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PROOF OF INSURANCE (2010) CLOSEDDATE (MMIDDIYY)
AMM. CERTIFICATE OF LIABILITY INSURANCE
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Dealey, Renton & Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P. . 0 . Box 10550 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Santa Ana CA 92711 -0550
INSURERS AFFORDING COVERAGE
INSURED
RBF Consulting
P0 Box 57057
Irvine CA 92619 -7057
COVERAGES
E
OTWDING
ERT
ERMUSIONS
To
—
z S OF INSURANCE LISTED
ANY REQUIREMENT,
MAY BE ISSUED OR MAY
AND CONDITIONS
YPE OFINSURANCE
LIABILITY
ERCIAL GENERAL LIABILITY
LAIMS MADE © OCCUR
RACTUAL
BELOW HAVE BEEN ISSUED TO
TERM OR CONDITION OF ANY
PERTAIN, THE INSURANCE AFFORDED
OF SUCH POLICIES. AGGREGATE
POLICY NUMBER
6 3 0 5 0 0 D 4 0 9 2
THE INSURED NAMED
CONTRACT OR OTHER
BY THE
LIMITS SHOWN
POLICY EFFECTIVE
POLICY
11/30/2009
ABOVE FOR
DOCUMENT
POLICIES DESCRIBED
MAY HAVE BEEN
POLICY EXPIRATION
11 / 3 0/ 2 010
THE POLICY PERIOD INDICATED.
WITH RESPECT TO WHICH THIS
HEREIN IS SUBJECT TO ALL THE
REDUCED BY PAID CLAIMS-
LIMBS
EACH OCCURRENCE S 009 0 0
_
FIRE DAMAGE (Any one fire
$1,000,009
MED EXP An one non
$10,090
PERSONAL & ADV INJURY
O
GENERALAGGREGATE
$
AUTHORIZED REPRESENTA
PRODUCTS - COMP/OP AGG
S O O
D XCU
REGATE LIMIT APPLIES PER:
A
Y PRO LOC
AUTOMOBILE LIABILITY
81094968499
11/30/2009
11/30/2010
COMBINED SINGLE LIMIT
(Ea accident)
$1 r 000,000
X ANY AUTO
ALL OWNED AUTOS
BODILY INJURY
(Per person)
$
SCHEDULED AUTOS
HIRED AUTOS
BODILY INJURY
(Per accident)
$
NON -OWNED AUTOS
PROPERTY DAMAGE
(Per accident)
:
AUTO ONLY - EA ACCIDENT_
$
GARAGE
LIABILITY
ANY AUTO
OTHER THAN EA ACC
AUTO ONLY: AGG
$
$
C
EXCESS LIABILITY
X OCCUR CLAIMS MADE
SSE71722276
11/30/2009
11/30/2010
EACH OCCURRENCE
$10,000,000
AGGREGATE
$
Profe si nal
s
Li bi it i8
$
DEDUCTIBLE
RETENTION S
Ad
WC STA. OTH-
TORY LIMITS ER
S
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
E.L. EACH ACCIDENT
$
E.L. DISEASE • EA EMPLOYEE
S
E.L. DISEASE - POLICY LIMIT
$
B
OTHER
Professional Liability
PI099400
11/30/2009
11/30/2010
Per Claim $1,000,000
Annl Aggr. $2,000,000
DESCRIPTION OF OPERATION $nM"TIONSNEHICLEWEXCLUSIONS ADDED BY ENDORSEMENUSPECIAL PROWSIONS
General Liability policy excludes claims arising out of the performance of professional services.
Independent Contractors Included
Re: Hampton Inn & Suites Project; REIF JN 10- 106715 City of E1 Segundo, its officials and employees are additional
insured as respects to General and Auto Liability as required by written contract. Primary and Non - Contributing
overage applies to GL as required by written contract.
CERTIFICATE HOLDER ADDITIONAL INSURED' INSURER LETMK:
I .-
HOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER
City of E1 Segundo
KILL MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER
Planning & Building Department, Kimberly
1AMED To THE LEFT.
Christens
350 Main Street
E1 Segundo CA 90245
AUTHORIZED REPRESENTA
ra A non rnRPAR TION 1988
ACORD 25-S (7197)
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
BLANKET ADDITIONAL INSURED
(CONTRACTORS)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
1. WHO IS AN INSURED — (Section II) is amended
to Include any person or organization that you
agree in a "written contract requiring insurance"
to include as an additional insured on this Cover-
age Part, but:
a) Only with respect to liability for "bodily injury",
"property damage" or "personal injury"; and
b) If, and only to the extent that, the injury or
damage is caused by acts or omissions of
you or your subcontractor in the performance
of "your work" to which the "written contract
requiring insurance" applies. The person or
organization does not qualify as an additional
insured with respect to the independent acts
or omissions of such person or organization.
2. The insurance provided to the additional insured
by this endorsement is limited as follows:
a) In the event that the Limits of Insurance of
this Coverage Part shown in the Declarations
exceed the limits of liability required by the
"written contract requiring insurance ", the in-
surance provided to the additional insured
shall be limited to the limits of liability re-
quired by that "written contract requiring in-
surance". This endorsement shall not in-
crease the limits of insurance described in
Section III — Limits Of Insurance.
b) The insurance provided to the additional in-
sured does not apply to "bodily injury", "prop-
erty damage" or "personal injury" arising out
of the rendering of, or failure to render, any
professional architectural, engineering or sur-
veying services, including:
1. The preparing, approving, or failing to
prepare or approve, maps, shop draw-
ings, opinions, reports, surveys, field or-
ders or change orders, or the preparing,
approving, or failing to prepare or ap-
prove, drawings and specifications; and
it. Supervisory, inspection, architectural or
engineering activities.
c) The Insurance provided to the additional in-
sured does not apply to "bodily injury" or
"property damage" caused by "your work"
and included in the "products - completed op-
erations hazard" unless the "written contract
requiring insurance" specifically requires you
to provide such coverage for that additional
insured, and then the insurance provided to
the additional insured applies only to such
"bodily injury" or "property damage" that oc-
curs before the and of the period of time for
which the "written contract requiring insur-
ance" requires you to provide such coverage
or the and of the policy period, whichever is
earlier.
3. The insurance provided to the additional insured
by this endorsement is excess over any valid and
collectible "other insurance% whether primary,
excess, contingent or on any other basis, that is
available to the additional insured for a loss we
cover under this endorsement. However, if the
"written contract requiring insurance" specifically
requires that this insurance apply on a primary
basis or a primary and non - contributory basis,
this insurance is primary to "other insurance"
available to the additional insured which covers
that person or organization as a named insured
for such loss, and we will not share with that
"other other insurance . But the insurance provided to
the additional insured by this endorsement still is
excess over any valid and collectible "other in-
surance", whether primary, excess, contingent or
on any other basis, that is available to the addi-
tional insured when that person or organization is
an additional insured under such "other insur-
ance".
4. As a condition of coverage provided to the
additional insured by this endorsement:
a) The additional insured must give us written
notice as soon as practicable of an "occur-
rence" or an offense which may result in a
claim. To the extent possible, such notice
should include:
CG D2 46 08 05 ® 2005 The St. Paul Travelers Companies, Inc. Page 1 of 2
COMMERCIAL GENERAL LIABILITY
I. How, when and where the "occurrence"
or offense took place;
Il. The names and addresses of any injured
persons and witnesses; and
Ill. The nature and location of any injury or
damage arising out of the "occurrence" or
offense.
b) if a claim is made or "suit" is brought against
the additional insured, the additional insured
must:
1. immediately record the specifics of the
claim or "suit" and the date received; and
II. Notify us as soon as practicable.
The additional insured must see to it that we
receive written notice of the claim or "suit" as
soon as practicable.
c) The additional insured must immediately
send us copies of all legal papers received in
connection with the claim or "suit ", cooperate
with us in the investigation or settlement of
the claim or defense against the "suit ", and
otherwise comply with all policy conditions.
d) The additional insured must tender the de-
fense and indemnity of any claim or "suit" to
any provider of other insurance which would
cover the additional insured for a loss we
cover under this endorsement. However, this
condition does not affect whether the insur-
ance provided to the additional insured by
this endorsement is primary to "other insur-
ance" available to the additional insured
which covers that person or organization as a
named insured as described in paragraph 3.
above.
5. The following definition is added to SECTION V.
— DEFINITIONS:
"Written contract requiring insurance" means
that part of any written contract or agreement
under which you are required to include a
person or organization as an additional in-
sured on this Coverage Part, provided that
the "bodily injury" and "property damage" oc-
curs and the "personal injury" is caused by an
offense committed:
a. After the signing and execution of the
contract or agreement by you;
b. While that part of the contract or
agreement is in effect; and
c. Before the and of the policy period.
Page 2 of 2 0 2005 The St. Paul Travelers Companies, Inc. CG D2 46 08 05
POLICY #:8109496B499
COMMERCIAL AUTO
CA 20 48 02 99
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED INSURED
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
TRUCKERS COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions ofthe Coverage Form apply unless modi-
fied by this endorsement.
This endorsement identifies person(s) or organization(s)who are "insureds" under the Who Is An Insured Provi-
sion of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated
below.
Endorsement Effective: 11 / 19 / 2 0 0 9 Countersigned By:
Named Insured:
RBF consulting
SCHEDULE
Name of Person(s) or Organization(s): Any person or organization for whom you have agreed in
a written contract or agreement to provide insurance
but only for damages which are covered by this
insurance and which you have agreed to provide in such
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to the endorsement.)
Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent
that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section II
of the Coverage Form.
CA 20 46 02 99 Copyright, Insurance Services office, Inc., 1998
OP II
Acow). CERTIFICATE OF LIABILITY IiNSURANCEISS�ED Ts
PRODUCER ONLY AND CONFERS NO RIGH
HOLDER.
United Captive Ins. Brokers
AL ER TE THIS AFFORDS
17151 Neahope St., Ste 211
Fountain Valley CA 92705 INSURERS AFFORDING COVERAGE
Phone: 714- 708 -4370 Fax:714- 708 -2300 INSURER u,9. ridelity and GuasantY
INSURED
INSURER B:
INSURER C:
� NSURER D:
jrvine CA 92618 ay INSURER E:
THE
DATE (MMIDDIYYYY)
NAIC 0
25887
OVERAGES
ANY REQUIREMENTgTERM ORLCONDITION OF ANY CON TACT OR OTHER OCUMENT WITH RESPECTT O WN CM THIS CERDTIFICATE MAY BE SSUED ORDING
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 CLAIMSi - -__- � � umn,w� LIMITS
POLICY NUMBER
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE D OCCUR
GENL AGGREGATE LIMIT APPLIES PER:
POLICY n PJEC LOC
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED ALTOS
NON -OWNED AUTOS
GARAGE LIABILITY
�I
I ANY ALTO
EXCESSIUMBRELLA LIABILITY
7 OCCUR 1:1 CLAIMS MADE
DEDUCTIBLE
RETENTION $
JAAW ORKERS COMPENSATION AND
MPLOYERS' LIABILITY D123WO0187 FFICEPJMEMBERPF- XCLUDED9 ECUTIVE ws, describe under -- "
EACH OCCURRENCE $
PREMISES Me —Mcs S
MED EXP (Arty one person) S
PERSONAL & ADV INJURY S
GENERAL AGGREGATE $
PRODUCTS . COMPIOP AGG S
COMBINED SINGLE LIMIT $
(En accident)
BODILY INJURY S
(Per Person)
BODILY INJURY S
(Per accident)
PROPERTY DAMAGE S
(Per accident)
AUTO ONLY • EA ACCIDENT E
OTHER THAN EA ACC S
AUTO ONLY: AGG S
EACH OCCURRENCE S
AGGREGATE S
S
5
S
0.7/01/09 I 0.7/01/10 E. L. 51000
E.L. DISEASE - EA EMPLOYE $1000
E.L. DISEASE -
pOLICV LIMIT S 1000
)ESORIPTION OF OPERATIONS I LOCATIONS I VENlcL-es r u.
*10 days notice of cancellation for non - payment of premium. [X
Re: Hampton Inn S Suites Project; RBF JN 10- 106715
City of El Segundo
Planning t Building Department
Kimberly Christensen
350 Main Street
E1 Segundo CA 90245 -3813
SHOULD OULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATI01
DATE THEREOF, THE ISSUING INSURER WILL BRCERTMW MAIL *30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.