PROOF OF INSURANCE (2022 - 2022) CLOSEDACORD CERTIFICATE OF LIABILITY INSURANCE DATE 5ii4rozo
;,PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Michael Williamson ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
2497 S. Bundy Dr. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Los Angeles, CA 90064
Ph (310) 312-0031
INSURERS AFFORDING COVERAGE_
NAIC #
-.INSURED
...
pant' zstst
INSURER A State Faun General Insurance Company
25151
FLOOR COVERING UNLIMITED INC.
�...........
9601 COZYCROFT AVE STE 8
state Farm Fire and Casual Company
INSURER B: Casualty Pan
____ y.....
25143
CHATSWORTH, CA 91311-5190
, INSURER C:
INSURER D:
0V PA11".'..F1.q
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
tNSR, _ _ _ _
POLICY EFFECTIVE POLICYEXPIRATION _........
POLICY NUMBER LIMITS
A
GENERAL
LIABILITY
'.., 92-05-Q196-6
12/02/2021
12/O2/2022
� EACH OCCURRENCE
$ 1000 000.00
COMMERCIAL GENERAL LIAIId ITY
I 0 ffA-
PR IS s areno
.._.-_.r
$ 1 OOQ 000.00
CLAIMS MADE 19 OCCUR
'...
MED EXP (An one erson
°
$ 5 000.00
PERSONAL &ADV INJURY
$ 1,000 000.00
GENERAL AGGREGATE
$ 2,000,000.00
_
GENT"LAGGREGATE UMITAPPIIESPER:
PRODUCTS-COMP/OPAGG
$ 2,000,000.00
POUCYFI IIEZIPR0.• LOC
A
AUTOMOBILE
LIABILITY
92-CS-Q196-6
12/02/2021
12/02/2022
COMBINED SINGLE LIMIT
$ 1,000,000.00
ANY AUTO
(Ea accident)
ALL OWNED AUTOS
BODILY INJURY
SCHEDULED AUTOS
(Per person)
$
X
HIRED AUTOS
_•_°.-....�.
'
BODILY INJURY
$
NON -OWNED AUTOS
(Per accident)
PROPERTYDAMAGE
..:AUTO
(Per accident)
GARAGE'LJASIUTY
ONLY -EA ACCIDENT
$
ANY AUTO
OTHER THAN EA ACC
S
AUTO ONLY: AGG
$
A
EXCESSIUMERiELLALIABILITy
92-86-9332-3
03/11/2022
03/11/2023
EACHOCCURRENCE
$ 5,000,000.00
OCCUR EI
_
CLAIMS MADE
AGGREGATE
$
DEDUCTIBLE
$_.v-..
RETENTION $
$
B
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
92-GO-KO05-0
12/23/2021
12/23/2022
WC STATU^ I OTH-
TORY LIMIT•°
°-
E.L. EACH ACCIDENT
••••
$ 1,000,000.00
-1,000,000.00
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBEREXCLUDED?
"
E.L. DISEASE-EAEMPLOYEE
$
If yes, describe under
SPECIAL , PROVISIONS below
E.L. DISEASE - POLICY LIMIT
•-----°-
$ 1,000,000.00
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Additional Insured: The City of El Segundo, its officials, and employees
The City of El Segundo, its officials, and employees
350 Main Street
El Segundo, CA 90245
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES. *NOC 10 daVs for non-DaVment Of Dremium
^"�'-� �" \"""••"I WM"Unu MUKYUKHI IUIY T`JOU
Policy No. 92-05-Q196-6
Policy No. 92-05-Q196-6
FE-6609
rr�u r�r�
SECTION II ADDITIONAL INSURED ENDORSEMENT
Named Insured: FLOOR COVERING UNLIMITED INC.
Additional Insured (include address):
The City of El Segundo, its officials, and employees
350 Main Street
El Segundo, CA 90245
WHO IS AN INSURED, under SECTION II DESIGNATION OF INSURED, is amended to include, as an
additional Insured shown above, but only to the extent that liability is imposed on that Additional Insured solely
because of your work performed for that Additional Insured shown above.
Any insurance provided to the Additional Insured shall only apply with respect to a claim made or a suit brought
for damages for which you are provided coverage.
The Primary Insurance coverage below applies only when there is an "X" in the box.
X Primary Insurance. The insurance provided to the Additional Insured shown above shall be primary
Insurance. Any insurance carried by the Additional Insured shall be noncontributory with respect to
coverage provided to you.
All other policy provisions apply.
FE-6609 Printed in U.S.A.
W RS' CO P ENSATI+ N
WAIVER OF SUBROGATION
ENDORSEMENT
Policy Number: (Workers' Compensation Policy number as it appears on certificate)
92-GO-KOOS-0
Workers' Compensation Carrier:
STATE FARM INSURANCE
IT IS AGREED THAT WE WAIVE ANY RIGHT OF RECOVERY WE MAY HAVE AGAINST THE
PERSON OR ORGANIZATION SHOWN IN THE SCHEDULE BECAUSE OF PAYMENT WE
MAKE FOR INJURY OR DAMAGE ARISING OUT OF "YOUR WORK" DONE UNDER A
CONTRACT WITH THAT PERSON OR ORGANIZATION.
SCHEDULE
(Name of Person(s) Or Organization)
The City of El Segundo, its officials, and employees
Date: 04/05/2022 Authorized Carrier Re "tie
Original Signature: