PROOF OF INSURANCE (2011) CLOSEDCommercial Certificate of Insurance
FARMER s
Agency . KENT E CHRISTENSEN
Name . 150 EAST 900 SOUTH
Issue Date (MM /DD/YY) 06/01/10
& • SALT LAKE CITY, UTAH 84111
Address • 801 - 364 -7800 FAX 801 - 364 -7864 This certi
ricate 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
St. 76 Dist. 25 Agent 304 coverage
fforded by the policies shown below.
Companies Providing Coverage:
Insured
Company A Truck Insurance Exchange
. WEIDNER & ASSOCIATES, INC.
Letter
Name . 135 WEST 7065 SOUTH
Company B Farmers Insurance Exchange
& • MIDVALE, UTAH 84047
Letter
Company Mr Mid- Century Insurance Company
Address •
Letter
Company
Letter
Coverages
This is to certify that the policies of insurance listed below have been issued to the ins
red 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 con
itions of such policies. Limits shown may have been reduced by
paid claims.
Co.
Ltr.
Type of Insurance
yp
Policy Number
y
Policy Effective
Date (MM /DD/YY)
Policy Expiration
Date (MM/DD/YY)
Policy Limits
B
X
General Liability
065894821
06 /01 /10
06/01/11
General Aggregate
$ 3,000,000
Products- Comp /OPS
Commercial General
Aggregate
$
Liability
Personal &
- Occurrence Version
Advertising Injury
$ 2,000,000
Contractual - Incidental
Each Occurrence
$ 2,000,000
Only
y
ire Damage
(Any one fire)
$ 50,000
Owners & Contractors Prot.
Medical Expense
(Any one person)
$ 5,000
Automobile liability
Combined Single
All Owned Commercial
Limit
$
Autos
Bodily Injury
(Per person
B
u
Scheduled Autos
065894821
06/01/10
06/01/11
$ 100,000
Hired Autos
Bodily Injury
(Per accident)
$ 300,000
Non -Owned Autos
Garage Liability
Property Damage
$ 100,000
Garage Aggregate
$
Umbrella Liability
Limit
$
Workers' Compensation
Statutory
and
Each Accident
$
Disease - Each Employee
$
Employers' Liability
y
Disease - Policy Limit
$
Description of OperationsNehicles /Restrictions /Special items:
MANUFACTURERS REP
Certificate Holder The City of El Segundo Cancellation
• ould any of
the above described policies be cancelled before the expiration date
Name thereof, the iss'
Public Works Departmen
ing company will endeavor to mail 30 days written notice to the
& ertificate holder
named to the left, but failure to mail such notice shall impose no
Address El Segundo City Hall bligati n o
bility of kind upon the company, its agents or representatives.
350 Main St, El Segundo,Ca 90245
esentative
rized Rep
56 -2492 4 -94 Copy Distribution: Service Cedter Copy nd Agent's Copy H -Ot
THIS ENDORSEMENT CHANGES THE POLI
COMMERCIAL GENERAL LIABILITY
CG 20 33 07 04
'. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - AUTOM TIC STATUS WHEN
REQUIRED IN CONSTRUCTION GREEMENT WITH YOU
This endorsement modifies insurance provided under the
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A. Section II Who Is An Insured is amended to
include as an additional insured any person or or-
ganization for whom you are performing opera-
tions when you and such person or organization
have agreed in writing in a contract or agreement
that such person or organization be added as an
additional insured on your policy. Such person or
organization is an additional insured only with re-
spect to liability for "bodily injury', "property dam-
age" or "personal and advertising injury' caused,
in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your
behalf;
in the performance of your ongoing operations for
the additional insured.
A person's or organization's status as an addi-
tional insured under this endorsement ends when
your operations for that additional insured are
completed.
B. ith respect to the insurance afforded to these
ditional insureds, the following additional excl u-
th(is ns apply:
insurance does not apply to:
"Bodily injury", "property damage" or "personal
and advertising injury" arising out of the ren-
dering of, or the failure to render, any profes-
sional architectural, engineering or surveying
services, including:
a. The preparing, approving, or failing to
prepare or approve, maps, shop drawings,
opinions, reports, surveys, field orders,
change orders or drawings and specifica-
tions; or
b. Supervisory, inspection, architectural or
engineering activities.
"Bodily injury" or "property damage" occurring
after:
a. All work, including materials, parts or
equipment furnished in connection with
such work, on the project (other than ser-
vice, maintenance or repairs) to be per-
formed by or on behalf of the additional in-
sured(s) at the location of the covered
operations has been completed; or
b. That portion of "your work' out of which the
injury or damage arises has been put to its
intended use by any person or organization
other than another contractor or subcon-
tractor engaged in performing operations
for a principal as a part of the same project.
CG 20 33 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 ❑
Fax Server 7/29/2010 11:54:22 AM PAGE
------------------------------- - - - - --
WCF1
July 29, 2010 .... .....I ........................:
Attn: ERIC MOORE
EL SEGUNDO FIRE DEPT
314 MAIN STREET
EL SEGUNDO CA 90245
CERTIFICATE OF INSURANCE
This will certify that:
WEIDNER & ASSOCIAT S C
135 W 7065 S
MIDVALE UT 84047
Policy Number 1606944
has an active Workers Compensation and Employers Liability policy in
accordance with the provisions of the Utah Workers Compensation Act
for the period 10/1/2009 to 10/1/2010 at 12:01 A.M.
If the policy is cancelled prior to the policy expiration date of
10/1/2010 you will be notified.
Employer's Liability:
Each Accident: 100,000
Disease - Policy Limit: 500,000
Each Employee: 100,000
Job Reference:
(A job -site location is the only valid entry in this section. Any other
language or representation is invalid and in no way extends or alters
the coverage issued.)
-------------------------------------------------
VV,wkov, `I I'v ^n� >tii!r. E Ull(: e ;')'� 11,1 64 1(t • 'r;.,lt I.t< : (:iry;. l as {z "W107 • �,�ip -d tt, -(.( t,`�tl' a �.�� t�!r,ttr�. ,m