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PROOF OF INSURANCE (2012) CLOSED09/21/2011 17:20 3103069022 BRENT WHITLOCK INS PAGE 02/04 AM CERTIFICATE OF LIABILITY INSURANCE OATE(MMIODIYYYYI 09/14/2011 ARM TYPE OF INSURANCE POLICY NUMBER THIS CERTIFICATE IS ISSUED AS MATTER OF INFORMATION B n49PW 1L -State farm insurance 7GNN)awoLer >,Vw 0185 P CA 90293 ph 310 - 821 -0864 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, TH16 CERTIFICATE DOFB NOT A►.MFNn, FXTFND nR, ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Fax 310 -648 -7560 A X INSURERS AFFOMING COVERAGE NAIC M NLSURED INSURER- State Farm General Insurance company 25151 04/05/12 James and Mary Bellisimo DBA Jim's Exotic Fish INSURERB:State Farm Mutual Auto Insurance Company 25178 MAMAGE TO RENTED' PREMISS "eeeunvner S MED EXP ww 630 N. Sepulveda Blvd. Ste 14 A & B INSURER C: INSURER O: CLAIMS MADE OCCUR El Segundo, CA 90245 INSURER E: I+A \IC�wnCC THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDRiON 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 CONDFTIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. KW L111 AWL SIM TYPE OF INSURANCE POLICY NUMBER DATE MMIDDIYYI XPRAnON DATE UMRS Fax 310 -648 -7560 A X aeNERALuAB X -ITY COMMERCIAL CENERAI- LIAA(L11Y 92 --24- 3672-7 04/05/11 04/05/12 EACH OCCURRENCE 1,000,000 MAMAGE TO RENTED' PREMISS "eeeunvner S MED EXP ww S 5,000 CLAIMS MADE OCCUR PERSONAL AADVINJURY 3 1, 000, 000 GENERAL AGGREGATE _2,000,000 GENLAOCREG91IIEUMITAPPLIESPF72� PRODUCES- COMPAIPAG(I S 1,000,000 PRO. POLICY FI JECT LOC b X AUTOMOOLZMABILRY 241- 0777- a25 -75 07/25111 01/25/12 COMBINED SINOLELIMIT (Eraaeitlertl) = 1,000,000 ANY AUTO BOOILYINJURY (Per perwn) 3 ALLOVMEDAVTOS SCHEDULED AUTOS BODILY INJURY (Per rmdaM) $ HIRED AUTOS NON -OMED AUTOS PROPERTY DAMAGE (Per radawft) 3 AARAGEL0JVU7Y AUTO ONLY - EAACCMENT S OTHER THAN EA ACC AUTO ONLY: AGO 3 ANY AUTO 4 EXCESSAJMBRELLALIABLITY EACH OCCURRENCE S AGGREGATE 3 OCCUR ED CLAIMS MADE D S DEDUCTIBLE 9 RETENTION S a WORRERSCOMPENSATMNAND 6MPLOYERa, UABLrrY ANY PROPRIETOWARTNEFUEXECUTNE OFFICERRAEMSEREJLCLUDED7 92 -HU- X202 -5 01/01111 01/01/12 W08'LlMr TORY LIMRB O1N ER E.L. EACH ACCIDENT S 100,000 EL DISEASE - EA EMPLOYEE S 100,000 E.LDISEASE - POLICY L R S 500+000 Nyw� deeaftumthr 3PECNL PROVISIONS DOW OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS The City of E1 Segundo is named as additional insured f'C0'rW1f'&TF Mee nERl CANCELLATION ` The City of El Segundo, its Off' .za1 and Employee aw"a ANY Cr THE AOOVE DESCATBEO POLK= BE CANCELLED BEPOR6 THE EXPIRATION 111 W. Mariposa ,Avg OATS THERP.OF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL -AL DAYS WRITTEN El Segundo, CA 90245 -3813 NOTICE TO THE CF .ImFICATE HOLDER KAMMTO THE LEFT, Attn: Jessie LeMay Fax 310 -648 -7560 REPRESENT - AU7110RQED TA registrationnoticesi Ica Owners Ip a ma y r re5pe owners 132849 o3-IM117 All TIgI11:S reserved 09/21/2011 17:20 3103069022 BRENT WHITLOCK INS PAGE 03/04 9TATI $AIM IN9YIANC% IMPORTANT If the certificate holder, is an ADDITIONAL. INSURED, the pol'icy(les) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject m the berms 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 lieu of such endorsement(s). DISCLAIMER The Certificate 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 it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon, ACORD 23 (2001108) 09/21/2011 17:20 3103069022 Policy No.: 92- 243672 -7 BRENT WHITLOCK INS SECTION 11 ADDITIONAL INSURED ENDORSEMENT Policy No.: 92- 243672 -7 Named Insured: (AMENDED) BELLISSIMO, JAMES J S MARY E Additional Insured (include address): PAGE 04/04 re-mov iww.�e CITY OF EL SEGUNDO, THE CITY, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS AND VOLUNTEERS 390 MAIN ST EL SEGUNDO CA 902 WHO IS AN INSURED, under SECTION II DESIGNATION OF INSURED, is amended to include as an insured the Additional Insured shown above, but only to the extent that liability is Imposed on that Additional Insured solely because of your work performed for diet Additional Insured shown above. Any insurance provided to the Additional Insured snail only apply with respect to a claim made or a suit brought for damages for which you are provided coverage. The Primary Insurance coverage below applies only when there is an "X" in the box ® Pdmary insurance. The insurance provided to the Additional Insured shown above shall be primary insurance. Any insurance carried by the Additional Insured shall be noncontributory with respect to coverage provided to you. AlI other policy provisions apply. F54mg P, A in U.&A.