PROOF OF INSURANCE (2005) CLOSEDCERTIFICATE OF LIABILITY INSURANCE oPlp s
DATE(MEP100IYY
A CORD
VltBAN -5
07/02/04
PIROOMM
P
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
A
X
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Marsh AdvAmer- Atlanta
06/14/04
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
9830 Colonnade Blvd #400
$110001000
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
San Antonio T3 78230
MED EXP Wry am person)
$10,000
PERSONAL 4 ADV INJURY
phonal BSS -591 -1954 FaxN210- 737 -3584
INSURERS AFFORDING COVERAGE
NAIL#
wrim
GEN'L AGGREGATE LIMIT APPLIES PER:
Fr
POLICY CT LOC
INSURERA: Hartford Fire Insurance Cc
19682
INSURER B:
urbI}a�yn p
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON- OWNEDAUTOS
INSURERC:
0 �1Sons
# 223
COMBINED SINGLE LIMIT
(Ea accident)
INSURER D:
BODILY INJURY
(Per person)
Santa itonicanCcca9Blvd.,
X
INSURER E:
t
COVERAGES
THE POLICES 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.
LTR
SM
TYPE OF INSURANCE
POLICY NUMBER
DA jyLA rD MC T rV6
P
LIMITS
A
X
GENERAL UABLITY
$ COMMERCIAL GENERAL LIABILITY
MAW MADE ® OCCUR
209BATF8972
06/14/04
06/14/05
EACH OCCURRENCE
$110001000
PREMtsESEaoccmence
$300,000
MED EXP Wry am person)
$10,000
PERSONAL 4 ADV INJURY
51,000,000
GENERAL AGGREGATE
t2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
Fr
POLICY CT LOC
PRODUCTS • COMPIOP AGO
s2,000,000
A
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON- OWNEDAUTOS
ZNCrJUDSD
COMBINED SINGLE LIMIT
(Ea accident)
$1,000,000
BODILY INJURY
(Per person)
$
X
BODILY INJURY
(Per accident)
t
$
PROPERTY DAMAGE
(Per accident)
$
GARAGE LWRI ITY
ANY AUTO
AUTO ONLY. EA ACCIDENT
$
OTHER THAN EA ACC
AUTO ONLY: AGO
S
$
EXCESSRAWRELIA LIA LRY
OCCUR CLAIMS MADE
DEDUCTIBLE
RETENTION $
EACH OCCURRENCE
$
AGGREGATE
$
$
$
$
WORKERS COMPENSATION AND
EMPLOYERS LIABLITY
ANY PROPRIETORIPARTNERIEXECUTIYE
OFFICERPAEMBER EXCLUDED?
N yak da 410M muter
SPECIAL PROVISIONS below
TORY LIMITS I I ER
E.L. EACH ACCIDENT
$
E.L. DISEASE • EA EMPLOYE9
$
E.L. DISEASE. POLICY LMNR
$
On=
DESCRIPTION OF OPERATIONS Y LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIC"
City of 21 Segundo - "City, its officers, officials, employees and
volunteersa are included as additional insured
$,%tiSGUN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED EEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING ENSURER WILL ENDEAVOR TO MAIL 60 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
City of 81 Segundo
350 Kain St.
al Segundo CA 90245
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPR
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, SaWa Monica Blvd #2.�J
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'�- Monica, CA 90401
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/CANCELLATION
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'�,'LE POLICY DECLARATION PAGE
� ,�n3v70 |,p"wV5/D9/D4 Ir" II/09/04
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� DENNIS T ZANE
` LOUISE MAINVILLE
/ 2943 DELAWARE AVE
SANTA MONICA CA 90404
** lNSURGDvS COPY **
RENEWAL DECLARATION OFFER
EFFECTIVE 05/09/04
IN THE EVENT PAYMENT IS NOT RECEIVED
By 'r"E RENEWAL EFFECTIVE DATE NOTED
ABOVE, YOUR POLICY BECOMES NULL ANT)
TO I D .
X* EVIDENCE OF INSURANCE **
CITY OF EL SEGVNDO
506 SANTA MONICA BLVD STE 223
SANTA MONICA C4 90401
wm"pn`""a/ Auto Policy, these ued"~o
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