PROOF OF INSURANCE (2004) CLOSEDPRODUCER
FEDERATED MUTUAL INSURANCE COMPANY
5701 W. Talavi Boulevard
Glendale, AZ 85036
Phone: 602 - 944 -5566
Home Office: Owatonna, MN 55060
INSURED 311 -368 -5
EDDINGS BROTHERS INC
13415 S HAWTHORNE BLVD
HAWTHORNE CA 90250
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COMPANY
C
COMPANY
D
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.
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
POLICY EXPIRATION
DATE (MM /DD/YY)
DATE (MM /DD/YY)
LIMITS
GENERAL
LIABILITY
GENERAL AGGREGATE
$ 2,000 000
PRODUCTS - COMP /OP AGG
S 2 000 000
COMMERCIAL GENERAL LIABILITY
A
CLAIMS MADE � OCCUR
634708
09/01/03
09/01/04
PERSONAL & ADV INJURY
$ 1
EACH OCCURRENCE
1001000
S 1.000.000
OWNER'S & CONTRACTOR'S PROT
X
FIRE DAMAGE (Any one fire)
$ 50,000
BUSINESSOWNER'S POLICY
MED EXP (Any one person)
$
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
$ 1,000,000
X
ALL OWNED AUTOS
A
SCHEDULED AUTOS
634710
09/01/03
09/01/04
BODILY INJURY
(Per person)
$
X
HIRED AUTOS
x
BODILY INJURY
(Per
$
NON -OWNED AUTOS
accident)
PROPERTY DAMAGE
$
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
ANY AUTO
OTHER THAN AUTO ONLY:
EACH ACCIDENT
S
AGGREGATE
$
EXCESS LIABILITY
EACH OCCURRENCE
S 1,000,000
A
X UMBRELLA FORM
634711
09/01/03
09/01/04
AGGREGATE
S 1 000 000
$
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
WC -
STALIMTIU TH
OER
EMPLOYERS' LIABILITY
TORY TS
EL EACH ACCIDENT
$
THE PROPRIETOR/ INCL
PARTNERS/EXECUTIVE
EL DISEASE - POLICY LIMIT
S
EL DISEASE - EA EMPLOYEE
$
OFFICERS ARE: EXCL
OTHER
DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLES /SPECIAL ITEMS
CERTIFICATEHOLDER IS AN ADDITIONAL INSURED FOR
BUSINESSOWNERS LIABILITY.
RE: DELIVERING PARTS TO THE CITY OF EL SEGUNDO
............. .................:..::::::.:....:::: ::::::.:...:.::::::.:.::..,,,.»
CITY OF EL SEGUNDO 2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
350 MAIN STREET EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
EL SEGUNDO CA 90245 -7037 30_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
O FA NY KIND UPON THE COMP , ITS AGE TS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIV / . /J
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED ENDORSEMENT
This endorsement modifies the insurance provided under the following:
BUSINESSOWNERS LIABILITY COVERAGE FORM
SCHEDULE
Name of Person or Organization:
CITY OF EL SEGUNDO
CITY HALL
350 MAIN ST
EL SEGUNDO CA 90245
Relationship to the Named Insured:
DELIVERING PARTS TO THE CITY OF EL SEGUNDO
A. The following is added to Paragraph C. Who is
(1) All work including materials, parts or
an Insured:
equipment furnished in connection with
5. Any person or organization shown in the
such work, on the project (other than
Schedule is also an insured, but only with
service, maintenance or repairs) to be
respect to "bodily injury" or "property
performed by or on behalf of the
damage" liability arising out of your ongoing
additional insured(s) at the site of the
operations performed for that insured or
covered operations has been completed;
premises owned by or rented to you.
or
B. This insurance does not apply to "bodily injury"
(2) That portion of "your work' out of which
or "property damage" liability arising out of the
the injury or damage arises has been
sole negligence of the additional insured named
put to its intended use by any person or
above.
organization other than another
C. The following exclusion is added to Paragraph B.
contractor or subcontractor engaged in
Exclusions:
performing operations for a principal as
This insurance does not apply to "bodily injury"
a part of the same project.
or "property damage" occurring after:
Insured:
Place of Issue:
EDDINGS BROTHERS INC FEDERATED MUTUAL INSURANCE COMPANY
13415 S HAWTHORNE BLVD Home Office
HAWTHORNE CA 90250 121 East Park Square
Owatonna, MN 55060
(507) 455 -5200
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
BP -F -239 (01 -03) Policy Number: 0634708 Transaction Effective Date: 09 -01 -2003
J �*
Workers Compensation and Employers Liability
Insurance Policy Information Page
A Stock Insurance Company
Corporate Offices: San Diego, CA
Carrier Code: 10900
Policy Number: CYN 112617 -1
1. The Insured Name & Mailing Address:
NAPA AUTO PARTS - HAWTHORNE (dba)
13415 HAWTHORNE BLVD
HAWTHORNE, CA 90250
P Employers
I U R A N C E C O M P A N Y
FEIN: 95- 1475247
Type of Entity: Corporation
Other Insured Names/Workplaces not shown above: See attached schedule
2. Policy Period: This policy is effective from 09/30/02 to 09/30/03 12:01 A.M.
3. Coverage:
A. Workers Compensation Insurance: Part One on the policy applies to Workers Compensation Law
of the state(s) listed here: California
B. Employers Liability Insurance : Part Two of the policy applies to work in each state listed in Item 3.
The limits of our liability under Part Two are:
Bodily Injury by Accident $ 1,000,000 each accident.
Bodily Injury by Disease $ 1,000,000 policy limit.
Bodily Injury by Disease $ 1,000,000
each employee.
C. Other States Insurance: Part Three of the policy applies to the states, if any listed here:
NONE
D. Endorsements and schedules included with this policy:
PE1101, PE1102, 1001, PE1119, PE1111, PE1107, PE1126, PE1127, PE1110, PE1128
4. Premium: The premium for this policy will be determined by our manuals of rules, classifications, rates and
rating plans. All information required below is subject to verification and change by audit.
See Classification and Rating Schedule
Minimum Premium: $ 800
Billing: Direct
Premium Adjustment Period:
Annual with 4 mo. check
Producer: AUSTIN COOPER & PRICE - CAWA
P. O. BOX 3280
SAN BERNARDINO, CA 92413
(909) 886 - 9861
Issue Date: 09/27/02 at SAN DIEGO, CA
PEI 100
04/01/98
Total Estimated Policy Premium: $ 22,311
Deposit Premium: $ 3,348
Authorized Representative