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PROOF OF INSURANCE (2011) CLOSED
AcoV CERTIFICATE OF LIABILITY INSURANCE 9 1 /MIDDIYYYY) l/2 2010 PRODUCER Phone: 530-661 -1300 Fax: 530- 661 -1303 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION InterWest Insurance Services ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR License #OB01094 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 222 Court Street Woodland CA 95695 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: scot tsdale Insurance Co. 1297 U.S. Healthworks, Inc. INSURER B: Travelers 25124 Springfield Ct. , Ste 200 INSURERC:St Paul Travelers (USHEA -1) INSURERD:Safety Nattional Casualty Cor 15105 Valencia CA 91355 INSURER E COVERAGES " ^'•"" �^ "' THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS NOTWITHSTANDING ANY REQUIREMENT, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON INSR DD' POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION TYPE OF INSURANCE DATE IMMI LIMITS A GENERAL LIABILITY BCS0022924 9/1/2010 9/1/2011 EACH OCCURRENCE $1,000,000 DAMA E T REN D X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 300,000 CLAIMS MADE k] OCCUR MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $1,000, 000 GENERAL AGGREGATE $ 3,000, 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $3,000,000 POLICY PRO X LOC EB 1 0 0 B AUTO MOBILE LIABILITY BA7470R699 9/1/2010 9/1/2011 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ (Per person) X SCHEDULED AUTOS X HIREDAUTOS BODILYINJURY $ (Per accident) X NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) AUTO ONLY - EA ACCIDENT $ GARAGE LIABILITY OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AGG C EXCESS I UMBRELLA LIABILITY QK0 91017 5 2 9/l/2010 9/l/2011 EACH OCCURRENCE $20 0 0 0 000 AGGREGATE $20,000 0 0 0 X OCCUR CLAIMS MADE DEDUCTIBLE WC STATU- 1 OTH- X v $ RETENTION $ WORKERS COMPENSATION LDC4 04 2 7 21 9/ 1/ 2 010 9/ 1/ 2 011 E.L. EACH ACCIDENT $11000,000 D AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER /EXECUTIVE E.L. DISEASE - EA EMPLOYEE $ 1,000,000 OFFICER /MEMBER EXCLUDED? (Mandatory In NH) 11 yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 1,00 .000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS *10 days notice applies if cancelled for non - payment of premium. DITIONAL INSURED IN FAVOR OF CITY OF EL SEGUNDO, ITS OFFICIALS, AND EMPLOYEES (ON ALL POLICIES EXCEPT WORKERS' OMPENSATION/EL AND MEDICAL PROFESSIONAL LIABILITY) WHERE AND TO THE EXTENT REQUIRED BY WRITTEN CONTRACT. CERTIFIGATt MULUtK " ^'•"" �^ "' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL *30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO CITY OF EL SEGUNDO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON 350 MAIN STREET THE INSURER, ITS AGENTS OR REPRESENTATIVES. EL SEGUNDO CA 90245 -3813 J ( AUTHORIZED REPRESENTATIVE .....� ^^nOf10 AT1/16l All r nhfa raaar arl ACORD Z5(Z009 /01) •' • ° ° °- ___..- -•- - - -• -- -- -- - .. The ACORD name and logo are registered marks of ACORD 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 This Certificate of Insurance 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 (2009/01) POLICY NUMBER:13CS0022924 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operations CITY OF EL SEGUNDO *10 days notice applies if cancelled for 350 MAIN STREET non - payment of premium. EL SEGUNDO CA 90245 -3 ADDITIONAL INSURED IN FAVOR OF CITY OF EL SEGUNDO, ITS OFFICIALS, AND EMPLOYEES (ON ALL POLICIES EXCEPT WORKERS' COMPENSATION /EL AND MEDICAL PROFESSIONAL LIABILITY) WHERE AND TO THE EXTENT REQUIRED BY WRITTEN CONTRACT. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sched- ule of this endorsement performed for that additional insured and included in the "products- completed operations hazard ". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1