Loading...
PROOF OF INSURANCE (2024)CERTIFICATE OF LIABILITY INSURANCE DATE (MWDDNYYY) 6/28/2024 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 pollcy(les) 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 endorsemenl(s). PRODUCER PHONE 939-8553 � DILLARD INSURANCE AGENCYCONTACT PHONE' (916 Arr� ND E�&;� 1121 White Rock Road Ste 205 .M,�iI lardOf agent.com mmADDREt�,w. INSURERM) AFFORDING e i armers _ El Dorado Hills, CA 957 62 � — ^ G COVERAGE (916) 933-5532 ......__...... . .�.............— INSURER A :. i$,'$'. COX Insurance Company Inc INSURED 34th Street Inc INSURER B ..ITITIT...- 531 Main Street #950 INSURER C mm - 104 Caroline Corner Ct Montgomery TX INSURERD: E1 Segundo, CA 90245 INSURER E "."""_"""""""" ( — 7 7316 INSURER P. _ NAIC# 10200 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ INSR LTR TYPE OF INSURANCE ADDL INSD "SUB WVD POLICY NUMBER POLICY EFF MWDDYYYY Lift P MM/DD/YYYY _—.._.... LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2 000 000 P CLAIMS -MADE � OCCUR Ex -- DAMAGE ­ PREMISES..,(ETtl orcu nce $ 100 000 -� P101.999.334.4 11/6/2023 11/6/2024 MED EXP (Any one person) $ 5 000 $ -2,000,000 A Y Y PERSONALS ADV INJURY .... GEN..... — L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2 , 000 , 000 X CI PRO- JECT LOC $ST Gen AggPOLICY OTHER AUTOMOBILE LIABILITY Ea acctderd $ ANYAUTO P101.999.334.4 ll/6/2023 11/6/2024 BODILY INJURY (Per person) $ OWNED SCHEDULED (Per ILYI NJIJ)RY Pe $.... A AUTOS ONLY HIRED AUTOS &TE $ X AUTOS ONLY X AUTO ONLY GB 10 Pe GL HNOA Limit $ 2,000,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE _ ... $ EXCESS LIAR_ CLAIMS -MADE EGAT AGGR E. "�.,_ ..... ... .��.. DED V RETENTIONS$ WORKERS COMPENSATION STATUTE ER AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE �TYTE E.L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? �) (Mandatory in NH) NSA E.L DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE POLICY LIMIT $ Each Claim 2,000,000 A Prof Liability E&O P101.999.210.4 11/6/2023 11/6/2024 Aggregate 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder is an additional insured with respect to General Liability CERTIFICATE HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo, Ca 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZ REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD25(2016/03) The ACORD name and logo are registered marks of ACORD Am HISCOX Policy Number: P101.999.334.4 Named Insured: 34th Street Inc. Endorsement Number: 7 Endorsement Effective: 11/06/2023 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any pep- son(s) or organization(s) for whom you are performing operations or leasing a premises when you and such person(s) or organiza- tion(s) have agreed in writing in a contract or agreement that such person(s) or orgianiza tion(s) be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to lia- blity for "bodly injury", "'property damage"' or 'personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing opera- tions; or 2. In connection with your premises owned by or rented to you_ A person's or organization's status as an adds tional insured under this endorsement ends when your operations or lease agreement for that additional insured are completed_ CGL E5421 CW (02/14) Includes copyrighted material of Insurance Services Office, Inc., with its Page 1 of 1 permission • Policy Number: P101.999.334.4 Named Insured: 34th Street Inc. Endorsement Number: 16 Endorsement Effective: 11/06/2023 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. • • a 0 Imp • - • • • • This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy, pro- vided: 1. you have agreed in a written contract or agreement to add such additional insured to a policy providing the type of coverage of forded by this poicy; and 2. you have agreed in a written contract or agreement with such additional insured that this insurance would be primary and wood not seek contribution from any other insur- ance available to the additional insured. CGL E5581 CW (03/16) Includes copyrighted material of Page 1 of 1 Insurance Services Office, Inc-, with its permission Aeo HI$CQX Policy Number: P101.999.334.4 Named Insured: 34th Street Inc. Endorsement Number: 17 Endorsement Effective: 11/06/2023 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. MODIFIED FIE AIVEI OF TRANSFER OF RIGHTS O RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The following is added to Paragraph 8, Transfer Of Rights Of Recovery Against Others To Us of Section IV— Conditions: You may waive your rights against another party so long as you do so in writing prior to: (i) an offense arising out of your business that caused a "personal and advertising injury"; or (ii) an 'occurrence" that caused "bodily injury" or "property damage". CGL E5402 CW (03/10) Includes copyrighted material ofInsurance Services Office,inc., with its permission. Page 1 of 1 AM H I SCO Policy Number: P101.999.334.4 Namedlnsured: 34th Street Inc. Endorsement Number: 18 Endorsement Effective: 11/06/2023 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. The coverage provided by this endorsement will apply only up to the Limit of Insurance specified above or in the Declarations, if no information is shown in the Schedule. 1. Hired Auto Liablity The coverage provided under Coverage A— Bodily Injury and Property Damage Liability in Section I — Coverages applies to "bodly injury" or "property damage" arising out of the maintenance or use of a "hired auto" by you or your "employees" in the course of your business. 2. Non -owned Auto Liability The coverage provided under Coverage A Bodily Injury, and Property Damage Liability in Section I — Coverages applies to w"bodly injury" or "property damage" arising out of the maintenance or use of any "non -owned auto" in your business by any person. B. With respect to the coverage provided by this endorsement only, the following apply: 1. The exclusions under Paragraph 2. Exclusions in Coverage A.. Body Injury and Property Damage Liability in Section I ..,.. Coverages, other than Exclusions a., b., dA, L, and i. are deleted in their entirety, and exclusions e. and j, are replaced by the following: hrre. Employer's Liability "Bodily injury" to: (1)An "employee" of the insured arising out of and in the course of: (a) Employment by the insured; or (b) Performing duties related to the conduct of the insured's business; or (2)The spouse, child, parent, brother or sister of that "employee" as a consequence of Paragraph (1) above. This exclusion applies: (1) Whether the insured may be liable as an employer or in any other capacity; and CGL E5691 CW (11/19) Includes copyrighted material of Insurance Services Offices, Inc., with its permission Page 1 of 2 2, (2) To any obligation to share damages with or repay someone else who must pay damages because of injury. This exclusion does not apply to: (i) Liability assumed by the insured under an "insured contract"; or (U)"Bodly injury" arising out of and in the course of domestic employment by the insured unless benefits for such injury are in whole or in part either payable or required to be provided under any workers' compensa- tion law, hm- Damage to Property "Property damage" to: (1) Property owned or being transported by, or rented orloaned to the insured; or (2)Property in the care, custody, or control of the insured, Section II - Who is An Insured is deleted in its entirety and replaced by the following: Each of the following is an insured under this endorsement to the extent set forth below: a. You; b. Any other person using a "hired auto" with your permission; a Solely for a "non -owned auto": (1) Any partner or "executive officer" of yours; or (2) Any "employee" of yours; but only while such "non -owned auto" is being used in your business; and d. Any other person or organization, butonly for their liablity because of acts or omissions of an insured under a., bo or a above. None of the following will be considered an insured under this endorsement: (1) Any person engaged in the business of their employer for "bodly injury" to any co - "employee" of such person injured in the course of employment, or to the spouse, child, parent, brother, or sister of that co -"employee" as a consequence of such "bodily injury", or for any obligation to share damages with or repay someone else who must pay damages because of the injury; (2) Any partner or "executive officer" for any "auto" owned by such partner or officer or a member of his or her household; (3) Any person whl'e employed in or otherwise engaged in duties in connection with an "auto business", other than an "auto business" you operate; (4) The owner or lessee (of whom you are a sublessee) of a "hired auto" or the owner of a "non -owned auto" or any agent or "employee" of any such owner or lessee; or (5) Any person or organization for the conduct of any current or past partnership or joint venture that is not shown as a Named Insured in the Declarations. C. For purposes of this endorsement only, Section III - Limits of Insurance is amended to the extent necessary to provide the following: Regardless of the number of "hired autos", "non - owned autos", or vehicles involved, or the number of claims made or "suits" brought, the most we will pay for all damages resulting from any one "occurrence" covered under this endorsement will be the Limit of Insurance stated in the Schedule above. All payments we make for damages covered by this endorsement will be a part of, and not in addition to, the General Aggregate Limit stated in the Declarations. D. For the purposes of this endorsement only, 4. Other Insurance in Section IV - Commercial General Liability Conditions is deleted in its entirety and replaced by the following: This insurance is specifically excess over any primary insurance covering the "hired auto" or "non -owned auto". D. With respect to the coverage provided by this endorsement, the foll'owiing additional definitions are added to Section V6 Definitions: 1w "Auto business" means the business or occu- pation of selling, repairing, servicing, storing, or parking "autos". Z "Hired auto" means any "auto" you lease, hire, rent, or borrow. "Hired auto" does not include any "auto" you lease, hire, rent, or borrow from any of your "employees", your partners, or your "executive officers", or members of their house- holds. 3. "Non -owned auto" means any "auto" you do not own, lease, hire, rent, or borrow which is used in connection with your business. This in- cludes "autos" owned by your "employees", your partners, or your "executive officers", or members of their households, but only while used in your business or your personal affairs. CGL E5691 CW (11/19) Includes copyrighted material of Insurance Services Offices, Inc, with its permission Page 2 of 2 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 El 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 El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone # ( X) I certify that, in the performance of the work set forth in the agreement with the City of El 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 workers' compensation provisions of Labor Code § 3700 1 must ! 7 V immediately comply with thos pr reement will automatically become void,.. July 15, 2024 Signature of Applicant Date Print Name Gerardo reciado Agreement for: Dated Reviewed by: