PROOF OF INSURANCE (2007) CLOSED-Feb-20-07 12:09pm From -Pan American Underwriters
LovIIIs[y -4407 FAX C626)844 -89
)'Pan-American Underwriters Inc
' 8� E. Green Street., Suite 206
Pasadena, CA 91105
INSURED MBN Services Inc ,
DBA: Bob Murray I Associates
1677 Euierka, Ste 202
Roseville, CA 95661
626 849 8959 T -461 P.001 /002 F -973
- — ' -- " "W ft- 1 02/05/2007
THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
VINSURERS AFFORDING COVERAGE NAIC #
artford Casualt y Ins Company 29424
hiladlp Ins Co
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NSR Op =LIABILIry E
POLICY NUMBER POLICY EFFEC VE POLICY EXPIRATION
GE 72SBANU3036 07/20/2006 07/20/2007 EACH OCCURRENCE LIMITS
S
X LIABILITY 1 .000.00(
DAMAGE TO RENTED S 3OO ,OOH
OCCUR '
A MED EXP (Any one peral S 10 00C
PERSONAL & Al INJURY S 1. 000. 00U
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE S 21000
POLICY M jRoT LOC
PRODUCTS. COMP /OP AGG i 2 OOO
AUTOMOBILE LIABILITY 72SBANU3036 07/20/2006 07120/2007
ANY AUTO
COMBINED SINGLE LIMIT
ALL OWNED AUTOS
(Eo odnaenl) 1,
000
SCHEDULED AUTOS
A
BODILY INJURY 6
X HIRED autos
(Per parson)
X NON -OWNED AUTOS
BODILY INJURY
(Per ecd of S
PROPERTY DAMAGE $
(Per 3cetdel
cARACe LIABILITY
ANYAUTO
AUTO ONLY. EA ACCIDENT S
OTHER THAN CA ACC S
eXCES3IUMBRELLA LIABILITY
AUTO ONLY: AGG S
OCCUR CLAIMS MADE
EACH OCCURRENCC S
AGGREGATE S
DEDUCTIBLE
—z–
S
RE'rENTION $
S
WORKERS COMPENSATION AND
S
EMPLOYERS' LIABILITY
WC STATU- 0TH•
ANY PROPRICTOR/PARTNERIEXECUTIVE
Tn
OFFICER/MEMBER EXCLUDED?
EA., EACH ACCIDENT $
Des. describe under
SPECIAL PROVISIONS Onlow
Ell, DISEASE • EA EMPLOYE S
B ro�essional Liability PHS017327S 02/27/2007 20/27/2 008
E.L. DISEASE 6
1,000,000
.000,000T Per claim
1,000,000 Per Aggregate
DESCRIPTION OF OPERATIO 3 / L ATIONS r VEHICLES r EXCLUSIONS ADDED BY ENDORSEMQNT r SPECIAL ROVISIONS Deduct . S 5000
he City, its of ic�alS. and employees are named
as additional insured in regards
rising out of any job being performed by the
to the liability
named insured. This insurance
)ntributory in regards to the general liability.
is primary and non
=xcept for 10 days notice of cancellation for non payment of premium-
-A
TAU'rMOPAZED-REPRr;SENTATIVE NY OF THE ABOVE De$cRlBep POLICIES BE CANCELLED BEFORE THE
N DATE THEREOF, TH12 ISSUING INSURER WILL ]IIISI X1XdW6'�6 MAIL
City of El Segundo YS WRITTEN NOTICE TO THE CERTIFlCATE MOLDER NAMED TO THE LEFT,
Cheryl White NX350 Main Street J6lLlN KXrXiidl9'(�fil .1.1X)II E1 Segundo, CA 90245 XXXXXXXXX
EPRE6ENTATIVE wood NAY J
;ORD 25 (2001/08)
mACORD CORPORATION 1988
o%4EEFo
'Feb -20 -07 12:09pm From—Pan American Underwriters 626 849 8959 T -461 P 002/002 F-973
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the pollcy(ies) must be endorsed. A statement
on this certiflcate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certiFlcate 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.
''ORD 25 (2001108)
POLICY NUMBER: 72SBANV3036 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Name of Person or Organization:
the City, its officals and employees are named as additional insured in regards to the liability arising out of any job
being performed by the named insured. This insurance is primary and non contributory in regards to the general
liability.
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations 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 ongoing operations performed for that insured.
ACORD 25 -S (7/97)
° ACORD CORPORATION 1988
O \e- -(M�
DATE.
ACORD,M CERTIFICATE OF LIABILITY INSURANCE
U0221 02 -08 -2007
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
PAYCHEX AGENCY, INC
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
210705 P:(877)287-1312 F:(877)538-4364
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
308 FARMINGTON AVE
FARMINGTON CT 06032
INSURERS AFFORDING COVERAGE
INSURED
INSURER.A: The Hartford Ins Group
MBN SERVICES INC. DBA BOB MURRAY AND
INSURER B:
!ASSOCIATES
INSURER C:
INSURER D:
1677 EUREKA RD. STE 202
ROSEVILLE CA 95661
INSURER E:
COVERAGES
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.
AGGREGATE LIMITS SHOWN
MAY HAVE BEEN REDUCED BY PAID
CLAIMS.
INSR
LTR
Y_.
TYPE OF INSURANCE _
- POLICY NUMBER -
POLICYEFFECTIVE
DATE (MM/DD/YY)
POLICY EXPIRATION...
DATE (MM/DD /YYJ. -..
.
_ -..._ LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $
FIRE DAMAGE (Any one fire)
$
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE 1:1 OCCUR
MED EXP (Any one person)
$
PERSONAL& ADV INJURY
$
GENERAL AGGREGATE
$
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP /OP AGG
$
POLICY _ PRO-
JECT LOC
-. - _. _..
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
$
ANY AUTO
(Ea accident)
ALL OWNED AUTOS
BODILY INJURY
$
SCHEDULED AUTOS
(Per person)
BODILY INJURY
$
HIRED AUTOS
NON -OWNED AUTOS
(Per accident)
PROPERTY DAMAGE
$
(Per accident)
GARAGE
LIABILITY
AUTO ONLY - EA ACCIDENT
$
ANY AUTO
OTHER THAN EA ACC
$
AUTO ONLY: AGG
$
EXCESS LIABILITY
EACH OCCURRENCE
$
AGGREGATE
$
OCCUR CLAIMS MADE
S
$
DEDUCTIBLE
$
RETENTION S
_ _
WORXERS COMPENSATION AND
_ _ _ _
X ` WC STATU- IOTH-
TORY LIMITS I ER
A
EMPLOYERS'L/AB/L/TY
76 WEG PF2345
02/10/07
02/10/08
E.L. EACH ACCIDENT
$1, 000, 000
E.L. DISEASE - EA EMPLOYEE
$1,000,000
E.L. DISEASE - POLICY LIMIT
$1,000, 000
OTHER
_
DESCRIPTION OF OPERATIONS /COCA T /ONSNEH /CLES /EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS
Those usual to the Insured's Operations.
CERTIFICATE HOLDER ADDITIONAL INSURED; INSURER LETTER: CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
'EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
City of El Segundo 130
DAYS WRITTEN NOTICE (10 DAYS FOR NON - PAYMENT) TO THE CERTIFICATE
Attn : Ms . Cheryl White
HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO
!OBLIGATION
OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
350 Main St. IREPRESENTATIVES.
E1 Segundo, CA 90245 1
- --
AUTHORIZED REPRESENTATIVE
ACORD 25 -S (7/97)
° ACORD CORPORATION 1988
O \e- -(M�
Page 1 of 2
White, Cheryl
From: Hogate, Richard
Sent: Wednesday, February 21, 2007 8:16 AM
To: White, Cheryl
Subject: FW: MBN Services- Workers Comp Cancellation Clause
FYI and file in MBN Services folder.
,Rdekaad IWogate
Risk Manager /Purchasing Agent
310 - 524 -2339
From: NH Select, Endorsement (Comm Lines, New Hartford /SCIC) [ mailto: SCIC.NewHartford @thehartford.com]
Sent: Wednesday, February 21, 2007 7:25 AM
To: Hogate, Richard
Subject: RE: MBN Services- Workers Comp Cancellation Clause
Richard,
Thank you for your correspondence. After perusing the email and attachment I must make clear that we are not
an agent/broker, we are in fact the Insurance Carrier (the Hartford). Per our legal department we will /can not
change the cancellation clause nor sign any document that will attempt to override its original intention.
We do apologize for any inconvenience that this may cause the City of El Segundo, it is not in our capabilities to
tailor every certificate for the additional insured when requested.
If you have any further questions or concerns please contact us at 866 -467 -8730 and any customer service
representative will be able to assist you.
Thank you for your time and cooperation.
Sincerely,
Customer Care
- - - -- Original Message---- -
From: Hogate, Richard [mailto:RHogate @elsegundo.org]
Sent: Tuesday, February 20, 2007 6:26 PM
To: McWain II, Dorian (Comm Lines, New Hartford /SCIC)
Cc: White, Cheryl
Subject: MBN Services Certificate of Liability Insurance - Workers Comp Cancellation Clause - Request to
have Agent/Broker take responsibility of notifying City
Importance: High
Dorian,
Please open the attached document. Since the insurance carrier is unwilling to modify the
cancellation clause on the Acord the City is requesting that you as the Agent/Broker place the
attached language onto your company letterhead, signed by a company official and returned to
me taking responsibility for the 30 day notice requirement to the City.
If you have any questions, please give me a call.
2/21/2007
V
Thank you,
R" 44d
Risk Manager /Purchasing Agent
310 - 524 -2339
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2/21/2007
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