PROOF OF INSURANCE (2011) CLOSEDyr w. on
CERTIFICATE OF LIABILITY INSURANCE
DAT08102111 "
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AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
THIS CERTIFICATE IS ISSUED
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
BELOW. THIS CERTIFICATE
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT; It the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. 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).
PRODUCER 805 -212 -4890
CONTACT
NAME:
FAX
PNONNe F.11-
',NA
United Agencies, Inc. (A) 805- 212.4891
CA License 80252636
1138 Lindero Canyon Rd.,Ste 302
Ao4RF _
Oak Park, CA 91377
rim Holland
PRODUCER $EACL�1
MTQM•I
WSURER )AFFORDING COVERAGE NAIC S
INSURED Sea Clear Pools, Inc.
INSURER A: Republic Insurance Group
ALL OWNED AUTOS
INSURER 6: Praetorian Insurance Company
23316 S Normandie Ave #B
INSURER C: United National Insurance Co.
PROPERTY DAMAGE
(Per accident)
Torrance, CA 90502
INSURER D : Underwriters at Lloyd's London
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
Ded $500
UMBRELLA UAa I X Or-CUR
EXCESS LIAR CLAIMS -MADE
AND03140
INSURER E: Nautilus Insurance Company
11/10/11
X
INSURER F:
f
X
COVERAGES "mIirmpmirz wimmocn. - - — - - - - - - - - -
THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE E POLICY NUMBER P DCDIYYYY POLICY IYYYY LSYIRS
LTR GENERAL LIABILITY OCCURRENCE E 1,000,00
C X COMMERCIAL GENERA_ L LIABILITY X L7217350 -A 11101N0 1111011111-0 pREMIS Ea occurcenee s 50'00
CLAIMS MADE X OCCUR MED EXP (Any one person S EXClude
PERSONAL 8 ADV INJURY S 1,000,00
GENERAL AGGREGATE
$ 2,000,00
nPRODUCTS
GEN'L AGGREGATE LIMIT APPLIES PER
X POLICY PRO LOC
• COMPIOP AGO
S 1,000,00
S
B
AUTOMOBILE
UABILI Y
ANY AUTO
PICCA0001877
10103/10
10/03111
COMBINED SINGLE LIMIT
(Es accident)
S 1,000,00
X
BODILY INJURY (Per person)
S
BODILY INJURY (Per accident)
S
ALL OWNED AUTOS
PROPERTY DAMAGE
(Per accident)
E
E
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
Ded $500
UMBRELLA UAa I X Or-CUR
EXCESS LIAR CLAIMS -MADE
AND03140
03/01111
11/10/11
X
f
X
EACH OCCURRENCE
E
$ 2,000,0
X
AGGREGATE
$ 2,000,
X
E
DEDUCTIBLE
RETENTION S
WORKERS COMPENSATION
X W TN
S
E.L. EACH ACCIDENT
$ 1,000,00
A
1)
AND EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE YD
OFFICERWEMBER EXCLUDED?
(Mandatory In NH)
II yes, describe under
DESCRIPTION OF OPERATIONS below
(Property
I
NIA ATW 000323.00
J BUE10307
07101111
1111011110
07/01112
1 11101/11
E.L. DISEASE - EA EMPLOYE
S 1,000,00
E.L. DISEASE - POLICY LIMIT
BPP
S 1,000,000
100,00
DESC IPTION OF OPERATIONS I LOCATIONS I VEHICgS (Attach ACORD 101, Additional Remarks 5 dule, it more speee Is required)
The City of EI Segundo is named as Additional Insured as required by wr ften
contract.
"30 days notice of cancellation except 10 days for non-payment of premium.
CERTIFICATE HOLULK
CITYELS
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City Segundo
E
Cit y Of E
ACCORDANCE WITH THE POLICY PROVISIONS.
M Street
El Segundo, CA 90245
AUTHORIZED REPRESENTATIVE
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ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: L7217350 -A
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Name of Person or Organl on:
City of E1 Segundo
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the
Schedule, but only with respect to liability arising out of "your work" for that insured by or for you.
CG 2010 1185 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 0