PROOF OF INSURANCE (2011) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE(MMAOMM
PRODUCER 1 -303- 534 -4567 03/03/2011
XNA of Colorado, Inc. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
1550 17th Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
suite 600 ALTER THE COVERAGE AFFORDED
Denver, CO 80207 BY THE POLICIES BELOW.
INSURED-
INSURERS AFFORDING COVERAGE
Tu!! Shad, Inc. INSURER A:Twfn city Fire Insurance Co. (Hartford Ins. Co)
1777 S. Harrison St. #600 INSURERS; Hartford Casualty insurance Company
INSURER C: Sentinel insurance C an (Hartford Insurance Co}
Denver, CO 80210
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.
w
GENERALLIABRM 34UMN06192 07/01/10 07/01/11
X COMMERCIAL GENERAL LIABILITY EACH OCCUI
FIRE DAMAGI
CLAIMS MADE X !: OCCUR MEO EXP
PERSONALS
GEN'L AGGREGATE LIMIT APPLIES PER; I GENERAL AO
A AUTOMO BILE LIABILITY 3402NNJ8730
07/01/10 07/01/11
X ANY AUTO
COMBINED SINGLE LIMIT
ALL OWNED AUTOS
(En accident)
SCHEDULED AUTOS
BODILY INJURY
X HIRED AUTOS
IPer p"on)
X NON -OWNED AUTOS
BODILY INJURY
X $500 Cone. Dad
(Per sxideng
X $500 Coll. Ded
PROPERTY DAMAGE
GARAGE LIABILITY
(Per accident)
ANY AUTO
AUTO ONLY - EA ACCIDEN
OTHER THAN EA A(
B EXCESSLIABIUTY 34RaUP06515
AUTO ONLY:
07/01/10 OT /01 /li
X OCCUR CLAIMS MADE
EACH OCCURRENCE
d DEDUCTIBLE
X RETENTION $20,000
C WORKERS COMPENSATION AND 34WXT01027 07/01/10 07/01/11
EMPLOYERS' LIABILITY
. EA
OTHER
= 1,000,000
$300,000
S 10, 000
s 1,000,000
:2,000,000
s2,000,000
S 11000,000
i
i
S
S
i
i
13,000,000
13,000,000
1,000,000
1,000,000
1,000,000
s
s
DESCRIPTION OF OPEMTIONWLOCATtON3NMICLESIEXCLUSI ON3 ADDED BY ENDORSEMENTISPECIAL PROVISIONS 5
City of El Segundo is included as Additional Insured on the General Liability Policy
agreement and with resrequired by written contract or
p �ct to work performed by Insured subject to the poli if Policy terns and requ conditions.
--- ....... ,....,..... avnan psi 1RR: GAIVGELLATION e10 Days for non - payment of remium
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City Of El SeguR DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAUL . _ 330• DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 80 SHALL
350 slain Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
El Segundo, CA 90245 REPRESENTATIVES.
USA AUTHORIZED REPRESENTATIVE
ACORD 25-S (7/97) jweir85
20028293 0ACORD CORPORATInM Iona
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 after the coverage afforded by the policies listed thereon.
25 -S
TUFF SHED, INC.
POLICY NUN14fft- 34UUN,NO6 192 COMMERCIAL GENERAL UABIUly
CO2010 07 04
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY,
ADDITIONAL INSURED - OWNERSt LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
Thy endorsement MOM" provided under the following:
COMWRCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Now Or AddMonei Inigmd r
Or 01juntratlsrr(s):
CITY OF EL BEGUND0
WQ .Mafti: Street:
El Segundo, CA 90245 -0989
Locatlon(s) Of Covered Operations
AS APPLICABLE
Inimrrrratlon raqufred b complete this Schedule, d not shown above, will be shown Intl* Declarations.
A. 9801110n E — Who Is An Insured Is amended to
lndudt ors an NU MOrW Insured the peraon(s) or
0lum] SM '(8) dmn In the Sohedula. but only
Will) respect to lisbNily for 'bo* injury", 'properly
dameSe' or "pereonad and advertldnrg tnjtW
carved, In whole or In part, by:
1. Your ids or Wnbelone; or
2. The ads or omissions of those acitng on your
bah*
In the performanoe of your ongoing Operatlons for
the additiona[ Insuned(s) at the locatlon(s)
designated above.
IL VVIOt reaped to the Irstxance afforded to these
additional Insureds, tta folloi ft addftlonal
exclusions uppfy;
This Insurance does not apply 10 'bodily Injury",or
OPMPWIY damage• occurring after,
1. All work, Including mstyerials, parts or
equipment furnlehed in connection with ouch
work, on the project (other then servios,
n1aftnsnoe or repairs) to be parformed by or
on behaff of the additional iwir+ed(s) at fire
Iocetlon of the 001Y ed operations has been
oompleted; or
2. 'Flat portion of 'your tnrork' out of whloh the
In tq or damage arises has been put to Its
Intended use by any person or organization
other than another contractor or subcontractor
entigaged In perfoming operations for a
PrincOW as a part of the same project.
00 20100704 0180 Properties, Eno., 2004 Page 1 of i