PROOF OF INSURANCE (2009) CLOSEDCOVERAGES
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.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
POLICY NUMBER
POLICY EFFECTIVE
POLICY EXPIRATION
LIMITS
City Clerk
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 9WALXX
EOFINSURANCE
ABILITY
ERCIAL GENERAL LIABILITY
LAIMS MADE � OCCUR
7GEN'L
HDO G23738119
02/01/08
02/01/09
EACH OCCURRENCE
$1,000,000
D A 0
PREMISES Ea occurence
$ 100,000
M ED EXP (Anyone person)
$10,000
PERSONAL &ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$2,000,000
PRODUCTS - CO MP /OPAGG
$2,000,000
REGATELIMITAPPLIESPER:
Y PRO LOC
A
AUTOMOBILE
LIABILITY
ISA H08239939
02/01/08
02/01/09
COMBINED SINGLE LIMIT
(Ea accident)
$2,000,000
X
ANY AUTO
ALLOWNEDAUTOS
BODILY INJURY
(Per person)
$
SCHEDULED AUTOS
X
HIREDAUTOS
BODILY INJURY
(Per accident)
$
X
NON -OWNED AUTOS
PROPERTYDAMAGE
(Per accident)
$
GARAGE LIABILITY
AUTO ONLY -EA ACCIDENT
$
ANYAUTO
OTHERTHAN EAACC
AUTO ONLY: AGG
$
$
EXCESS /UMBRELLA LIABILITY
EACH OCCURRENCE
$
OCCUR CLAIMS MADE
AGGREGATE
$
DEDUCTIBLE
A
A
RETENTION $
WORKERS COMPENSATION AND
EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
WLR C44483774
SCF C44484365
02/01/08
02/01/08
0 2/01/09
02/01/09
X WCSTATU- OTH- 1 ER
I T OaYj
E.L. EACH ACCIDENT
$1,000,000
E.L. DISEASE - EA EMPLOYEE
$1,000,000
E.L. DISEASE - POLICY LIMIT $1,000,000
Ifyes,describeunder
SPECIAL PROVISIONS below
A
OTHER
Professional Liability
EON G21680965 002
04/01/08
01 /01 /10
Each Claim /Aggrega 1,000,
ggregate 2,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
City of E1 Segundo, its officials and employees are shown as additional insureds solely with respect to General and
Automobile liability coverages as evidenced herein on a primary /non- contributory basis as required by written contract
with respect to work performed by the named insured.
CERTIFICATE HvLUEK
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL 2NMX=X4I MAIL 30 DAYS WRITTEN
City of E1 Segundo
City Clerk
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 9WALXX
XIt Ii1K�✓ iC �X�{ ��ailXil�1��7�X/ i�i1�Q� ►7���'iflXXliK�X��K"��I�X
350 Main Street, Room #5
xxgxmzxgim=xxxxxxxxxxXXXXXXXXXXXXXXXXXXXXYXxxxxxxxxxxxxxx
AUTHORIZED REPRESENTATIVE
E1 Segundo, CA 90245 -3813
USA
r,�--
n ArrnI211 f1n17DnQATInW 4QRR
ACORD 25 (2001/08) fremcint -
8984989
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 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 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 25 (2001/08)
POLICY NUMBER: HDOG23738119
ENDT. 0'113
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS9 LESSEES OR
CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization;
Any owner, Lessee or Contractor whom you have agreed to include as an additiOnoal
insured under a written contract, provided such contract was executed prior
the date of loss.
(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 work" for that insured by or for you.
CG 20 10 11 85 Copyright Insurance Services Office, Inc., 1984