PROOF OF INSURANCE (2010) CLOSEDa
a
7 ® DATE (MM /DD /YYYY)
A� o CERTIFICATE OF LIABILITY INSURANCE 06/22/2009
PRODUCER THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
RJF Agencies, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
6000 Nathan Lane North, Suite 400 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Minneapolis, MN 55442
INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURERA Lexington Insurance Company 19437
Performers of the U.S. & Club Members INSURER B
PO Box 24 �NSURER C _
New Richmond, WI 54017 INSURER D:
Phone: 715 - 246 -8908 Fax: 715 - 2464257 INSURER E:
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LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
THE POLICIES OF INSURANCE
CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH
THIS CERTIFICATE MAY BE ISSUED OR
ANY REQUIREMENT, TERM OR
BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH
MAY PERTAIN, THE INSURANCE AFFORDED
POLICIES. AGGREGATE LIMITS SHOW MAY HAVE BEEN REDUCED BY PAID CLAIMS.
-- — _T-
POLICY EFFECTIVE POLICY EXPIRATION LIMITS
INSRIADD'L POLICY NUMBER
LTR INSR TYPE OF INSURANCE DATE MM /DDIYY DATE MM /DDIYY
GENERAL LIABILITY 04/25/2009 04/25/2010
008844163
EACH OCCURRENCE $ 3,000,000
DAMAG TofiE�
A x COMMERCIAL GENERAL LIABILITY
PREMISES Ea occurencel $ 100,000
1SMADE x OCCUR
MED EXP (Any one person) $ 5,000
I
X ! LX 9466 10/03
PERSONAL & ADV INJURY $ 3,000,000
-
- -
X� CG-2002 11/85
,
GENERAL AGGREGATE $ 4,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP /OP AGG $ 4,000,000
., ._ —,! PRO- - -'
X: POLICY JECT LOC
!, $
AUT OMOBILE LIABILITY !
-
COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO
ALL OWNED AUTOS !
BODILY INJURY $
(Per person)
SCHEDULED AUTOS
HIRED AUTOS
BODILY INJURY $
(Per accident)
NON -OWNED AUTOS !
- -__ - -.
PROPERTY DAMAGE $
_. - -. --
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
ANY AUTO
OTHER THAN EA ACC . $
AUTO ONLY: AGG $
EXCESS /UMBRELLA LIABILITY
EACH OCCURRENCE $
AGGREGATE $
OCCUR, CLAIMS MADE..
DEDUCTIBLE
$
RETENTION $
$
WC STATU- '. OTH-
WORKERS COMPENSATION AND
'i_ TORY LIMITS., ER.
EMPLOYERS' LIABILITY
E.L. EACH ACCIDENT $
ANY PROPRIETOR /PARTNER/EXECUTIVE
E.L. DISEASE - EA EMPLOYEE $
OFFICERIMEMBER EXCLUDED?
If yes, describe under
E.L. DISEASE - POLICY LIMIT $
SPECIAL PROVISIONS below
OTHER !
I
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Performer is an insured as a member of Performers of the U.S. (FORM CG2002 11/85):
Peter A. Ellison dba One World Rhythm
Additional Insured: The City of El Segundo, its officers, officials, employees, agents & certified volunteers
GtK I I1-16A 1 C nvLUMlc
ACORD 25
City of El Segundo Public
111 W. Mariposa Avenue
El Segundo, CA 90245
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL EADE7Nmi1II MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
EPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
created with
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IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statment 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)
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GEICO Phone Number: 1 -800- 841 -300o
gwcoxom
The coverage provided by this policy meets the requirements of Sections bed b & 16500.5
of the California Vehicle Code, minimum liability limits prescribed by law.
CALIFORNIA EVIDENCE OF LIABILITY INSURANCE
Effective Date Expiration Date
Policy Number 12 -16 -08 06 -16-09
4116- 96 -98 -35
Year /Make /Model /Vehicle Identification Number
96 FORD RANGER 1FTCR10U4TTA12814
Insure& PETER Art'F -HOMY ELLISUN
1810 N AVON ST
13URBANK CA 91505 -1505
GEICO INDEMNITY COMPANY
P.O. Box 509090
San Diego, CA 92150 -9090
NAIC #: 22055 USE THIS CARD TO REGISTER YOUR VEHICLE