PROOF OF INSURANCE (2011) CLOSED10/29/2010 14:57 3103059022
BRENT WHITLOCK INS riiVt 17Y! 04
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A CERTIFICATE OF LIABILITY INSURANCE 10/39/2010
P THIA CSR ICA E 1 I SUED AS MATTER OF INFOIIMATION
far n k -State Farm InsuranC4 ONLY 'AND COMPE14S NO R10"T5 UPON THE CERTIFICATE
77 9 estar Ave 4105 MOLDER. THIS CERTIFICATE DOES NOT AMEND, EX19ND OR
pl Na CA 90293 ph 310 -021 -0864 ALTER T B C vt:RA D BY,THE P01.1CIE9 BELOW.
INIBURIPM APPORDING COVERA06 INAIC Y
INSURED INSURERA State Farm General insurance comany 26151
Janos and Very Bellisimo INSURER$ :Static Farm Mutual Auto IaSUCARCe C=P&tky 25118
MA Jim' B Exotic Fish ENWRILK
630 N. Sepulveda Blvd. Ste 14 A & B
El Segundo, CA 90295 INWRGRD'
_ unv -�tsn raf�YWR1ICTAN!)iN0
THE POLICIES.Of INSURANCE LISTEO BELOW IiAVE BEEN 16SVCR TV me movnw m -r . �v -.• • -^ • •- -' -
DOCUMENT WITH RESPECT TO WHICH T"$ CERTIFICATE MAY BE ISSUED OR
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER
SUBJECT TO AL!_ THE TERM6,
gAVLU6ION3 AND CONDITIONS
OF SUCH
MAY PERTAIN, THE INSURANCE AFFOROW BV THe POLICIES OEBCNIAep HEREIN 13
=1:CR70rA MMMATIF "OLDER NAMED TOTHEUTT ,WTFALM TOW ft.$wuL
Attn L Je33 i c LeMay
PQUCIES. &9GRECIATE LIMIT V VE B N ED ED sY P Ip
Fax 310 -648 -1560
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ADUL POLICYNU"vk DATE MIW DATE IWN)DfM
LTR ISM TIM OFINSUPANt6
04/03/10 04/09/11
UMITS
e�E t 1 000, 000
A A GENERAL LIABILITY 92-24-672-7
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PRO LOG
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241- 0777 - 225 -')5 0 "Il2yllp G1 /z� /11
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a 1,000,000
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01/01/11
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I F E- POLICY UMrT
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QaaawrloN Ot 9POKATIONS 1 LOCATIONS I V61,119LEe I wWLV"Ne ADDED BY EM504mGMCNT I SFSOIAL PIbVIMeNa
The City of E1 Segundo .ie rlaTasd as additional insured
CCRTIPICAT C IA)welc
The City of El 969undO, it* Off �c,ia),s and Employto
$No= ANY OF THE AMM MCRM rOLM= BE CAMMLO BWM nE RMUTMO
111 W. Maripoaa Ave
PATE TNERBOr, T»E aSU940 1N9URER WILL aNDMVAR TO MA& " VAYS WRITTEN
El Segundo, CA 9D245 -3813
=1:CR70rA MMMATIF "OLDER NAMED TOTHEUTT ,WTFALM TOW ft.$wuL
Attn L Je33 i c LeMay
IMrOes No cKwo 10N LIABILITY OF ANV RIND V It INSURIM, Re AGENTS VR
Fax 310 -648 -1560
R>SPr�nIITe
AUTHOR im R
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10/29/2016 14:57 3103069022 BRENT WHITLOCK INS roc 09+fQ%
IrATI FARM
1MIYIAMC
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the cardAcate holder In lieu of such endoreement(s).
It SUBROGATION IS WAIVED, subJeet to the to ms end Conditions of the PvIL-y, eertaet poldes may
require an endorsement. A statement On this certificate does not confer rights to the certificate
holder In lieu of such endorsement(').
DISCLAIMER
The Certfficate of Insurance on the reverse side of this form does not constitute a contract between
the Issuing Insurer(s), authorized representative or producer, and the certificate holder, nor does h
eMlmtatively or n gobvey amend, extend or alter the coverage afforded by the policies IiSW thereon.
ACORD 29 (2001108)
10/29/2010 14:57 3IB3069022 BRENT WITLOCK IN5 r-Am n6/wo
Poky No.: 92-24- 9387'2 -7
$IGTION N ADDITIONAL. MIRED ENDORSEifA M
Palky No.: 84-24- 96724
I'mm Ineumd: (AMENWO) BELUSSIMO, JAMES J & MARY E
Additiontl Insun®d (include address):
CITY OF EL SEGUNDO, THE CITY, ITS OFFICERS, OFFICIALS EMPLOYEES, AGEI"ITS AND
VOLUNTEERS
350 MAIN ST
EL SEGUNDO CA 90246,UIS
WHO 15 AN INSURED, under SECTION II DESIGNATION OF INSURED. is amended to kufiide as
an kmed "AdOmM msuml shown abav% W only to the soft(* thud kbiYty 1s I igmeed cn that
Additions( hrsued eolelyt beorAs of your work paFaviod fbr tfnt Addillonet kwwed shaven Mom
Any borate provklsd to the Addbonel kwAvd did only apply Mtt h respect b a dgM1 mmla or a
*0 brotght for dstuaas W Which you are WWAW coverage.
The Primary Ineuranoe careruAp below eppip, s orgy wW Mans Is an O(" in the boar.
® Pft y Ifturanm The NUMMM provided 10 ftlo Ad*W* lMknd shown elbow Mtaai be
pdmary insun.nCe. Arty k=mnos cwn'fed by the AddW oriel Insured shag be rlCripor>tirlaftry
wb m9pecl t,0 c overrops pmvkled to you.
All ad m polky prravhkm apply.
PA N SA