PROOF OF INSURANCE (2005) CLOSEDNo. 8210_ P. 2
_Sep- 1 6 , 2 0 0 4 -10 : 1 4 AM A c o r d i a of C a l i f o r n i a DATE (M ID01"YY)
1 08110/04
ACORD. CERTIFICATE OF LIABILITY INSURANCE ID $
AssSoc -5
PRODUCER THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION
PR Ordia of California ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
PR
Insura o Services, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
15760 Ventura Boulevard, 1400 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
Encino CA 91436 -3007 NAIC #
Phcne:818- 377 -3800 Fax:818 -377 -3899 INSURERS AFFORDING COVERAGE
hiRURED INSURERA Hartford Insurance C
INSURER 1:
INSURER C:
mociates purchaS].n r In '�1O INSURER D.
Santa Monica CA 90025
INSURER E
COVERAGES
THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT O R OTHER DOCUMENT
PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DE$CRi8EO HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
MAY
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS,
PIRATlON LIUt3
POLICY NUMBER
LTR INS TYPE OF INSURANCE POLICY
DATE MMlD YMIDDm
OCCURRENCE $1,000,000
GIINERIILLUUIILlTY
A X X COMMERCIALGENERALLIABILITY 72UUNGr%0852
05/17/04 05/17/05 PREMI5ES(Eeaacurenoe 5 30O 000
CLAIMS MADE 7X
MED EXP (Arty one Person) $10,000
PERSONAL &AOV INJURY S 1, 000 , 000
GENERAL AGGREGATE S 2 OOO 000
PRODUCTS - COMPIOPAGG S 2, 000 , 000
GENL AGGREGATE LIMITAPPLIES PER
POLICY JET LOC
COMBINED SINGLE LIMIT $1,000,000
AUTOMOBILEL>ABE.m'
72VUGK0852
05/17/04 05/17/05
A X ANY AUTO
BODILY INJURY g
ALL OWNED AUTOS
(Per person)
SCHEDULED AUTOS
HIRED AUTOS
BODILY 04IURY g
(Pa wridem)
NON -OWNED AUTOS
TY DAMAGE g
em)
LY • EA ACCIDENT S
___0!T
GAMGELIABRJTY
EA ACC S
ANY AUTO
001% NLYN AGO S
EACH QCCURRENCE s2 000,000
EXCL"UMBRELLA LWBWTY
CLAIM8MADE 72RHUGKI581
05/17/04 05/17/05 AGGREGATE $2,000,000
A X OCCUR
i
g
DEDUCTIBLE
8
X RETENTION $10,000 1
TORY LIMITS ER
WORxERS COOPENSATION AND
F.L EACH ACCIDENT S
EMPLOYERS' LIABILITY
P>ROPRIErORIPARTNOER� ='VE
E.L. DISEASE • EA EMPLOYE S
QkNF
E.L. DISEASE - POLICY LIMIT f
N yyeep� Mwae urtlsr
B PEC lAL PROVISIONS Dhow
OTHER
DESCRIPTION CF OPEPATIONS r t0CAT10NS rVEHICLEb! E)MCLUS10N6 ADDED BY ENDORSEMENT I SPE MAL. PROVISIONS
Additional Iasureds:the CitY,its officials,
All Operations of the insured.
and employees
of cancellation for non-payment of premium
*10 days notice
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 17MRA7ION
CMELSE
DATE THEREOF, THE 199UINb INSURER WILL ENDEAVOR TO MAd DAYS wwTTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT MORE TO 00 SO SMILL
City Of El $ag11I1dC
Office of the City Clerk
IMP�SE No OBLIGATICN OR UAMUTY F ANY gND UPON THE INSURER ITS AGENTS 0R
350 Main St. Roam 5
El Segundo CA 90245 -3895
REPRESENT'ATIVBS.
aM ORS DW pRESENTATNE, A 7
ACORD n (2001108) 1
p
Sep. 16. 2004 10:14AM Acordia of California
No. 8210 P. 3
POLICY NUMBER: 72UUNGKO852 COMMERCIAL GENERAL LIABILITY
TE [IS ENDORSEMENT CHANGES THE POLICY. PLEASE READ TT CAREFULLY
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS [Form B]
This endorsement modifies insurance provided under the following:
COM N ERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization: The City of El Segundo, its officials, and employees
(if to entry appears above, information required to complete this endorsement will be shown in
the Declared= as applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the
schedule, but only with respect to liability arising out of `your work" for that insured by or for you.
CG 20 10 1185 Copyright, Insurance Service Office, Inc., 1984
Sep. 16. 2004_10:14AM_Acor6ia of California
No. 8210 P. 4
IMPORTANT
If the certificate holder is an ADDITIONAL o the certificate holder nelie lieu such endorrsemen). statement
on this certificate does not confer rights
If SUBROGATION IS WAIVED, su otn to the terms and this certificate does nto�c:onferh policy,
to,the certificate � may
require an endorsement. A statement
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the re or producer, and the certificate holder, nor oese to
the issuing insurer(s), authorized
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
25