PROOF OF INSURANCE (2004) CLOSEDACC?RD„ CERTIFICATE OF LIABILITY INSURANCE oi/21/zoos
PRODUCEK (509)325 -3024 FAX (509)325 -1803 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATNNI
NOloney, O'Neill, COrkery i Tones, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
1206 N Lincoln, Suite #1200 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Spokane, WA 99201 INSURERS AFFORDING COVERAGE
Jan Fenton —__ _
INSURED SkybewM Sports Aca111e01Y Inc et al INSURERA: Lnicago Insurance a.olTpRany
P 0 Box 18529 INSURER B: Security Ins Co of Hartford
Spokane, WA 9922$ INSURER C:
INSURER D:
INSURER E:
THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NDTWIIH5TgrvDirvG
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. EIml FFECTIVE IAN POLCY UwS
TYPE OF INSURANCE POLICY NUMBER GAVE O
GENERAL LIABILITY L52021987 02/08 /2003 02/08/2004 EACH OCCURRENCE s 1,000, ON
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE 7X
A X Sports General
Liability
GM L AGGREGATE UMIT APPLIES PER:
FIRE DAMAGE (Any one fire) S
S 50,000
MED EXP (Anyone person I $
$ T eXCI ud
PERSONAL 6 AOV INJURY $
$ 1 000 00
GENERAL AGGREGATE S
S 2 , OOO
PRODUCTS - COI6IP/0P AGG I S
S 21000,000
POLICY n jPEA LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMB S
(Ea eccideo)
ANY AUTO
ALL OWNED AUTOS BODILY INJURY S
(Per person)
SCHEDULED AUTOS
HIRED AUTOS BODILY INJURY S
(Per accident)
NON -OWNED AUTOS
B
�GARAGE UASIL.ITY
}
1 ANY AUTO
EXCESS LIABILITY
OCCUR n CLAIMS MADE
DEDUCTIBLE
RETENTION S
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
Accident
�i ty o E l begundo s a��e�i Xas Sansadoi t o
the named insureds per form CG2026 (11/85)
PROPERTY DAMAGE S
(Per accident)
AUTO ONLY - EA ACCIDENT S
OTHER THAN EA ACC S
AUTO ONLY: AGG S
EACH OCCURRENCE S
AGGREGATE S
S
S
S
E I- EACH.ACCIOENT _ 1$
E.L. DISEASE - EA EMPLOYE S
E.L. OISEASE - POLICY LIMIT $
,
mum
$10,000 AD+D
$5,000 Dental Maximum $100 Ded
respects to operations
CERTIFICATE HOLDER ADDITIONAL INSURED; INSURER LETTER: CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DAIS THEREOF, THE ISSUING COMPANY WILL *)tK)OLIM MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
E1 Segundo, City of
Attn Rick Clark
I 401 Sheldon St
El Segundo, CA 90245 ALIT yoR�ED REPRESENTAT / g
1-d E69E -aac SNJRd Pug oaa opunUS 13 dSi• =E0 Co 92 qad
B
�GARAGE UASIL.ITY
}
1 ANY AUTO
EXCESS LIABILITY
OCCUR n CLAIMS MADE
DEDUCTIBLE
RETENTION S
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
Accident
�i ty o E l begundo s a��e�i Xas Sansadoi t o
the named insureds per form CG2026 (11/85)
PROPERTY DAMAGE S
(Per accident)
AUTO ONLY - EA ACCIDENT S
OTHER THAN EA ACC S
AUTO ONLY: AGG S
EACH OCCURRENCE S
AGGREGATE S
S
S
S
E I- EACH.ACCIOENT _ 1$
E.L. DISEASE - EA EMPLOYE S
E.L. OISEASE - POLICY LIMIT $
,
mum
$10,000 AD+D
$5,000 Dental Maximum $100 Ded
respects to operations
CERTIFICATE HOLDER ADDITIONAL INSURED; INSURER LETTER: CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DAIS THEREOF, THE ISSUING COMPANY WILL *)tK)OLIM MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
E1 Segundo, City of
Attn Rick Clark
I 401 Sheldon St
El Segundo, CA 90245 ALIT yoR�ED REPRESENTAT / g
1-d E69E -aac SNJRd Pug oaa opunUS 13 dSi• =E0 Co 92 qad
I
POLICY NUMBER:
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization: City of El Segundo
401 Sheldon St
El Segundo CA 90245
(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 as
an insured but only with respect to liability arising out of your operations or premises owned by or rented to you,
CG 20 26 11 85
Copyright, Insurance Services Office, Inc., 1984
2-d CBSC -22C sMJ%d Pue oaa opun2aS 13 d5b =Co Co 92 qa3