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PROOF OF INSURANCE (2009) CLOSED3964. A CORD . CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD/YYYY) 7/1072009 PRODUCER (909) 592 -2215 FAX: (909) 305 -0391 Southern California Insurance Brokerage, Inc. P.O. Box 758 License #OC91978 Glendora CA 91740 -0758 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 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 NAIC # INSURED Vido Samarzich, Inc. 4972 Crestview Place Alta Loma CA 91701 INSURER A: Navigators Specialty 350 MAIN ST. INSURER B: Endurance Reinsurance 11551 INSURERc:Nat. Union Fire Ins. INSURER D: INSURER E: COVERAGES 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. IN SR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD/YY POLICY EXPIRATION DATE MM /DD/YY LIMITS A X GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE FR OCCUR SF06CGLOO6480 -02 12/23/2008 12/23/2009 -EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 MED EXP (Any one person) $ 5, 000 PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEML AGGREGATE LIMIT APPLIES PER: 7X POLICY 7 PRO L C $ 2,000,000 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ GE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN AUTO ONLY: AGG EXCESS/UMBRELLA LIABILITY 7X OCCUR FICLAIMSMADE DEDUCTIBLE RETENTION BE038424859 07/23/2009 12/23/2009 1,000,000 AGGREGATE $ 1,000,000 S $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER /MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below WEN0012680 -03 1/1/2009 1/1/2010 X WC STATU- OTH- E. L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 OTHER DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS CERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED PER THE ATTACHED FORM. JOB REF: FABRICATION AND INSTALLATION OF LIGHTPOLE BANNERS. PROJECT #PW09 -05. REVISED TO ADD UMBRELLA POLICY ON 7/24/09. REVISED TO ADD PROJECT 7/27/09. CERTIFICATE HnLDFR /`Ahlr M1 1 ATInu /�IiVRU LU 14VU -1 1U01 INS026 (010e).08a © ACORD CORPORATION 1988 Page 1 of 2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE CITY OF EL SEGUNDO EXPIRATION ' DATE THEREOF, THE ISSUING INSURER WILL M&YASIVOW MAIL PUBLIC WORKS 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, XX 350 MAIN ST. EL SEGUNDO, CA 9024 AUTHORIZED REPRESENTATIVE - Diana Kubo, CISR /JNP /�IiVRU LU 14VU -1 1U01 INS026 (010e).08a © ACORD CORPORATION 1988 Page 1 of 2 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 alter the coverage afforded by the policies listed thereon. I1vV1 \✓ - JLVV 1 1VV) INS025 (0108 ).08a Page 2 or 2 COMMENTS /REMARKS *10 DAY NOTICE OF CANCELLATION SHALL APPLY FOR NON PAYMENT OF PREMIUM OR NON SUBMISSION OF PAYROLL REPORT* OFREMARK COPYRIGHT 2000, AMS SERVICES INC. ' From: unknown Page: 5/6 Date: 7/9/2009 2:21:27 PM 9 6.4 • • GENERAL LIABILITY ADDITIONAL INSURED ENDORSEMENT CITY OF EL SEGUNDO In consideration of the premium charged and notwithstanding any inconsistent statement In the policy to which thi6 endorsement is attached or any endorsement now or hereafter attached thereto, It Is agreed as follows: 1. ADDITIONAL INSURED, The City of El Segundo, Its officers, agents and employees are included as additional Insured with regard to liability and defense of suits arising from "your work" performed by or on behalf of the named insured regardless of whether liability is attributable to the named insured or a combination of the named and the additional Insured. 2. CONTRIBUTION NOT REQUIRED. Any other insurance maintained by the City of Ell Segundo is excess of this Insurance and will not contribute with It. 3. SEVERABILITY OF INTEREST. This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the company's limits of liability. The inclusion of any person or organization as an Insured does not affect any right which such person or organization would have as a claimant if not so included. 4. CANCELLATION NOTICE. With respect to the interests of the City of El Segundo, this Insurance may not be canceled, reduced In coverage or limits or non- renewed, except after thirty (30) days prior written notice by REGISTERED ON 2ERTIFIED MAIL has been given to the Public Works Director of El Segundo, addressed as follows: Public Works Department, FI Segundo City Hall, 350 Main Street, El Segundo, CA 90245 S. APPLICABILITY. The Insurance pertains to the operations and/or tenancy of the named insured under all written agreements In force with the City of El Segundo unless checked here ( ) In which case only the following specific agreements with the City of El Segundo are covered: 6. MAILING ADDRESS: Completed endorsements shall be Issued to the City of €I Segundo as follows: PUBLIC WORKS DEPARTMENT El Segundo City Hall 350 Main Street El Segundo, CA 90245 7. CLAIMS: Underwriter's representative for claims pursuant to this Insurance: Except as stated above, nothing herein shall be hold to walve, after or extend any of the limits, conditions, agreements, or exclusions of the policy to which this endorsement is attached. I Gary ql Lrnanns (prinl/type name), warrant that I have authority to bind the below - listed insurance company and by my signature hereon o d this company to this endorsement. 6. Signature, Authadzed Pr tative (original nature required on copy furnish to the City Attorney) s. ORGANIZATION:_ Southern Cam Ins. Brokerage, Inc. ADDRESS: P.O. BOX 758 Glendora, CA 91740 N TELEPHONE: ( 909) 592-2215 (erne code) (telephone number) Page 1 of 2 rew•- w•ruwwaweer�ae i era 04.3&0) This fax was received by GFI FAXmaker fax server. For more information, visit: http: /twww.gfi.com . From: unknown Page: 6/6 Date: 7/9/2009 2:21:27 PM-- --- 3964--- GENERAL UARLRY ADDITIONAL INSURED ENDORSEMENT CITY OF EL ftwnioO (CONTINtlED) 10. hrJudes (dwell as gWIMbb): 011 Md Form LbUft Endom.nwrrt Werosd from Properly Dwn.as and Opemllons >`arpbskrn Masud COIF�dUnd�rrpround Hmrd rodiME.WCOM~ OpNaf)on. O WderoraN LhbWy () Gangs k4wees Legal Llrre w 13 e,0 � M.dical blslpractiw (�> OM Aubnwb�Ms 1) Nm4WM Mtonwbll.s () Mind AaMniabil.. () Fire Legal LMbmky l) l) 11. Typ. Coverage: General Liability 12. L4oll.erNab%r $2, 000, 000 13. PQ ky Period: F n - _ - _ n 8 To: 12- 2 3 - 0 9 14. X DaducWW () SeW4murad RekTom (Wwc* whkh) oft ? r S n n applies b o:owraga. () Per Cldm )per OOeraw" 1s. 011m PoWakaw: N / A 1s• N.rn.sln.raedWWAWme: Vido Samarzich, Inc. 4972 Crestview Pl. 17. bwumrr*00ffpadyc Navigator's Specialty Alta Loma, CA 91701 1s. P"wNw"ber: SP06CGL006480 -02 is. En40rasnrarlt Number. 20. eve Daly of Endoreft" ►t; Page 2 of 2 NVORIAKWTiCE.ma MpjljVM Wp This fax was received by GFI FAXmaker fax server. For more information, visit: http: //www.gfi.com 3964. Ac R ® CERTIFICATE OF LIABILITY INSURANCE GUVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING 7ATE (MM /D2009) — 7/22/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS MATTER OF INFORMATION RICHARD H. VOSSMEYER, AGENT, LIC. #0532861 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 3517 N. VERDUGO ROAD, GLENDALE, CA 91208 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR PHONE (818) 248 -8773 FAX (818) 248 -8332 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. LTR 1 INSURERS AFFORDING COVERAGE NAIC # INSURED VIDO SAMARZICH, INC. INSURERA:State Farm Mutual Auto Insurance Company 25178 25178 , INSURER B: 4972 CRESTVIEW PLACE INSURER C: RANCHO CUCAMONGA, CA 91701 -1260 INSURER D: $ Ei PREMISES Ea occurrence INSURER E: GUVERAGES 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, INSR ADDT EL SEGUNDO, CA 90245-0989 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE MM /DD/YY DATE MM /DD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ Ei PREMISES Ea occurrence $ COMMERCIAL GENERAL LIABILITY MED EXP (Any one person) $ CLAIMS MADE F OCCUR PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GENL AGGREGATE LMITAPPLIES PER PRO- PRODUCTS - COMP /OP AGG $ POLICYFI JECT LOC A X AUTOMOBILE LIABILITY ANY AUTO 269 2224— FOl -75 049 2620— F27 -75 06/01/2009 06/01/2010 COMBINED SINGLE LIMIT (Ea accident) $ 2,000,000 BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS X X BODILY INJURY (Per accident) $ A A X X HIRED AUTOS NON -OWNED AUTOS X PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY — EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR FI CLAIMS MADE DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND WC STATU- OTH- EMPLOYERS' LIABILITY TORY LIMITS ER E.L. EACH ACCIDENT $ ANY PROPRIETOR /PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS THE CITY OF EL SEGUNDO IS NAMED AS ADDITIONAL INSURED ** *FABRICATION AND INSTALLATION OF LIGHT POLE BANNERS PROJECT * ** PW 09 -05 ^­­ A- %/CR 1 1 G null-uCR / x CANCELLATION CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION ATTN: CITY CLERK DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN 350 MAIN STREET NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL EL SEGUNDO, CA 90245-0989 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REP, S NTATIVES. A EPRE E e re s ?,-44 ­A LW RICHARD VOSSMEYER to ra Ion no Ices In Ica a Ownership o e r s y elr respec Ive ow Hers c 132849 03 -13 -2007 All rights reserved State Farm® GK Providing Insurance and Financial Services Home Office, Bloomington, Illinois 61710 July 22, 2009 City of El Segundo Attn: City Clerk 350 Main Street El Segundo CA 90245 -0989 Re: Certificate of Automobile Liability Insurance for Vido Samarzich, Inc. To Whom It May Concern: Richard H. Vossmeyer Agent, Lic. No. 0532861 3517 N. Verdugo Road Glendale CA 91208 818 248 8773 Fax 818 248 8332 3964. We have reviewed your requirements for a Certificate of Automobile Liability Insurance, and unfortunately, we cannot modify the cancellation clause by crossing out any words nor can we include the wording "10 Day Notice of Cancellation." Our Certificates of Insurance are worded by State Farm's Corporate Attorneys, and by making changes to the document, we alter State Farm's contract. With that being said, our office does not have the authority to make any changes whatsoever to the contract that has been set in place by State Farm and their attorneys. We wish we could make your requested changes, but unfortunately, it's out of our hands. If you would like to discuss this with State Farm, please call our corporate office in Bloomington, IL. Kindest regards, Y41 Heather Banul for Richard H. Vossmeyer Best's Rating Center - Search Results Page 1 suer Credit Securities Advanced Search Other Web Centers: Select One Page 1 of 1 Search Results page 1 of 1 Results Per Page 20 1 Financial Strength or Issuer Credit Rated companies found, results sorted by Company Name Criteria Used: Company Name: Company names starting with navigators specialty To refine your search, please use our Advanced Search or view our Online-Help for more information. Note: If you don't see the company you are looking for, _expand you.u..r search to include non -rated companies. New Search navigators specialty View results starting with: A B C D E F G H I J K L M N O P g R S T U V W X Y Z Reset list Company Information Financial Strength Ratings Issuer Credit Ratings Outlook / Outlook/ AMB# Company Name Rating Implication Long -Term . Implication Short-Term Domicile 10761 Navigators Scecial Insurance A Stable a+ Stable US: New York Company Insurance - Property/ Casualty (Operating Company) Note., Financial Strength Ratings as of 0712812009 11:22 AM E.S.T. Financial Strength Ratings (FSR) are sometimes assigned to Property /Casualty - A.M. Best Consolidated Groups. Please note that Life /Health - A.M. Best Consolidated Groups and Company Consolidated Financial Statements are not assigned FSR ratings. * Denotes Under Review Best's Ratings Visit Best's Rating Center for a complete overview of our rating process and methodologies. Important Notice: Best's Ratings reflect our independent opinion, based on a comprehensive quantitative and qualitative evaluation of a company's balance sheet strength, operating performance and business profile. These ratings are neither a warranty of a company's financial strength nor its ability to meet its financial obligations, including those to policyholders. View our entire notice . for complete details. Customer_ Service_ I Product.Support I Member _Center I Contact Info I Careers About A.M. _ Best I Site Map I Privacy Policy Security I Terms of Use I Legal &_Licensing Copyright ® 2009 A.M. Best Company, Inc. All rights reserved. A.M. Best Worldwide Headquarters, Ambest Road, Oldwick, New Jersey, 08858, U.S.A. http: / /www3.ambest. con /ratings/RatingsSearch.asp ?SR =1 7/28/2009 Best's Rating Center - Search Results Page 1 Suer Credit Securities Advanced Search Other Web Centers: Select One Page 1 of 1 6 9 6 4 . at ,aid Search Results Page 1 of 1 Results Per Page 20 2 Financial Strength or Issuer Credit Rated companies found, results sorted by Company Name Criteria Used: Company Name: Company names starting with endurance reinsurance To refine your search, please use our Advanced Search or view our Online_He for more information. Note: If you don't see the company you are looking for, expand _your _search to include non -rated companies. New Search endurance reinsurance View results starting with: A B C D E F G H I J K L M N O P O R S T U V W X Y Z Reeet ust Company Information Financial Strength Ratings Issuer Credit Ratings Outlook / Outlook/ AMB# - Company Name Rating Implication Long -Term - Implication Short-Term Domicile 12559 Endurance Reinsurance Co__ rpof A Stable a Stable US: Delaware America Insurance - Property/ Casualty (Operating Company) 66516 Endurance Reinsurance Coro p - -- Stable a Stable CA: Ontario America CAB Insurance - Property/ Casualty (Operating Company) Note: Financial Strength Ratings as of 0712812009 11:22 AM E.S.T. Financial Strength Ratings (FSR) are sometimes assigned to Property /Casualty - A.M. Best Consolidated Groups. Please note that Life /Health - A.M. Best Consolidated Groups and Company Consolidated Financial Statements are not assigned FSR ratings. " Denotes Under Review Best's Ratings Visit Best's Rating Center for a complete overview of our rating process and methodologies. Important Notice: Best's Ratings reflect our independent opinion, based on a comprehensive quantitative and qualitative evaluation of a company's balance sheet strength, operating performance and business profile. These ratings are neither a warranty of a company's financial strength nor its ability to meet its financial obligations, including those to policyholders. View our entire_notice for complete details. Customer Service I Product Support I Member Center I Contact Into I Careers About A.M. Best I Site MaR I PrivacYP olicv I Security I Terms of Use I Legal &Licensing Copyright ® 2009 A.M. Best Company, Inc. All rights reserved. A.M. Best Worldwide Headquarters, Ambest Road, Oldwick, New Jersey, 08858, U.S.A. http: / /www3. ambest .com /ratings/RatingsSearch .asp ?SR =1 7/28/2009 Best's Rating Center - Search Results Page 1 B !sts Latin', Center over Credit Securities Advanced Search Other Web Centers: Select One onomw Imp Page 1 of 1 3964.,III Search Results page 1 of 1 Results Per Page 20 2 Financial Strength or Issuer Credit Rated companies found, results sorted by Company Name Criteria Used: Company Name: Company names starting with national union fire insurance To refine your search, please use our Advanced_ Search or view our Online Help for more information. Note: If you don't see the company you are looking for, expandyouu_r._searc_h to include non -rated companies. New Searoh national union fire insurance View results starting with: A B C D E F G H I J K L M N O P 9 R S _T U V W X Y Z_ Reset List Company Information Financial Strength Ratings Issuer Credit Ratings AMB# Com an Name Outlook / Outlook/ P y Rating Implication '- Long -Term Implication Short-Term '- Domicile 10725 National Union Fire Insurance Co of A Negative a Negative LA 9 US: Louisiana Insurance - Property/ Casualty (Operating Company) 02351 National Union Fire Ins Cc Pittsburgh A Negative a Negative PA US: Pennsylvania Insurance - Property/ Casualty (Operating Company) Note: Financial Strength Ratings as of 0712812009 11:22 AM E. S. T. Financial Strength Ratings (FSR) are sometimes assigned to Property /Casualty - A.M. Best Consolidated Groups. Please note that Life /Health - A.M. Best Consolidated Groups and Company Consolidated Financial Statements are not assigned FSR ratings. * Denotes Under Review Bests Ratinos Visit Best's Rating Center for a complete overview of our rating process and methodologies. Important Notice: Best's Ratings reflect our independent opinion, based on a comprehensive quantitative and qualitative evaluation of a company's balance sheet strength, operating performance and business profile. These ratings are neither a warranty of a company's financial strength nor its ability to meet its financial obligations, including those to policyholders. View our entire _notice for complete details. Customer Service I Product Support I Member Center Contact Info I Careers About A.M. Best I Site Map Privacy Policy! I Security I Terms of Use I Legal &Licensing A.M. Best Worldwide l ide Headquarters, s, Ambest Road, Oldw ck, New Jersey, 08858, U.S.A. http: / /www3. ambest- com/ratings/RatingsSearch. asp ?SR =1 7/28/2009