PROOF OF INSURANCE (2010) CLOSEDDATE (��YI
,+corrd CERTIFICATE OF LIABILITY INSURANCE 09/30/2009
THIS CERTIFICATE IS ISSUED AS MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHT'S UPON THE CERTIFICATE
Brent Whitlock -State Farm Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
7740 W. Manchester Ave #105 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
playa Del Rey, CA 90293 ph 310 -821 -0864
R - ENYION i WC 6TATU- OTµ
a C(WWMTVNAMD 92- BD- RI15 -3 01/01/09 01/01/10 trORYLOMMI I ER 100,000
w"Yaw LIAB[ITY EL EACH ACWeNT
AWPR0PRM'TO"AATWJW0W UT*& ELD%TA&E•EAEMPLOYEE L 100, 000
OFFICBfKEX=Dfb' 500, 000 bo 8Y�ECMJMtdIAS�IONS EL DISFASE -POLICY L61YT Z
bMow
OTHER
IESC=PTM OF OPERAT10Ni f ROGATIONS / V&*NCL" ! EXCLUSIONS ADDED %Y RNb0RWMENT 18PECIAR PROVISIONS
me City of E1 Segundo is named as additional insured
CERTIFICATE HOLDER CANCELLATION
The City of Bl Segundo, its Officials and Employee DAT9 TMISSM N MA ° YSM
111 W. Mariposa Ave
E1 Segundo, CA 90245 -3613 NoTICETT3THECtNISIOY ►�IIOLDrJ<RNA�>OTI(EIEFT,
Attn: Jesoie LeMay
FaX 310 - 648 -7560 AVnKl® A •
132846
Z0 /10 39Vd SNI A00-1iIHM 1N3bg ZZ0690£0TE £Z :IT 600Z/0£/60
AFFORDING COVERAGEE NAIL
LTtAState parm�eM7 Ynauraace CdIA an 25151
James and Maly' Bellisimo
JWSURERS
jRB:State Farm Mutual Auto insurance Company 25178
DBA Jim's Exotic Irish
�C
630 N. Sepulveda Blvd. Ste 14
A d B
,S1 Segundo, CA 90245D
�
WSURER E:
COVERAGES
ABOVE FOR THE POLICY PERIOD INDICATED. }15 DIOR
THE POLICiE.S OF PMRANCE LISTED BELOW HAVE BEEN MSUEU TO TW INSURED NAMED h'Y BE UE
RESPECT TO VvFIN:H � CERTIFICATE MAY BE ISSUED OR
ANY REQUIR MMI. TERN OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 1AlITT{
BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TFAMS. EXCLVSIONB AND CONDITIC/N$ OF SUCH
MAY PERTAIN, THE. NISURANCE AFFORDED
BEEN REDUCED BY PAID CLAMi.S
lE wN MAY
KAVE Y
A9Eti
POLM NEIIIOR DATE DATE Lf•I13
92 -24- 3672 -7 04/05/09 04/05/10 PC."occuR a cE s 1,000,00 0
841EY
PRElM8E6 ouurencs s
X .RCyti 0tp1 LIABAf v
MED EJE onv = 5, 000
ea Maw 11 comm
P0%WN LAMWPLU Y S 1,0001000
AGGEIEGATE i 2,000,000
000, 000
=FL1WAPRffi PBt
Y .ERG LOO
241- 0777- a25 -75 07/25/09 01/25/10 o SOME LWT i 1,000,000
+AIMA
E UABaEEY
(Es aaa#+U
TO
90041y "JURY i
NED AUTOS
O'erDel
SCHEDULED AUTOS
BODILY Ri.N1RY $
AUTO$
(Px 3;6*r4
WNED AUTOS
PROPERTY DAMAGE i
(PW aaid4"U
AUTO ONLY- EaAM-10V MT i
GARAG! UASKM
�IANYAVTO
OTHER " Eaacc i
AUTO ONLY:
R - ENYION i WC 6TATU- OTµ
a C(WWMTVNAMD 92- BD- RI15 -3 01/01/09 01/01/10 trORYLOMMI I ER 100,000
w"Yaw LIAB[ITY EL EACH ACWeNT
AWPR0PRM'TO"AATWJW0W UT*& ELD%TA&E•EAEMPLOYEE L 100, 000
OFFICBfKEX=Dfb' 500, 000 bo 8Y�ECMJMtdIAS�IONS EL DISFASE -POLICY L61YT Z
bMow
OTHER
IESC=PTM OF OPERAT10Ni f ROGATIONS / V&*NCL" ! EXCLUSIONS ADDED %Y RNb0RWMENT 18PECIAR PROVISIONS
me City of E1 Segundo is named as additional insured
CERTIFICATE HOLDER CANCELLATION
The City of Bl Segundo, its Officials and Employee DAT9 TMISSM N MA ° YSM
111 W. Mariposa Ave
E1 Segundo, CA 90245 -3613 NoTICETT3THECtNISIOY ►�IIOLDrJ<RNA�>OTI(EIEFT,
Attn: Jesoie LeMay
FaX 310 - 648 -7560 AVnKl® A •
132846
Z0 /10 39Vd SNI A00-1iIHM 1N3bg ZZ0690£0TE £Z :IT 600Z/0£/60
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the poticy(ies) must be endorsed- A statement
on this cwffcate does not comer rights to the cerificate holder in Neu of such er►dorsemerrt(s).
ff SUBROGATION IS WAIVED, sew b the testes and co N= Of the po cyl oertain Policies may
require an endorsement. A statement on this cerhk:ate does not confer rights to the certificate
holder in lieu of such endom men(s).
DISCLAIMER
The Cer6firate of Insurance on the reverse side of this form does not constitute a contract between
the issuing irrsurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmativey or negatively amend, extend or alter the overage afforded by the policies listed thereon.
AGORD 26 (3001108)
Z0 /Z0 39VJ SNI A007iIHM 1N369 ZZ0690E01E 6Z:LZ 600Z /0C/60
10/26/2009 14 :59 3103069022 BRENT WHITLOCK INS PAGE 02/03
poky No.: 92- 2"72 -7
SECTION N ADDITIONAL INSURED ENDORSEMENT
Policy Nm: 92-24-3672-7
Named IrmnW: (AMEN DM) BELLISSIMO, ,TAMES d & MARY E
Mom
!Lt { 6:0
IYfYf
Additional Insured (include address):
CITY OF EL SEGUNDO, THE CITY, ITS OFFICERS, OFFICIALS. EMPLOYEES, AGENTS AND
VOLUNTEERS
360 MAIN ST �
EL SEGUNDO CA 80245-381
WHO IS AN INSURED, udder SECTION 11 DESIGNATION OF INSURED, is amended to include 88
an insured the Additional, Insured shorn above, but only too. the mc*d that liability is imposed on that
Add &xm d Ind aaW beta of yaw vwolik peftnvd for that Additional irasuned shown above.
My ko"m d to the AddWW Insured shalt only apply with rasped to a Balm made or a
so brought for dattnages for which you are Rovided wve"e-
The Primary insurance coverage below appkis only when there is an W in the box
® P*lm y krsuramm. The lnsurSnCe INVAd8d to the Addit" Irk shown above shall be
pm„ffiy roxanoa. Any kourance ca~med by the Additional Insured shall be nonooftlbuGory
with respect to coverrage pmvkled to you.
AN other POW PMVW" aPPIY-
P#Vmd in u.s.n.
10/26/2009 14:59
3103069022
BRENT WHITLOCK INS
itepreduoWn of insumnss Swvk es O flea. lrw. Farm
Mgt,M: ISO FORM 00 20 10 11 85., (MaDnmD)
POLICY IVi3AfMM' COMUMCIAL ORNM0tAL LIABILITY
dNM] RSE1tMzNT fMMZM EJCMMT I-A
T MS EMDORS2MM CNAMM'RO PQLICY, FLRAU VJ"" CAREFULLY.
ADDImN iN �0�L9S8M ()R
This sodorsma# bnoaa6oe bw=ce povided tabder the UeUowi .
C4MMBRCIAL 09MM + LS1181I M COVERAGE PART.
SCIEDULZ
The City. its officer% omd" emp , *ftgalba► "d volts
pf ao entry gyp t , - AOTC, the WkWr M MWW ID 00=406061 thfs mdcasamant
'will be shown in the Dmig tong as vooable to to 4tydar e=t.)
WINO IS AN INStiM(SectiM II) ie amended to iacluda a: at insured &e pawn or
shown in du UbcMt, but enbr wkb vMed to fi"W -j' ° oa of "yaur work" for *a ba"vd by of
for you.
�—�CC2t1011
l . 7We insured sehe& Md taboxe incsttaes 'tho Mrnamh of8axa, Ambit" sa+PiOY
vob .,teem
2 This tomeams shag be psWwy as Mpeots the bMW Shown i>a *e schedak 6C
or if excess, Abell tutand in a mbmbu Chin of covaW Aeons of the Nay
Ibbsussdt scheduled undab0s8 pwmY in 04W 6` t. any O&K Rom
maintldned by the Matted tdwbled abate •bail be in twt m of this ltutttrmoe ,
sball not b4 mdW Wm to canAraht►te with it
3. The iasmom afforded by ibis policy OMIJ not be cooWed f
pnot w jdM DOW* by osroad mail n4= reoelpt
TmtitY.
4. Covmp shell not o lmd e _W indgamwiey caps p je du ecdma nx�oft
M& ioaat wuvd in any use ! � fivx
ym
PAGE 03/03
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