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PROOF OF INSURANCE (2005) CLOSEDACORD CERTIFICATE OF LIABILITY INSURANCE OCCU - 1 OP ID E DATE(MAA/ 07/27/04 DDI- PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Marsh AdvAmer CBC 9830 Colonnade Blvd #400 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. DATE MWDD/YY LIMITS San Antonio TX 78230 Phone:888 -591 -1954 Fax:210- 737 -3584 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Hartford Casualty Ins Cc 29424 INSURER B: PREMISES (Ea occurence) $ 3 0 0 0 0 0 Occu-Med. Ltd. Mr. Jim Johnson 7050 North Fresno St., #210 Fresno CA 93720 INSURER C: PERSONAL & ADV INJURY INSURER D: REPRESENTATIVES. ^ INSURER E: GENERAL AGGREGATE nwi+�c. v 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. CITYE - 2 TYPE OF INSURANCE POLICY NUMBER DATE (MiWDDIYY DATE MWDD/YY LIMITS City of El 7GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR Business Owners 54 SBATE0 6 52 08/13/04 08/13/05 EACH OCCURRENCE $ 1000000 PREMISES (Ea occurence) $ 3 0 0 0 0 0 MED EXP (Any one person) $ 10 0 0 0 PERSONAL & ADV INJURY $ 1000000 REPRESENTATIVES. ^ AUTHORIZED REPRESENTATIVE Ama, GENERAL AGGREGATE $ 2000000 GENT AGGREGATE LIMIT APPLIES PER: JO POLICY PRO LOC PRODUCTS - COMP /OP AGG $ 2000000 A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS 54SBATE0652 08/13/04 08/13/05 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ X BODILY INJURY (Per accident) $ X PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY H ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC AUTO ONLY: AGG $ S EXCESS /UMBRELLA LIABILITY OCCUR EI CLAIMS MADE DEDUCTIBLE RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? It yes, describe under SPECIAL PROVISIONS below Y TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS 6729 N. Palm Ave Fresno CA 93650. Contract No. 92 -4225. Certificate Holder is named as Additional Insured. 11C0T1C1/-ATC UAI IICO CANC_FLLATION ACORD 25 (2001/08) v FI UKU L UKrUKFII IUn Tvaa c?O_% CITYE - 2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 60 DAYS WRITTEN City of El Segundo NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Officer of the City Clerk IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON HE INSURER, ITS AGENTS OR 350 Main Street E1 Segundo CA 90245 -3895 REPRESENTATIVES. ^ AUTHORIZED REPRESENTATIVE Ama, ACORD 25 (2001/08) v FI UKU L UKrUKFII IUn Tvaa c?O_% CERTHOLDER COPY STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142 -0807 COMPENSATION I N S U R A N C E FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 06 -25 -2004 GROUP: POLICY NUMBER: 1742197-2004 CERTIFICATE ID: 9 CERTIFICATE EXPIRES: 05 -01 -2005 05 -01- 2004/05 -01 -2005 CITY OF EL SEGUNDO CITY CLERK 350 MAIN ST EL SEGUNDO CA 90245 -3813 This is to certify that we have issued a valid Worker's Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance 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. �6� AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06 -09 -2004 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER OCCU -MED LTD /� 7050 N FRESNO ST STE 210 °� / FRESNO CA 93720 ��f� rRRC,NE] PRINTED: 06- 25-2004 SCIF 10262E Accept this certificate only if you see a faint watermark that reads "OFFICIAL STATE FUND DOCUMENT" PAGE 1 OF 1 ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID L 4 DATE(MM/DD/YYYY) 0CCU - -1 06/15/04 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION TYPE OF INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Marsh AdvAmer CBC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 9830 Colonnade Blvd #400 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. AUTHORIZED REPRESEN w GENERAL LIABILITY San Antonio TX 78230 Phone:888- 591 -1954 Fax:210- 737 -3584 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Landmark American Ins Co $ INSURER B: Occu -Med. Ltd. Mr. Jim Johnson INSURER C: INSURER D: MED EXP (Any one person) 7050 North Fresno St., #210 Fresno CA 93720 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. LTR NSR TYPE OF INSURANCE POLICY NUMBER EFFECTIVE DDS DATE DATMM /DD/YY LIMITS REPRESENTATIVES. - AUTHORIZED REPRESEN w GENERAL LIABILITY EACH OCCURRENCE $ PREMISES (Ea occurence) $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE F—] 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 ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AGG EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F—I CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY MUSTATIT —1 TORY LIMITS I ER — E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYEE $ OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER A Professional E &O LHR704267 06/06/04 06/06/05 LIMIT 11000,000 DED 5,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Re: 7050 N. Fresno St., Suite 210 - Contract No. 3264 CERTIFICATE HOLDER CANCELLATION CITYE - 2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of El Segundo DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3 0 DAYS WRITTEN Officer of the City Clerk NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Fax: 310-615-0529 350 Main Street IMPOSE NO OBLIGATION O (ABILITY OF ANY K D UPON THE INSURER, ITS AGENTS OR El Segundo CA 90245 -3895 REPRESENTATIVES. - AUTHORIZED REPRESEN w ACORD 25 (2001/08) v A © ACORD CORPORATION 1988 ��`'`