...
PROOF OF INSURANCE (2021 - 2021) CLOSED�,y �-0 DATE (MM/DDIYYYY) III I CCERTIFICATE OF LIABILITY INSURANCE 1/8/2021 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 CONIAGiNAME: Gabriel Stubin ............................................ Western Republic insurance Services PHONEp ,a Ext)! 714.536.0500 I I Nag, 19900 Beach B[%,d ADI°,ES,S, gabeeiwrinsurance,com Suite FI INSURER(S) AFFORDING COVERAGE NAIC k Huntington Beach CA 92648 INSURER A: SCOTTSDALL- INS CO 41297 ........................_ INSURED INSURER B SCrgiu Boerica DBA: Jaguar Tennis Academy INSURER C 401 SHELDON ST INSURERD;; INSURER E EL SEGUNDO CA 90245-4013 I 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, Au"L MSK TYPE OF INSURANCE INSD VIVID POLICY NUMBER PULL Dt Y -I- POLICY LAP LTR INSD WVD (MMIDD/YYYY) (,MMIDDIYYYY) .......................... LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE l ,000,000 CLAIMS -MADE OCCUR cfV KCNICU M$ PREMISES Ea occurrence) $ PREMISES 100,000 �i M ED EXP (Any one person) $ 5,000 _ _ A Y CPS7236577 09/11/2020 09/11/2021 PERSONAL &ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 .......... POLICY T'RS}• pECt ........ PRODUCTS UCTS -COMP/OP AGG $ 2,000.000 OTHER: .. LITY AUTOMOBILE LIABILITY NLD SU(.b UMI I ffQ tL'aI xclrjenq $ ANY AUTO BODILY INJURY (Per person) $ ". ." OWNED SCHEDULED ww.............._................e' BODILY INJURY (Per accident) S AUTOS ONLY AUTOS _ " HIRED ""-""""° NON -OWNED PKUPtKIY L)AMAUL $ I AUTOS ONLY AUTOS ONLY (Per accident} __............ i UMBRELLA LIAB OCCUR _. EACH OCCURRENCE $ EXCESS LIApBCLAIMS-MADE (AGGREGATE $ DIED J"RETENTI ON$ NVORKERS COMP ENSATION I ISTATUTE I VER H AND EMPLOYERS' LIABILITY YIN PART NER/EXECUTIVE IEL EACH ACCIDENT S ANY PROPRIFTOR� ❑ NIA OFFBCEIvtfp�P� 8ERrXCl,UDED7 RV (Mand'atory' in NH) IEL DISEASE - EA EMPLOYEE $ If yes, describe under ' IEL DESCRIPTION OF OPERATIONS below DISEASE- POLICY LIMIT ........_.�........................—_. 1 ................ �,... DESCRIPTION OF OPERATIONS I LOCATIONS / VEHIC -ES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the insured's operations. A blanket additional insured endorsement is included with the general liability policy. Additional insured status is automatically granted where required by written contract. CERTIFICATE MOLDER The City of EI Segundo, its officers, officials, employees, agents and volunteers 401 Sheldon Avenue EI Segundo, CA 90245 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ENDORSEMENT A� SCOTTSDALE INSURANCE COMPANY`- NO. ATTACHED TO AND ENDORSEMENT EFFECTIVE DATE FORMING A PART OF (12;01 A.M. STANDARD TIME) NAMED INSURED AGENT NO. POLICY NUMBER ,,..,(.1 ! i , ; r r .;u; �, THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS - COMPLETED COMMERCIAL OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Commercial Project Location And Description Or Organization(s) Of Completed Commercial Operations o`;t""i-"(i.l, I J 1�14�'Ir.:`i4 v"`, � ! i.":',�', � F'�l`iG'; �'�. (➢II'I,!"n;'I ('I'I'�G°�'l'� (�I� ;I''.(";�Iy1;'rVPi''+ � r''.„ 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 include as an additional insured the person(s) or or- ganizations) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the commercial project location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard." However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law. 2. If coverage provided to the additional insured is required by a contract or agreement, the insur- ance 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. 3. This insurance does not apply to "bodily injury" or "property damage" arising from "your work" on, in connection with or in any way relating to a "residential project." Includes copyrighted material of ISO Properties, Inc., with its permission. Copyright, ISO Properties, Inc., 2012 GLS -447s (2-15) Page 1 of 2 B. With respect to the insurance afforded to these additional insureds, the following is added to Sec- tion 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. For purposes of this endorsement, the following definitions apply: 'Residential project' means any project involving the original development or original construction, recon- struction, renovation or remodeling of one or more single-family or multi -family housing units, town- houses, townhomes, residential condominiums or cooperatives, duplexes, other structures converted into condominiums or any other type of domicile intended for individual or collective residential ownership, and shall include all phases of the development, construction, reconstruction, renovation or remodeling of all areas appurtenant to these structures, including but not limited to land acquisition, site improvements, ex- cavation or grading of land, utilities, driveways, walkways, roadways, swimming pools, retaining walls, construction of any other structure, building, or common areas. "Residential project' does not mean "your work" performed in connection with an apartment building, or "your work" performed solely on or in com- mercial space of "mixed-use buildings." "Mixed-use buildings" means structures and improvements thereto, which contain both residential units and commercial space. AUTHORIZED REPRESENTATIVE DATE Includes copyrighted material of ISO Properties, Inc., with its permission. Copyright, ISO Properties, Inc., 2012 GLS -447s (2-15) Page 2 of 2 PERSONAL AUTOMOBILE POLICY OFFER TO RENEW COVER PAGE NAMED INSURED AND ADDRESS 71 SERVICE OFFICE SERGIU BOERICA WAWANESA INSURANCE VIRGINIJA KIRKILIENE PO BOX 82867 906 E IMPERIAL AVE UNIT 1 SAN DIEGO CA 92138-9492 EL SEGUNDO CA 90245-2519 Telephone: 1-800-640-2920 Policy Number Account Number Policy Period 12:01 A.M. standard time at the address of the 32400050 34883441-1 From Feb 1, 2021 to Aug 1, 2021 Named Insured as stated herein Thank you for your continued business with Wawanesa General Insurance Company ("Wawanesa Insurance"). We appreciate the opportunity to provide you with quality coverage and peace of mind knowing that we strive to provide the most dependable coverage at the lowest price possible. Please review your Renewal Declaration. This Declaration is an offer only. Payment of the premium renews your policy for the period shown. If your payment is not received before Feb 01, 2021, this Offer to Renew becomes null and void. Your coverage expires Feb 01, 2021 at 12:01 A.M. If you are responsible for the payments due on this policy, please refer to the invoice statement (enclosed or mailed separately). The invoice statement also includes additional payment information, such as our flexible payment options. You should also carefully review your coverage limits for Bodily Injury Liability and Property Damage Liability to ensure they are appropriate for your lifestyle, income, and risk tolerance. If you are found legally responsible for damages which exceed your Liability coverage limits, personal assets such as your savings or even your home could be at risk. Industry organizations and consumer groups recommend limits higher than what the law requires. By accepting this Policy and the Declaration pages you consent to be legally bound by the provisions of the policy, including the coverage limits, options and endorsements. Questions? If you'd like to make change to your policy, please contact us at renewals. usi 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: L_) 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 # LX_) 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 wrath those provdsions or the agreement will automatically become void, Signature of Applicant Date 1 Agreement for: Dated: 1—d<; �m Reviewed by: --