Loading...
PROOF OF INSURANCE (2024 - 2025)• e1011P)!1, CERTIFICATE LIABILITY les.� L #r8 k 5 1 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(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, sub)e'ct 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 flau of such endorsement s PRODUCER 506.8-91-1000 C +ACT Core Business Blasingamo Insurance PHONE 509-891-100( 200 N. Argonne Rd .. o e„ Exa Spokane, WA 99212 -N: Core Business Unit J Footfilil' Blvd. Ste 125 B mo'nt, CA 91711 CQY9RAGE,S qEajlFjgAjE, 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 HA REDUCED BY PAID CLAIMS. . IMISR ADO SUB TYPE OF PNS'URANCE' POLICY NUMBERImmiWay=L CY EXP M1CY E6'F POLtl LIMITS A X COMMERCIAL GENERAL LIABILITY E'ACHOCCU&iSECE *e. 1,000'0ti'0 CLAIMS -MADE OCCUR X X RBS0262171 DAPAAGE'T'O RENTEttl 100,000 07108/20,24 07108/2025 CPx s rFn Erg ra r _ 5,000 P ICD EXP trt or e psis atg)_ _ 1,000,000 � y " 000x000 l GEN'L AGGR' GATE LIMIT APPLIES PER: Gq,NE.RAL AGGREGATE _ mm... 2,CiC�CI,Q00 X POUCY� JELQT LOG _ _RqD CTS�COMR�"ID_, AN�Cr 5 .� OTHER: i COMBINED siNGLE LIMIT AUTOMOBILE LIABILITY Aul. " ANY AUTO 1S067tLY; tN�UtY Ppr a"ru m OWNED _ SCHEDULED AUTOS ONLY AUTOS BODILY BNJUPtY Per mcuds r1}° q Gr p AUTOS ONLY X AINO ONi P �yOPERTY A.MAGE dPoraCidoauH UMBRELLA LIAB OCCUR mAc140cCURREh4aE� IT EXCESS LIAB CLAIMS -MADE AN':,'CRE;GAT'. DED RETENVON $ V40AKERS COMPENSATIOPx� PER OTPN- :fA."ttdt C._ AND EMPLOYERS' LPABILITY YIN ANY PRC)PRIFTOIP' PARTNERiEXECAJti:VE (M anOr".FI'-C.ERN�EMI�R EXCLUDED? N/A. EA PPukPLOYLE ION os, ddos kTnaNu darPE T pS below E L DISF = POLICY L4'i�74T _ A Errors S Omissions RBS0262171 07/01812024 0710812025 achClaim i,000,000 D 0 Additional Remarks Schedule may be attached If more space Is required) N F OPERATIONS 1 LOCATIONS /VEHICLES (ACORD 1 1 P DESCRIPTION O OPE 0 Y I Certificate holder is additional insured per GLS578. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIODATE THEREOF, City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS.E WILL BE DELIVERED IN 348 Main St. El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Underwritten by Scottsdale Insurance Company • ATTACHED TO AND FORMING A PART OF ENDORSEMENT EFFECTIVE DATE NAMED INSURED AGENT ND. POLICY NUMBER (72:01 A.M. STANDARD TDr1E) RBS0262171 7/8/2024 Joe Mar Polygraph 46722 THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. • + + • • �•"mwilm This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ERRORS AND OMISSIONS COVERAGE PART A. With respect to this endorsement, SECTION II —WHO IS AN INSURED is amended to include as an additional insured any person or organization whom you are required to add as an additional insured on this policy under a written contract, written agreement or written permit which must be: 1. Currently in effect or becoming effective during the term of the policy; and 2. Executed prior to the "bodily injury," "property damage," "personal and advertising injury" or "damages." B. The insurance provided to these additional insureds is limited as follows: 1. That person or organization is an additional insured only with respect to liability for "bodily injury," "property damage," "personal and advertising injury" or "damages" caused, in whole or in part, by: a. Your acts or omissions; or b. The acts or omissions of those acting on your behalf. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. 2. With respect to the insurance afforded to these additional insureds, the following exclusions are added to SECTION I —COVERAGES, paragraph 2. Exclusions: This insurance does not apply to "bodily injury," "property damage," "personal and advertising in- jury" or "damages" occurring after: a. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or b. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. 3. The limits of insurance applicable to the additional insured are those specified in the written con- tract, written agreement or written permit or in the Declarations for this policy, whichever is less. Includes copyrighted material of ISO Properties, Inc., with Its permission, Copyright, ISO Properties, Inc., 2004 Nationwide GLS-5713-TAG (05-21) Page 1 of 2 .• These limits of insurance are inclusive of, and not in addition to, the Limits of Insurance shown in the Declarations for this policy. 4. Coverage is not provided for "bodily injury," "property damage," "personal and advertising injury" or "damages" arising out of the sole negligence of the additional insured. S. The insurance provided to the additional insured does not apply to "bodily injury," "property dam- age," "personal and advertising injury" or "damages" arising out of an architect's, engineer's or surveyor's rendering of or failure to render any professional services including: a. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, re- ports, surveys, field orders, change orders or drawings and specifications; and b. Supervisory, inspection, architectural or engineering activities. 6. Any coverage provided hereunder will be excess over any other valid and collectible insurance available to the additional insured whether primary, excess, contingent or on any other basis unless a written contract specifically requires that this insurance be primary. When this insurance is excess, we will have no duty under SECTION I --COVERAGES to defend the additional insured against any "suit" if any other insurer has a duty to defend the additional insured against that "suit." If no other insurer defends, we will undertake to do so, but we will be entitled to the additional insured's rights against all those other insurers, C. With respect to the insurance afforded to these additional insureds, the following is added to paragraph 8. Transfer Of Rights Of Recovery Against Others To Us Condition of the Commercial General Liability Coverage Form and Errors And Omissions Coverage Form: We waive any right of recovery we may have against an additional insured because of any payment we make under this Coverage Part, to whom the insured has waived its right of recovery. Such waiver by us applies only to the extent that the insured has waived its right of recovery against an additional insured prior to loss, but only with respect to liability for "bodily injury," "property damage," "personal and advertising injury" or "damages" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations. AUTHORIZED REPRESENTATIVE DATE Includes copyrighted material of ISO Properties, Inc., with its permission. Copyright, ISO Properties, Inc., 2004 Nationwide` GLS-576-TAG (05-21) Page 2 of 2 0 p Amended auto policy declarations Total Amount Due for the Policy Period Please review your insured vehicles and verify their VINs are correct. 1997 Chevy Trk Blazer 2010 Mercedes-B E350_ 6 Ram Trucks 1500 2wd California Fraud Assessment Fee Total* Summary Named Insured(s) Joe & ■Delia Mailing address $ ,,707.47 Policynumber 024 601607 * Your bill will be mailed separately. Before making a payment, please refer to your Your policy provided by latest bill, which includes payment options and installment fee information. If you do Allstate Northbrook Indemnity not pay in full, you will be charged an installment fee(s). Company See the Important payment and coverage information section for details about installment fees. Discounts (included in your total premium) Good Driver (20%) $908.49 Anti -theft $18.07 Distinguished $310.84 Driver Total discounts $1,237.40 Discounts per vehicle tl997_Chqvy Trk Blazer $216.98 Good Driver (20%) $216,98 2010 Mercedes-8 E350 $343.95 Anti -theft $9.21 Good Driver (20%) $334.74 2016 Ram Trucks 1500 2wd $676.47 Anti -theft $8.86 Good Driver (20%) $356.77 Policy period Beginning February 11, 2024 through August 11, 2024 at 12:01 a.m. standard time Your policy changes are February 11, 2024 Your Allstate agency is Navarro Ins Svs Inc 16179 Whittier Blv Whittier CA 90603-256 (562) 947-5219 RandyNavarro@al (state. Some or all of the inforn.o..,,...,,. ,..... Policy Declarations is used in the ratin of your policy or it could affect your eligibility for certain coverages. Pleas notify us immediately if you believe t any information on your Policy Declarations is incorrect. We will make corrections once you have notified us. Amended auto policy declarations Policy number: 1024 6016071 Policy effective date: February 11, 2024 Page 3 of 7 WAllstate. Coverage detail for 1997 Chevy Trk Blazer Automobile Liability Insurance • Bodily Injury • Property Damage Auto Collision Insurance Auto Comprehensive Insurance Rental Reimbursement TowingLabor and Lao _ Costs _ Uninsured Motorists Ins _. urance Limits $1,000,000 each person $1,000,000 each occurrence $100,000 each occurrence Not... purchased* ....._ .. Not purchased* Not purchased* Not purchased* * This coverage can provide you with valuable protection. To help you stay current with your insurance needs, contact your Allstate agent to discuss coverage options and other products and services that can help protect you. Deductible Premium Not applicable $717.00 Not applicable $210.05 VI Rating information Your premium is determined based on certain information inclu Allstate uses mileage information as one factor to help determine your premium amount. The estimated number of miles that this vehicle is driven annually is 100 - 999. Important Note: The estimated annual mileage figure applicable to this vehicle for the expiring policy period was:11,000 - 11,499. The estimated annual mileage figure applicable to this vehicle for the current policy period is:100 - 999. If any of the information shown above is incorrect, missing or changes in the future, please contact your Allstate representative. Please keep in mind that a change in any of the information may result in an adjustment to your premium. maw. R Amended' auto policy declarations Policy number: 024 601 fi0y Policy effective date: February fir 204 detail. for 2010 Mercedes.B E350 Automobile Liability Insurance a Bodily injury Limits Dadne#1his Not applicable $1,000,000 each person $1,000 000 each o Page 4 of 7 rremlum $505.16 Prope mm...,g: . "Collision y caa,a e ccurrence 00 each occurrence OOa�cash Auto ion insurance . �_. � v� of 250 Waiver of deductible a dies pp...._ OJ4 _. Auto Comprehensive Insurance A cash value ue _... RentalReiibursement purchased* $175._01Not o In and Labor Costs _ Not urchased* uninsured Motorists Insurance for 8odriy$100,000 _.Actua! Injury eacp Not applicable$ $199.22accidtAutombIedicaI Paymants .l �00 each person Coordinated Medical Protection - _._..._ Not purchased* '.aplmmicable $8 85 _. _ ._. Sou System y m Not purchased* ._.. apnd blot puwchased Total premium for 2010 Mercedes-B E350 * This coverage can provide you with valuable protection. To help you stay current with your insurance needs, contact your Allstate agent to discuss coverage options and other products and services that can help protect you. VIN $1',338.98 Rating information Your premium is determined based on certain information, including the following. This vehicle is driven for pleasure, ratedas an extra vehicle with no assigned operator, Allstate uses mileage information as one factor to help determine your premium amount. Important Note: The annual mileage figure applicable to this vehicle for the etc it annual mileage figure applicable to this vehicle for the current Policy p policy period was: 5,500 - 5,999. The p cy period 1s:8,000 - 9,499,. The following odometer information for current policy period: If any of the information shown above is incorrect, missing or changes In the future, please contact your Allstate representative. please keep In mind that a change in any of: the Information may result in an ad)ustment to your premium. in 2 0 4 U Amended auto policy declarations Policy number: 024 601607 Policy effective date: February 11, Z024 Page 5 of 7 detail for 2016 D,,. Trucks 1500 2wd Automobile Liability Insurance • Bodily Injury Limits L odnrtihin $1,000,000 each person Not applicable _.y$1,000,000 each occurrence ".$ _0 each occurrence Auto Collis on I Damage .�.._ g rremium $688.69 Waiver o f dedunsurance ctible applies Actual cash value $250 W _..._.. _ __.,.�..$388_... .67 ompreens�ve �_ Insuran e Actual cash value en n al Reimbursement ._.: . _ . N _ ,.. .� .. __, of purchased* $0 _ w � . ._ ._. $168.34 ng and Labor Costs, ts Co_. No�t Purchased* - i Uninsured Motorists for Bodily $-100,,90-0_eaci_p_erso n.- $300,000 each Not applicable 2._.1.8 .s uomo rle Medical Payments caccident mq matedMe +cal Protection NOchpeson _.. Not purchased* .�$�1 m7 Not aPplicableour $91 _..� oynd System � .... _ _ t Nopurchased _ _ .� ... ,..�._ Tape _— Not purchased*� ..... for 2016 Ram Trucks 1500 2wd * This coverage can provide you with valuable protection. To help you stay current with your insurance needs, contact your Allstate agent to discuss coverage options and other products and services that can help protect you. $1,427.05 VIN Rating information Your premium is determined based on certain information, including the following: This vehicle is driven 1.0-20 miles to work/school, married person Allstate uses mileage information as one factor to help determine your premium amount. licensed 60 years Important Mote: The annual mileage figure applicable to this vehicle for the ex irin annual mileage figure applicable to this vehicle for the current Policy p g policy period was: 17,000.17,499. The p y period is:'16,500-16,999. Thefelleu�lnon.l.......a_ for current policy period: it any of the information shown above is Incorrect, missing or changes in the future, please contact your Allstate' representative, please keep in mind that a change In any of the Information may result in an adjustment to your premium. M Amended auto policy declarations Policy number: O24 60160 Policy effective date: February 11, 2024 Additionalcoverages Automobile Death Indemnity Insurance Not purchased* �........ .... _ _ ....... - Automobile Disability Income Protection Not purchased* Identity Theft Expenses Not purchased* * This coverage can provide you with valuable protection. To help you stay current with your insurance needs, contact yourAllstate agent to discuss coverage options and other products and services that can help protect you. Your policy documents Page 6 of 7 Your automobile policy consists of this Policy Declarations and the documents in the following list. Please keep these together. • Allstate Automobile Policy - AU104-3 • Additional Interest Endorsement (Notice of Policy Cancellation or Change) - AU2334 • Amendment of Policy Provisions - AU14626-1 • California Paperless Disclosure - AU14943 • California Amendatory Endorsement - AU14629-3 Important payment and coverage information Here is some additional, helpful information related to your coverage and paying your bill: ►Your rate is lower because you are insuring multiple cars. ►Your bill will be sent to you in a separate mailing and will list any payment option(s) available to you. If you are eligible to pay your premium in installments, your first bill will reflect your available payment options, including the option to pay in full or to pay in monthly installments. Please note that any amounts payable for the first renewal bill will not include an installment fee (unless you have an unpaid balance from a previous policy period, in which case the Minimum Amount Due will include an installment fee, or unless ,you are participating in the Allstate Easy Pay Plan). The following applies to installment payments made after your first renewal bill. If you decide to pay your premium in installments, there will be a $3.50 installment fee charge for each payment due. If you make 6 installment payments during the policy period, and do not change your payment plan method, then the total amount of installment fees during the policy period will be $21.00. a 0 If you are on the Allstate@ Easy Pay Plan, there will be a $1.00 installment fee charge for each payment due. If you make 6 installment payments during the policy period, and remain on the Allstate@ Easy Pay Plan, then the total amount of installment fees during the policy period will be $6.00. D If you change payment plan methods or make additional payments, your installment fee charge for each payment due and the total amount of installment fees during the policy period may change or even increase. Please note that the Allstate@ Easy Pay Plan allows you to have your insurance payments automatically deducted from your checking or savings account. 6 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: (_J 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 Name of Agent Policy Number Expiration Date Phone # 1 certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not Wm —ploy 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 the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with tho provisionsar the agreement will automatically become void. Signature of Applicant Date_Lk -J� Agreement for: Dated: Reviewed by: