PROOF OF INSURANCE (2004) CLOSEDACDRD, CERTIFICATE OF
—1—nR
LIABILITY INSURANCE
DarEIMMrnp3
ALANDALE INSURANCE AGENCY��_
-`
6/12/'1003
P 0 BOX 97
THIS CERTIFICATE IS� ISSUp q� g -q`
ONLY AND CONFI.RS
jyIgTTER pF
IN
GLENDORA
NO RIGHTS
HOLDER. THIS CERTIFICATE DOES
ALTER THE COVERAGE AFFORDED
UPON THE
NOT AMEND,
CERTIFICATE
EXTEND OR
CA 91740
- .• BY
THE POLICIES
BELOW.
(626) 335 -4008
_.___ -_.,
S:!R "rn
INSURERS AFFORDING COVERAGE
rbL 1, Dimensions DBA Denny Zane
INSURER A Scottsdale Insurance Co.
56 Manta Monica Blvd # 223
��� INSURrRB
INSURER C
anta Monica IA
INSIMU. -R 0
THE: POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 'O TUF. INSURED NAMED ABOVE FOR THE�POLICY PERIOD INDICATED INOTWI1TiSTANDIN(' �
ANY REQUIREMENT, TERM OR CONDITION Of ANY CONTRACT 01', OTHER DOCUMENT WIT "H RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN THE INSURANCE AFFORDED BY THE POI.ICIE:S DF "SCRIBED HEREIN IS SLJB,IECT TO ALL T1E: TERMS. EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES FlUGREGFlT[ LIMITS SHOWN MAY I1AVE BEEN REDUCED Bl' PAID CLAIMS
INSR TYPE OF INSURANCE
POLICY NUMBER POLICY EFFECTIVE: POLICY EXP'.RATION
C°NEPAL LIABILITY � `- -- "` `-� - —DATE lMM1pD1YY) on7c innnerilD YYj L lml,rs
X COMMERCIAL GENFRAI LIABILITY EACH OCCURRFW(F I :F 1 000 666
CLAIMS MADE X OCCUR I IRE DAMAGE'. (Arty (ne fire) $
: R
CPS0299298RC2 5/14/2003 5/14/2004 PEER (Any one I arson) >ON $ AL. & ADV INJt)RY �.. S
Fd!N'I AGGRE:GAIF I IMff APPI IE:S PER GFNE RAL AGGK GATE $ 2,QOO,Up�
-
_ POLICY PRO COMP /OP AGG PROUIJCTS - � 9;
AIJTOMOBILE L.IABII_I'iY ---- --
ANY AUTO
ALI. OWNED AUTOS
SCHEOLILED AUTOS
HIRED AUTO S
111 "N. OWNED ALIT OS
GARAGE LIABILITY
ANY ALIT O
COMHINFD SINGLE I.IMIT I
(Ea accident) $
BODILY INJURY
(Per person) �
BOLM -Y INJURY
(Per accident)
PROPERTY DAMAGE:
(Peraccidew)
AU 10 ONLY EA ACCIDE4NT�$
OTHF'R TT IAN EA ACC $
AUTO ONLY
nnr.;taa LIABILITY
EA(hl CCl1RRf NC[::
OCCUR CLAIMS MADE -
OAGGRF.F;ATE ,g
DFf1uC IT61.E $
RIIENTION $
W,
WORKERS COMPENSATION AND ----•---- W.��._._.,w...,.,.__.,_,.,,,
9�
EMPLOYERS' LIABILITY
IORYLIMIFS 1.. -.R
E I EACEI ACCIDENT y
I- .1_ DISEASE - FA F.MPI.OYi.f.1
,... .i,..._._.____.,_,__,,,,_,_. =-i ._._... ••.-- ---` -- E'. .L UISFASII_ - F'01 _ICY LIMIT
- _..._......._...__.-
D'c'SCRIF`Tr7N OF OPERATIONS /LOCATIONSIVEHICLESlEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL- PROVISIONS ---- - - - -• -•
r 'yrti +1. ' A.,,.E HOLDER ADDITIONAL INSURED; INSURER LETTER: -� CANCELLATION � �•Y�� - r- `°'°°"""` °"-°�
SHOULD ANY OF THE ABOVE DFSCRIBED POLICIES BE CANCELL ED BEFORE T'HE EXPIRATION
C``�r of El Segundo, "City, Its officers, DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL_ DAYS WRITTEN
O``'tCis 15, employees and volunteers" NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHAL L.
350 Main St, IMPOSE NO OBLIGATION OR LABILITY F ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVE
El Segundo, CA 90245 AUTHORIZEn 7hY10fNam(
_ _ ACORD 25 -S (7/97) 0 ACORD CORPORATION 1988
M: L PW v1 9.8 on F123lU3 - 13 69 by UserName !. P LL W v1.9 8 c n 61)1103 - I PFvI01
AC®RDM CERTIFICATE OF L
PRODUCER (562)493 -3521 m FAX�(562)684 -4167
Alandale Insurance Agency
11022 Winners Circle
Suite 100
;A ^ •�ri tos , CA 90720
E.ipnny Zane
D3A: Urban Dimensions
3% Santa Monica Blvd #223
Santa Monica, CA 90401
L I TY I N S U i2A N C E -DATE (MMIDDIYY) -
06/23/2003
Ti" ff5- CEiiT�Ff�AiE1ri7�IJE131C�1ClPfA 'rTEAZiF'- �N- .__.._.__......
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
INSLJREF2 A:
Markel Insurance
INSURER B
INSURER ( - - - --
INSURER U.
INSURER E
ANY REQUIREMENT, TERM OR CONDITION O
- n.vvr. v
v rvnvrcu r�ncwc r
rvr< I rtt. ruLI(,Y I
I- 'FHIOD INDICATED. NO`I-WITHSTANDING
MAY PERTAIN, THE INSURANCE AFFORDED B
BY THE POLICIES DESCRIBED HEREIN I
IS SUBJECT TO A
TO VA'HICH THIS C
CERTIFICATE MAY BE_ ISSUED OR
POLICIES. AGGREGATE LIMITS SHOWN M
MAY HAVE BEEN REDUCED BY PAID C
CLAIMS.
EXCLUSIONS AND CONDITIONS OF' SUCH
INSR _ _ ._.__..._.... ___. - -._.. _. __ .__
POLICY NUMBER
Y(ME! M
PDDATE (
M F
(M MPIDIRDA/TYYRI) N
LIMITS
ENERAL LIABILITY
' COMMERCIAL G
FACFIOCCURRENCE $
GENERAL L.MBILI'I'Y -
- -- - -
Mf D Ei .
i
(ENE RAL AUCRFGAIE $
i
P ftODL1CTS C OMF %OP ACG $
Y RO -
-- -
A`,17'OMOBILE LIABILITY
COMBINEi0 SINGLE LIMIT
ANY AUTO (
(Ea accident)
At OWNED AUTOS
SCHEDULED AUTOS (
BODILY INJURY $
HIREDAUlOS
-
BODILY INJURY
NON -OWNED ALIIOS (
(Per accident
FROI FRTY DAMAGE[ __.__...
(Per accident)
°. '.:ABILI7V A
AUTO ONLY - FA ACCIDENT- '
'$
- AN'YAUTO -
- -.. - ._..... _.0 _
_
At ONLY
EXCESS LIABILITY
rACH OCCURRENCF_ $
$
jl
OCCUR C' -
- ..
I
......... ....
_
ULOL1Cl "IBLE 9
RL11 NTION $ $
WORKERS COMPENSATION AND �Al% ` TA EU IITTfi' ' - "` -°
IORYI (FR
EMPLOYERS. LIABILITY _... LIMIIS
F.L. LACH ACCIDENT
........
FT_ DISEASE FA EiMf I OYEF $
___.
F I DISEASE POI CY I IMI I $
ar'�ER G814657 05/28/2003 05/28/2004 1,000,000
i�� °v�f�ssional liability
_.. -. -. _. _ __ _ _r__ ___--- .._.___�_ _._.. ... ._..__-__-_--_.____._..___. _:- ____..._.._. _
Or gPERATIONSlLOCAT 'IONSNEEIICLESlEXCl.t1S10N5 ADDE:b BY ENUORSEMEN'T' /SPECIAL PROVISIONS
2500 DEDUCTIBLE
•r r�r�i. •T�- � �r....e -.. v..^•_. ---- -- - - _.........._...._.._.. --..- ..._.ter..__._.
ADDITIONAL INSURED; INSURER LETTER:
City of El Segundo, "City, its
officers, officials, employees & volunteers"
350 Main St.
ud
Segundo,, CA 90245
GANGtLLA I IUN -
SHOULD ANY OF'THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE'!'HF.
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL.
_. _ ___ DAYS WRITTEN NO rICE TO THE CERTIFICATE HOLDER NAMEO TO THE LEFT,
BUT FAILURE I'D MAIL SUCK NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE COMPANY, I'FS AGENT'S OR REPRESENTATIVES.
AUTHGRIZEO REPRESENTATIVI?
Shannon Neuhart /S11ANNk'^
MEMORANDUM COPY** 061403-3AR-02'-1
AMENDED DECLARATION �
`�"°w=r m ^m, EFFECTIVE DATE 06/18/03 '
REASON FOR AMENDMENT - !
AP 344 01 A TIM[
,99-7o 05/09/03
|---' | MULTIPLE POLICY CHANGES
Please review this document carafullv,It confirms Your requested li v» c anm�s h
FOR CUSTOMER CARE CALL 1-800-443-3100 OR VISIT OUR WEB SITE AT 2lpv.C'
DM
** Known Drivers of Your Vehicles
** DENNIS �
** LOUISE MAINVTLLE
� |
QDRESS INQUIRIES T0-
21ST CENTURY INSURANCE Co
P.O. BOX 2020
WnPD!xND HILLS CA 91365 �
u/�cen*�muvm"veconro= 6301 nw"nmnvmoxvnnvo wvvuuo*n ills, ca|n^nmoo1oor
DENNIS T ZANE
|
** EVIDENCE OF INSURANCE
* *
LOUISE M4INVILLE
|
CITY OF EL SEGUNDd
2943 DELAWARE AVE
506 SANTA MONICA BLVD STE 223
SANTA MOWICA CA
90404
SANTA MONICA CA 90401
199a CIV'IC LX
JAII
5118375 027112 2? 14
18 GOOD PRIVFR HISC01041
2,003 1_OV
TOY PRIUS
076651 03912821318
GOOD DRIVER DISCOUNI
I)ID 11
1511
54
SION
TCE-78 01/99
Please review this document carafullv,It confirms Your requested li v» c anm�s h
FOR CUSTOMER CARE CALL 1-800-443-3100 OR VISIT OUR WEB SITE AT 2lpv.C'
DM
** Known Drivers of Your Vehicles
** DENNIS �
** LOUISE MAINVTLLE
� |
QDRESS INQUIRIES T0-
21ST CENTURY INSURANCE Co
P.O. BOX 2020
WnPD!xND HILLS CA 91365 �
u/�cen*�muvm"veconro= 6301 nw"nmnvmoxvnnvo wvvuuo*n ills, ca|n^nmoo1oor
Y - A L, A H UA L L - Cjl,J: NIJOH A;
CERTIFICA
—se 77)493 - 3 'S21
Alandale Insurance Agency
Circle
CA 90720
Lane
.'USA:: Urban DimemSinns
Santa Monica Blvd #223
'ionka. CA 90401
Ll
)694 41,67
J u
DAI 1: jMM10I)jyy)
L"1TY1NSUR----'-- E
06/os/2003
77HIS rERTtMATFT9J OF [ FORM
ONIV4N0 CONGs NO FUGHTS UPON TV`iF CERTIFICATE
HULUR, UHIS CERTIFICATE DOES NOT AMEND. 6XIEND OR
AL.'rFR TIDE COYLRAOL AFF6RDED BY THE POL ICIES BEL.OW.
. ... ... ..... - .
INSURFR8 Arropnitjr, COW RAGE=
JW°f ERE f? A r.'verest Ndtional Insurante o I
IN �i UR F'R B
I
N5(11d[ N 1);
1 W S, I I ILI P L
ANY RL'QUI REML-NT, TERM OR CoNr)l
Y I III`; W#0VMr-LJ
1:10- N -6f.- ANY '--(;()-N�J'T�?AG1 -R
NAMIJ.) ANOVE
FOR'T'HE 1-�OLIGY
OR Q 11-11 00CUMEN
IFREIN
T Vvi-rH RF'5t+C;'1
1,13
T`0 VVHI(],H
Tills (�v.Tz rivICATE MAY nF'Fjf) OR
POUCIES, AGGRFGAI F LIMF S 911OWN
MAY HAVE nFFN Rr.r)lj(,Fb rjy pAIU
(';LAIM3.
TO ALL. THF TF�pMfir
V Xf:','(, USIONF; ANT) GOW)ITIONS OF iUCEI
OF IN59.)RAW.J:
1`1 F $I X'y NI)MBER.
Ao(}1417.6/0[
j,(7LfcT ExFjf0,jj()N
UA TE (MMUNYyj
F)A TE (mmW IYY)
.... .... ...
V,' e I A I Tj (I I W
KRAV UARK I TY
y
F; .1 A -,I I I ()(J
I
11000,000
II IRIF. DAMAW. �Aliy Nir hr
O)F
001) oloo
ME 1) L'XVI (Any oar F"mA
mm, o(m
PF RSONAJ & h.DV INJUNY
PW)f)IJGT$ (,(`MPf)f1 A( I:j
t. I A 311, 1 TY
ANY ALI if)
A)MBINIE -DS114(il F; I IoA17
Al 1. 0II9191-t) Awrw,
JU FD AUTOS
Fi0f)(1Y INJURY
W-1) AUTOS
MA)Ity INJW y
W ILIIY
CP;Sq 1.1AIAlt ITY
CLAIW-, MAOi-,
nE()IJC I IBIJ�
\41 IQ"
,f!MPPN$ATION ANtt
14 1 :ASIL'ITY
W-AT—R -N71,X-11f]
V-SPI 7-0 DAYS FOR NON PAYMENT
-77
tN NNY ZANE
VVJ'A MONICA 01 VD #223
;aAN;A MONICA, CA 90404
SHOULD ANY Qf. THE AMOVIII, n�Kn --- . . .......... . . lft) POLICICS OC oH1 Tl F
F-XFJIRATION r)AFF THFIlmr, THE. IPAIJIN(L COMPANY WE I rNF)I:A%j,Iri
I0 MAL4
rmym, vmirTrm Hrmu Vn TfIr Cirwrim'ATT' w,il njn 4AIMStI fO `f HL` (.wtl,
B" FA141-01RIP TO "11 MUCH NOTICr nIIA[A IM!"W4 NO 011411 7A111 )r4 �n INAf4k.tr1,
()F ANY KIND UPON r1ir COMP /,NY, ITIS A('.PItj" OR RFPRF.'4PNTA'rIV)-..A
�RA 1,7r-
-hannon Neu �!!ANN (
ar�
_/ 6 I-A h � 1�
h _
Pw
AUTO ONIA IA A(,CIT)FN f
$
"PHUR WAN E'A AC'Cl
1;
AIJ I0 WAY
.. ...........
Ao(}1417.6/0[
.... .... ...
V,' e I A I Tj (I I W
y
F; .1 A -,I I I ()(J
I
11000,000
O)F
001) oloo
F t I)Of AFV POE if: y I Iml I
mm, o(m
SHOULD ANY Qf. THE AMOVIII, n�Kn --- . . .......... . . lft) POLICICS OC oH1 Tl F
F-XFJIRATION r)AFF THFIlmr, THE. IPAIJIN(L COMPANY WE I rNF)I:A%j,Iri
I0 MAL4
rmym, vmirTrm Hrmu Vn TfIr Cirwrim'ATT' w,il njn 4AIMStI fO `f HL` (.wtl,
B" FA141-01RIP TO "11 MUCH NOTICr nIIA[A IM!"W4 NO 011411 7A111 )r4 �n INAf4k.tr1,
()F ANY KIND UPON r1ir COMP /,NY, ITIS A('.PItj" OR RFPRF.'4PNTA'rIV)-..A
�RA 1,7r-
-hannon Neu �!!ANN (
ar�
_/ 6 I-A h � 1�
h _