Loading...
PROOF OF INSURANCE (2010) CLOSED310 -217 -1836 PETERSON HYDRAULICS, 12:36:30 p,m. 05 -07 -2009 ACORD CERTIFICATE of LIABILITY INSURANCE PRODUCER (888) 825 -4322 AGGREGATE LIMITS SHUVVN MAT TYPE or THIS CERTIFICATE 18 ISSUED AS A MATTER OF ONLY AND CONFERS NO RIGHTS UPON THE Bowermaster & Associates POLICY P.XPIRA -nON HOLDER. THIS CERTIFICATE DOES NOT AMEW NL ALTER THE COVERAGE AFFORDED BY THE PO P.O. Box 6026 sm 10805 Holder Street - Suite 350 Cypress, CA 90630 A INSURERS AFFORDING COVERAGE INSURED Peterson Hydraulics, Inc. DGLLA207374018 INSURERA: Liberty Surplus Insurance Corporation 13509 Raymond Ave. PREMISES a r, ee $ 50,00 INSURER B: RSUI Indemnity Company Carden, CA 90247 -2007 WSURERC: E: 2/3 HYD-09 Ht DATE (MWDDIYYW) 4/2012009 IFORMATION TIFICATE EXTEND OR LIES BELOW. NAIC # THE POLICIES OF INSURANCE LIS 1 tLI FstLUW ruivc Orr_[,* 10.7­ • • • •� ••- - -• • -- • - - -- - - - ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY PERTAIN. THE INSURANCE AFFORDED IBY THE_POLICIES DESCRIBED HEREIN IS SUBJECT TOALL THE TERMS, EXCLUSIONSAND CONDITIONS OF SUCH POUCIES. ININ WK AGGREGATE LIMITS SHUVVN MAT TYPE or r1r+Vt nccn r%;uva o. • .. POLICY NUMBER ••••� POLICY l"IcrIVE DATE IMW Y1 POLICY P.XPIRA -nON LIMITS 1,000,00 im sm EACH OCCURRENCE $ A X GENERAL UABILITY X COMMERCIALGENERALLIABILITY CLAIMS MADE OCCUR DGLLA207374018 412812009 4/2812010 PREMISES a r, ee $ 50,00 MED EXP (An one arson $ Excluded PERSONAL 8ADVINJURY $ 1,000,00 GENERALAGGREGATE Is 2,000,00 PRODUCTS- COMPIOPAGG $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: ' T POLICY PRO- LOC A UTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea auidenf) ANY AUTO ALLOWNEDAUTOS BODILYINJ RY $ SCHEDULED AUTOS HIRED AUTOS BODILYIN,IURY $ (Par accident) NON -OWNED AUTOS PROPERTY DAMAGE $ (Per aecid") AUTO ONLY- EAACCIDENT S GARAGE LIASLITY ANY AUTO OTHER THAN EA ACC S .� AUTO ONLY: AGG S EACH OCCURRENCE $ 4,000,00 B ERCESWUMBRELLA LIABILITY -3i] OCCUR ❑ CLAIMSMADE NHA221360 4/28/2009 4/28/2010 4,000100 AGGREGATE $ s $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WC 0TH - LI STATU- SL EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEES ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? Ityes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT S OTHER ------- I aoee,ei PrIeWIMNS DESCRIPTION OF UvhKAI 1vN*I awn, n+no..�...��• �- -- - - -- - -- '10 Day Notice of Cancellation for Non - Payment of Premium. te: City of El Segundo, 150 Illinois St., El Segundo, CA 90245.4311 "ity of El Segundo Is listed as Additional insured with respects to General Liability per form CG 20101185. City of El Segundo 150 Illinois St. 1 El Segundo, CA 90246- ACORD 25 (2001108) SHOULD ANY OF THE ABOVE OESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WIL001131 MMIMP& 3d DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 8 AUTHORIZED REPRESENTATIVE ® ACORD CORPORATION 1988 310 - 217 -1836 PETERSON HYDRAULICS, IMPORTANT 12;37:07 p,m. 05 -07 -2009 313 PETEHYD -01 HIJE 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. 25 (2001108) 310 - 217 -1836 PETERSON HYDRAULICS, POLICY NUMBER: DGL, -LA 207374018 .NAMED INSURED: Peterson Hydraluics, Inc. 01:53:43 p.m. 05 -11 -2009 414 COMMERCIAL GENERAL LIABILITY THis ENDORSf.MENT CHANGES THE-POLIGY, PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -- OWNERS; LESSEES OR CONTRACTORS (FORM B) This'eridorsement modlfles Insurance provided under the following:. COMMERCIAL OENERAL LIABILITY 'COVERACiE PART. SCHEDULE Name of Person'orOfganization: The City of El Segundo, its officials, employees and volunteers (Ir no entry appears above. the informatlon mquirsd'ta oomplets this endorsemenGwiil.beshown in (ha Declarations as applicable to this endorefaent.) WHO IS AN INSURED (Seiicn 11) Is amended to Include as.an.lnsured Ih&peison or organization shown In the Schedule but only with respect to IIsbAltyadsing out of'.yourwoW tof that lnsured by qr faryau,_ CG 20 10 1185 Copyright, Insurance SetVlces Office, Inc., 1984 fun rA4N CERTIFICATE OF INSURANCE INf u4ANt� SUCH INSURANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAMED BELOW WILL NOT BE CANCELED OR OTHERWISE TERMINATED WITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE CERTIFICATE HOLDER, THIS UCERTIFIIC CERTIFICATE INSURANCE DOES CERTIFICATE NOT CHANGE THE COVERAGE PROVED BIY THE DATE WRITTEN. ANY POLICY DESCRIBED BELOW. This certifies that: ® STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY oBo smington, Illinois ❑ STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, II ❑ STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas, Texas ❑ STATE FARM INDEMNITY COMPANY of Bloomington, Illinois, or ❑ STATE FARM GUARANTY INSURANCE COMPANY of Bloomington, Illinois has coverage in force for the following Named Insured as shown below: NAMED INSURED: PETERSON HYDRAULICS, INC. ADDRESS OF NAMED INSURED: 13509 RAYMOND AVENUE,GARDENA, CA 90247 POLICY NUMBER 0382016- AO3 -75C EFFECTIVE DATE OF POLICY 01/03/09- 01/03/10 DESCRIPTION OF VEHICLE (Including VIN) LIABILITY COVERAGE LIMITS OF LIABILITY a. Bodily Injury Each Person Each Accident b. Property Damage Each Accident c. Bodily Injury & Property Damage Single Limit Each Accident PHYSICAL DAMAGE COVERAGES a. Comprehensive b. Collision EMPLOYERS NON -OWNED CAR LIABILITY COVERAGE HIRED CAR LIABILITY 2007 CHEVRO�NO ® YES ❑ �[:] Y ES ❑ NO ��[] NO ❑ YES ❑ NO 2 MILLION ❑ YES $ ❑ NO Deductible ❑ YES $ ❑ NO Deductible ❑ YES $ ❑ NO Deductible ® YES ❑ NO $ 1000 Deductible ® YES $ 1000 ❑ NO Deductible ❑ YES $ ❑ NO Deductible ❑ YES $ ❑ NO Deductible ❑ YES $ ❑ NO Deductible ® YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ® YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO FLEET - COVERAGE FOR ALL OWNED AND LICENSED ®YES F-1 NO 4 AnTnD AJ.Gi -Or`I PQ Name and Address of Certificate H, CITY OF EL SEGUNDO 150 ILLINOIS STREET EL ASEGUNDO, CA 90245 -4311 ❑ YES ❑ NO AGENT ❑ YES ❑ NO 1129 ❑ YES ❑ NO 04/09/09 Title Agents coae Numutn DIder Name and Address of Agent WAYNE D BETTIS INSURANCE AGENCY INC 350 WEST 5TH STREET, SUITE 205 SAN PEDRO, CA 90731 PROJECT: CITY OF EL SEGUNDO,150 ILLINOIS STREET, EL SEGUNDO, CA 90245 -4311 FF AYNE D. BFM INS. AGENCY, IN ADDITIONAL INSURED: CITY OF EL SEGUNDO Lic.#OD60851 350 West 5th Street, Suite 205 San Pedro, CA 90731 INTERNAL STATE FARM USE ONLY: ❑ Request permanent Certificate of Insurar us: (310) 833 -5261 Fax: (310)&Q3-8470 122429.3 Rev. 07 -26 -2005 ® Request Certificate Holder to be added a. Date: 5/6/2009 Timer 2:41 PM Tor Bonita Atkins @ 9,13103233606 Pager 2 ACORD. CERTIFICATE of LIABILITY INSURANCE 5/06120094 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Allen Lawrence &Assoc., Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR License #0442083 7 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O. Box 7948 Canoga Park, CA 91309 -7948 INSURED Peterson Hydraulics, Inc 13509 Raymond Avenue Gardena, CA 90247 INSURERS AFFORDING COVERAGE INSURERA: Zenith Insurance Comp INSURER B: INSURER C: INSURER D: INSURER E: NAIC # 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. TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMJDDJYY POLICY EXPIRATION DATE MWDDIYY LIMITS LTR NSR EACH OCCURRENCE $ GENERAL LIABILITY DAMAGE TO RENTED $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE FJ OCCUR MED EXP An one person $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY jE o LOG AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO ALL OWNED AUTOS BODILY INJURY (Per person) $ SCHEDULED AUTOS HIREDAUTOS BODILY INJURY (Per accident) $ NON -OWNED AUTOS PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC AUTO ONLY: AGG $ $ EACH OCCURRENCE $ EXCESSNMBRELLA LIABILITY AGGREGATE $ OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Z068450903 07/01/08 07/01/09 WC STATU- OTH. X FR A E.L. EACH ACCIDENT $1,000,00 E.L. DISEASE - EA EMPLOYEE $1,000,000 ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? If yes, describe under E.L. DISEASE - POLICY LIMIT $1,000,000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS *Except 10 days notice of cancellation for non - payment of premium. Re: Operations of the named insured Project Name: City of El Segundo /150 Illinois Street, El Segundo, CA 902454311 -Aram! 1 ATICINI City of El Segundo Dept of Public Works 150 Illinois Street El Segundo, CA 90245 -3813 ACORD 25 (2001108) 1 of 2 #S127364/M102446 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL XVJ) N(IIRXIt MAIL *An DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 7GJIXICAIpIJfN��QfQfAtat1l9CK REPRESENTATIVE E I LEW O ACORD CORPORATION 1988 Pages 3 Dates 5/6/2009 Time: 2,41 PM To, Benita Atkins @ 9,13103233606 — 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 -S (2001108) 2 of 2 #S127364IM102446