Loading...
PROOF OF INSURANCE (2022 - 2023) CLOSED/— BREAT-1 OP ID: SP Alm DATE (MMIDD/YYYY) CERTIFICATE F LIABILITY INSURANCE F 03/31/2022 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 �'� Jack Tahanian ISU-The Ultifma A enc PHONE FAx 3848 E. ColDrado BIVdy# 2 (AIc NQ, E,� :626-792-5000 )mac No): 626 792-5639 Pasadena, CA 91107 E-MAIL Tahanian Insurance Services Jack@ultimainsurance.com ADDRESS; INSURER(S) AFFORDING COVERAGE NAIC # 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. __ e,/'1' ,u4tAe,71.: "�atlS'`R .... ILTR ..,mm PMIDR E1CP TYPE OF INSURANCE POLICY NUMBER IDDrE INSIBUMBER, Md�flODWYYYY MMlDDdYYaY LIMITS GENERAL LIABILITY EACH OCCURRENCE 5 1,000,,000 A X t G:PIUIMf��RCIAI C,EIVE'RAL.1..IABIL..I"I"Y X EPK-138429 01/16/2022 01/16/2023 L"I EMIS 50 REI `ED rrf .. g1"rAEMI;.iES y'ES �ar�r,�rrt,r?w,aJ _ 50,00 5 .... CLAIMS -MADE X..... OCCUR .. ME D E:.X.P (Any one pea5;m) S 10,00. ..... PERSONAL & ADV INJURY S 1,000,000 C GI.NRALA(,f_R C At"E: S.... 2,000,000 N AGGRE CAFE... L..IMII AI I I IG S PER: R i RODl. CFS' .COMPIOP AGG S 000,000' �...mmVM �. X POLICY f C; 5 AUTOMOBILE LIABILITY '... f=AENNFD S%Na" ff LIMITT L Id unf,) 5_ 1 �000,01,10010 ,. ;. B,RAU3'41601 01/01/2022 01/01/2023 B ANY AUTO BODILY IN,A.IRY (Poi person) ....... S .,,. , „ „ .",...., ALL OWNED — SCHEDUIJ::D BODILY INJURY (I'eruse.cideal) 'S AUTOS FALL 167S ..X NON OWNED .,. PRR'EvC,UI�.PiAAGS: L1Pf S X HIREDAUTOS � A6.U'FOS ,(PER ACCIDENT) _ - omplColl S 1000/100C UMBRELLA LIAB OCCUR EACH OCCURRENCE s EXCESS LIAB (:;ILAINIS MADE AG REGALE S DED RETENTION S '� S WORKERS COMPENSATION SAC STATgU' 01H' AND EMPLOYERS' LIABILITY YIN...., ,ER ., .... ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT S OFFICER/MEMBER EXCLUDED ❑ '.I I A - (Mandatory in NH) E L DISEASE EA EMPC 95Y�E 5 _ If yes, describe under DESCRIPTION OF OPERATIONS below DISEASE L E SE POLICY LIMIT S A Pollution Liab EPK-138429 01/16/2022 01/16/2023 Condition 1,000,001 A Professional Liab EPK-138429 01/16/2022 01/16/2023 Per Claim 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate holder is named as additional insured on the GL policy when specified by a written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE i�.lt of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Y g ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD DATE (MMIDD/YYYY) ACC>R", 03/31 /2022 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: Automatic Data Processing Insurance Agency, Inc, Automatic Data Processing Insurance Agency, Inc. PHONE 1 €300 524 7024 FAY, L% No,,E�tj:, lNC,Nol - I %IL. ADDRESS:. 1 Adp Boulevard INS`URE'R(S3 AFFORDING COVERAGE NAIC 0 Roseland NJ 07068 ......... ......._ INSURER A : Te&inology Insurance Company, Inc 423(6 ..... „ ..... ..... .,.... ......... ......... ... INSURED 03reathe Sate G:: nvlronrnental, Inc INSURER B ; INSURER C 3010 Wilshire Blvd ste 260 INSURER D ; INSURER E : Los Angeles CA 90010 INSURER F COVERAGES CERTIFICATE NUMBER: 2390653 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 CONTRACTOR 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 AOUL SUER TYPE OF INSURANCE POLICY NUMBERXo LTR 1. , l'J.... �MIDDVY'yy,,Y MMIDD1yjr LIMITS COMMERCIAL GENERAL LIABILITY .EACH OCCURRENCE DUWA(»,G T0lal-A6"�1Fr� CL..%AIIM i� MADEi I OCCUR ,PRIEMISi S �CIa (r CLIVr"rnt`es1 MED EXP (kw y one parm. r $ ... . ...... , ., .... .... ---. _.. PERSONAL & ADV INJURY � GENT- AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE _.. — POL..ICY ,JECrT I..00; PRODUCTS - COMP/OPAGG 5....- OTHER:: AUTOMOBILE LIABILITY (' OMO IN E5 91N L E L0,0 C'Ea acc:dnntV ANY AUTO B(DDIILY INJI..IRY (Per Itemon) S.... ....._ OJNNED ....... ...... SCHEDULED 11:3JDII Y INJURY (E mr ar.cid¢.nl} $ AUTOS ONLY ............... AUTOS HIRED NON OWNED ..... ......... , BTd2tyG"F pW 099v1A05 ........... AUTCJ" ONLY .._....._ AU CO"' ON L.Y 9- (., rer is I^d tle¢II), ...... ...... ,,,, ,. UMBRELLA LIAB OCCUR EACH OCCURRI:::INCE S EXCESS LIAB CLAIMS -MADE AGGREGATE DED RETENTION Si 5 WORKERS COMPENSATION P•q• rE �L„9Tw EMPLOYERS'AND YIN IANYOETOIPARTNRI XEECUTIVF Y A INPA' IN TWC4003775 06/25/2021 06/25/2022 e7_ ..$, I FACHACCIDFNT 1,000,000 RE 1,000,000 (Mandatory InNHl E L, DISEASE EA EMPLOYEE S s 3 atcnb(rmde Y'11RION OF OPERATIONS below E DISEASk POLICY IMIT ,,$,1 000, 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EL Segundo Fire Department ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St, AUTHORIZED REPRESENTATIVE El Segundo CA 90245 �q,„.•.,..�) U 19BB-2015 ACORD CORPORATION. All rights reserved, ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD