Loading...
PROOF OF INSURANCE (2022 - 2022) CLOSEDSEACLEA-01 TH LLAND CERTIFICATE OF LIABILITY INSURANCE DATE/1/2021�) 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 CONTACT ..."ME;1............................................................................................................................................................................................................�m......... H&S Insurance Services, LLC. AExs , 805 212-4890 887 Patriot Drive JIC No HONE .....c taut (805) 212-4891 EAAT Ste. D Moorpark, CA 93021 .... ... INSURER(p) NG COVERAGE P y ..M....... � # INSURER United National Insulrance Corn an 1,3064c,,,,,m INSURED INSU_RERB:Allstate Insurance Company _ 19232 Sea 19445 233161S Normand ecAve #B INSURER D r Pacific Com . INSURER C: National pensation Insurance Torrance, CA 90502 INSURER _._.m..m_� ..m F? w__ �.......... J1,5,55.................: RE: INSURER F COVERAGES CERTIFICATE NUMBER:ITITITITITITITITITITITITITITITITITITITITITITITIT__ ....._ 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, POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EXCLUSIONS AND CONDITIONS OF SUCH _ — — INSR ADDL SUBR POLICY EFF POLICY EXP R TYPE OF INSURANCE �r W.V.I POLICY NUMBER LIMITS A X COMMERCIAL GENERAL LIABILITY EACH O _50 1,000,000 ......�......�_ � OCCURRENCE $ CLAIMS -MADE X OCCUR L7219632-1 7/1/2021 7/1/2022 DAMAGE TO RENTED ,000 X PEER�lka1 iEI frlIt) ....... MED EXP LAn� one_person) ...... $ ° a. GEN"L. A�G�rRE-ra_A VI', LIMIT A � PERSONAL & ADV INJURY $ ..... 2,000,000 _. PPLIES PER: GENERAL AGGREGATE $ mo 2,0oo,00ll X POLICY LOC PRODUCTS COMPIOP AGG $ ...m. AUTOMOBILE LIABILITY ...... ..............................� 13COMBINEDI)SINGLE LIMIT....... ......_....... ... .. 1 000,000 X ANY AUTO 648930824 5114/2021 5/14/2022 BODILY INJURY (Per person) $ .. (XJX.. OWNED SCHEDULED AUTOS ONLY AUTOS i BODILY INJURY (Per accident] $ I� HIRED NON -OWNED --... ...... ... ...., I PROPERTY DAMAGE ------- AUTOS ONLY __— AUTOS ONLY ,[Per accident C CUR EACH acA UERFi,FNCE 5,000, .. .. AGGREG 000 X� EXC ss LIABAB� %� � °LAIMs MADE EBU 021169965 .._..7/1/2021WWW.W ....7/1/2022WWWW1 5,000,000„ DED RETENTION $ _ WA-004676-03 7/1/2021 7/1/2022 PER '. OTH_--..- .. 1,000,000 D WORKERS COMPENSATION X I $TAT(�TE FR AND EMPLOYERS' LIABILITY ! ,COO .ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑ X { E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED N ! A (Mandatory in NH) E L DISEASE EA EMPLOYEE $ 1,000,000 ...E , - ......... If yes, describe under ` 1,000,000 DESCRIPTION OF OPERATIONS below ..... .............................................................E,L DISEASE._ PpLICV LIMIT I $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEWCLEs (ACORD 101„ Additional Remarks Schedule, may be attached if more space is required) *30 days notice of cancellation except 10 days for non-payment of premium. The City of El Segundo is named as additional insured as required by written contract. A waiver of subrogation applies to the Workers' Compensation policy. ..........................._ W ....................... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Y 9 ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St. El Segundo, CA 90245................................... AUTHORIZED REPRESENTATIVE ._.__._.....-.. I ._...........,......... ..................... ..._..—._.. ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 1-7219632-i COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWES, LESSEES OR CONTRACTORS - (FORM E ) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: AS REQUIRED BY WRITTEN CONTRACT (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" for that insured by or for you. CG 20 10 11 85 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 0 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA Ed. 4-84 We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 225% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Blanket Waiver of Subrogation As respects to all CA jobs performed by the named insured during the policy period where by written contract a waiver of subrogation is required prior to the commencement of work. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 07-01-2021 Policy No. WA004676-03 Endorsement No. 1 Insured Insurance Company: Sea Clear Pools, Inc. (A Corp) Pacific Compensation Insurance Co. Countersigned By sro c� Harfv-ty ©1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved.