PROOF OF INSURANCE (2004) CLOSEDACM CERTIFICATE OF LIABILITY INSURANCPID T
DATE(MM/DD/YY)
G 1
09/04/03
PRODUCER
Smith - Newman & Adamson
Insurance Agency, Inc.
1800 E. Lambert Rd. Suite 215
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Brea CA 92821
A
Phone: 714- 257 -9644 Fax: 714- 257 -9833
INSURERS AFFORDING COVERAGE
INSURED
INSURER A: The St. Paul Companies
INSURER B:
Orange County Striping
Services, Inc.
183 N. Pixley St.
Orange CA 92968
INSURER C:
INSURER D:
INSURER E:
r�nvenen��
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
TYPE OF INSURANCE
POLICY NUMB ER
POL ICY EFFECTIVE
DATE MM/DD /YY
POLICY EXPIRATION
DATE MMIDD/Y
LIMITS
A
GENERAL
LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE FXI OCCUR
Contractual Liab.
KK06100143
06/01/03
06/01/04
EACH OCCURRENCE
$ 1000000
X
FIRE DAMAGE (Any one fire)
$ 100 000
MED EXP (Any one person)
$ 5000
X
PERSONAL & ADV INJURY
$ 1000000
X
BFPD
GENERAL AGGREGATE
$ 2000000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY X PRO-
JECT f I LOC
PRODUCTS - COMP/OPAGG
$ 2000000
A
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
KK06100143
06/01/03
06/01/04
COMaccident) B NGLE LIMIT (Ea
dent)
$ 1000000
X
BODILY INJURY
(Per person)
$
X
BODILY INJURY (Per (Per accident)
X
PROPERTY DAMAGE
(Per accident)
$
GARAGE LIABILITY
ANY AUTO
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
AUTO ONLY: AGG
$
$
EXCESS LIABILITY
OCCUR E� CLAIMS MADE
DEDUCTIBLE
RETENTION $
EACH OCCURRENCE
$
AGGREGATE
$
$
A
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
OTHER
WVK6100093
10 DAY N.O.C. FOR
NON - PAYMENT OF PRMaUN
06/01/03
06/01/04
PEL. TORY LIMITS ER
EA CH ACCIDENT
$ 1000000
E.L. DISEASE - EA EMPLOYE
$ 1000000
E.L. DISEASE - POLICY LIMIT $ x,000000
DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
Re: All Operations. The City of E1 Segundo, its officers, officials, &
employees and volunteers are named as additional insured per attached form
#40502.
CPRTIFICATF Wr%I n=0
CYELSEG
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City of El Segundo
Attn: Cindy Mortesen, CMC
DATE THEREOF, THE ISSUING INSURER WILL 1 OMEGOO MAIL *30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
350 Main Street
El Segundo CA 90245
AUTHORIZED REPRESENTATIVE
ACORD 2M 17/971
Tammara Fritschi y
ACORD CORPORATION 1988
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 26S
TheSt Paul
CONTRACTORS ADDITIONAL PROTECTED PERSONS ENDORSEMENT
This endorsement changes your Contractors Commercial General Liability Protection.
How Coverage is Changed
The following is added to the "Who is protected Under This Agreement" section. This change
broadens coverage.
Additional Protected Persons. The person or organization shown in the schedule below is an
additional protected person, but only with respect to their liability arising out of your ongoing
operation for that additional protected person.
The following is added to the "Other Insurance" section of your policy.
This agreement is excess over other valid and collectible insurance available to the additional
protected person, whether primary, excess, contingent or on any other basis.
However, we'll consider this agreement to be primary or primary and non - contributory insurance if
your contract with the additional protected person requires that this insurance be primary or
primary and non - contributory, or you request that it apply on a primary or primary and non-
contributory basis prior to a loss.
Schedule:
Name of person or organization: Any person or organization you are required in a written
contract to show as an additional protected person is an additional protected person.
Other terms
All other terms or your policy remain the same.
Name of Insured: Orange County Striping Policy Number: KK06100143
Effective Date: 06/01/03
Processing Date: 9/4/03
40502 Ed 1-80 Printed in U.S.A.