PROOF OF INSURANCE (2024 - 2025) CLOSEDDATE (MWDD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE [3/29/2024
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 U
NAME;
Dave Terpening Insurance Agency, Inc. �P-H16r�Q FM() ? m822? ... sl�-1�02
310 51.�. "91 N ...�._ ... -
22850 Crenshaw Blvd., Suite 206 AODR Dave@Te enin Insurance.com
Torrance, CA 90505 ra,DR s...... -.w.. DRER(91 AFFORD NG CO _ ........... _ _. .m
IN NAICg
OG47857INSURERA Certain Underwriters at Lloyd's Lon
ORD NG COVERAGE
Tiffany HomeCare Inc. INSURERS: Cypress - ..
on 15792
iNs�uRE�.....����������� y � � � C ress Insurance Company 10855
dba Always Right Home Care INSURER c
9700 Reseda Blvd. Suite 105 INSURERD
." ,.... _.
Northridge, CA 91324 R E _
g r � INSURE._.
COVERAGES CIEVIMITE », .,
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.
R — TYPE OF
..u-
SR ..b. �DDL au�w-_,_,_... .......
L INSURANCE u t SD IWVD POLICY NUMBER MM/DD/YYYY MNVDDNYYY LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1 OOO OOO
w. _X,., CLAIMS -MADE � OCCUR t"N'Jd9oanctw) $ 1 0
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� 00 00 ...
A
Retro Date 6 15 03
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GEN'L AGGREGATE LIMIT APPLIES PER:
tl POLICY PRO-
JECT LOC
O FHER
W2B8EF230401
6/15/2023'6/15/2024
MEDEXP(Anyone person)
PERSONAL & ADV INJURY
GENERAL AGGREGATE
PRODUCT OP AGG
S COMP/OP
w. ...
$ �5,000y
$ Included
$ 3 , 000 , 000
$ 1 0 0 0, 0 0 0
!..................... ...
$
AUTOMOBILE LIABILITY
COMBINED
ANYAUTO
W2B8EF230401 6/15/2023
6/15/2024
BODILY INJURY (Per person)
`Y _._
$ i
!
A
X OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJUR(Per accident)
$
HIRED NON -OWNED
PROPERT r OAhfAOk
$
AUTOS ONLY AUTOS ONLY
.Grr nId E
UMBRELLA LIAB OCCUR
EACH OCCURRENCE
_y
$
EXCESS LIAR CLAIMS -MADE
AGGREGATE
$
DED RETENTION$
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
OTFr—
STATUTE ER
-,
B
ANY PROPRIETOR/PARTNERIEXECUTIVE YIN
OFFICERIMEMBER EXCLUDED?
NIA
�TIWC531447
y
�3/l/2C243�1�2D25
EL EACH ACCIDENT
. ` " '
$ 1,000,000
m�
(Mandate In NH
E.L. DISEASE - EA EMPLOYEE$
1 , 000 , 000 E
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$ 1 , 0 0 0 , 0 0 0
A
Prof Liab RD 6/15/03
W2B8EF230401 6/15/2023 ,6/15/2024
1,000,000
A''Prof
Liab RD 6/15/03
W2B8EF230401 6/15/20236/15/2024
3,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached if more space is required)
CERTIR=ICATE HOLDER CANCELLATION
Community Development Block Grant Consultant
Development Services Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
E1 Segundo, CA 90245 AUTHORIZED REPR NTATIVE
01988-2015 A ORD CORPORAT'I N. All rights reserved.
ACORD25(2016/03) The ACORD name and logo are registered marks of ACORD
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 04 02 C
(Ed. 9-14)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA
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 5% of the applicable manual premium otherwise due on such remuneration
subject to a policy maximum charge for all such waivers of 5% of total manual premium.
The minimum premium for this endorsement is $350.
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
Schedule
Specific Waiver
Person/Organization: City of EI Segundo
Job Description: City referral, cleaning of apartments
Waiver Premium: 350.00
Payroll Subject
Class State to Waiver
8827 CA 18,000.00
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: 03/01/2024 Policy No.: TIWC531447 Endorsement No.:
Insured:
Insurance Company: Cypress Insurance Company
WC 99 04 02C
(Ed. 9-14)
Countersigned by
Premium $