PROOF OF INSURANCE (2014) CLOSEDAgreement No. 4524
Always Right Home Care
DEC-1T-13 09:05AM FROM-ALWAYS RIGHT HOMECARE Page 1 of 1
tY�i��cuta r�..,N ••..- -_� ____ 818-8B6-1847 T-597 P.001/001 F-847
Client#:5608 I3Q1'IFFAHOMEC tyAr�I �fo1�
A UR, ,� CERTIFICATE OF LIABILITY INSURANCE
THIS G�TtFICI�TI t I u1 AS A IItA Ell i tpClRi�IATICN I t,1L�ANI�C13NFl=FtI�f�i�RICi1 tal��r�t TItS CGf31If*iCA1 f H I�Poti
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REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE IiOL IJ
WI1.t FIIS C:EIT I FiIATS OF ldar ie fah Ail ITNC At,t S-FtEII,thOl poI M.y11tMrM1 Inuel as alndtlr�fSdr t SHSItC TICI~I tS WAl ,m�ut1loct to
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tha terms and conditions of the pollcy,certain pottM:I'os may require on endor�IDMnont.A atatamertk on this certificate dogs not aorifBr rlAfatat o{ha
certificate holder In lieu of such a andaraorn®nt1s), ero1 MorII
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9570 Cantor Ave INfaaFacRftMl�FeIInINO aIVFRAGS n aaoll
R7anFho Cucamonga,CA 91730 mtlaUR 1'hlladelPllPa 1rldlrinity Itts
WSUHL'D IN UN6f t'P:
Tiffany Home Carr:,Inc 114OURFR C
ii Always Right Home Care Mn e
9700 Reseda Blvd Ste 105 Ruee
Northridge,CA 91324 lone GPs
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ULICY PERIOD f:t, ICATE NUMBER.. JSr H U ENC ftiT3 IS s � CT t lG � I P IR
1i t N TI &TH 1G 'TERM CoN C
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QCRII� �I� IN 16 SUBJECT TO ALI.THE PERMS,
t� OI tVAITILMN OF 9tIGH PCi#1GN . L Mrrs SHOWN:MAY HAVE SEEN REDU TJ a1� I�ANrI CLAIt�19.
lCtt1SIOIIFJ ' I PULICYNJI6R SOFMNn 1oA 11t 6
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BILJ Includes 6900 000
axaul'rI'Rt�AI.eCt1 MaAI.N�Irt I�EI9E7aP a>QIIra dlaMfl71� 56000
clalMS4rwue OCCUR Sexual Abuse PenMJ.sAQVINJIJRY 211000,000
t Rattto Via lka 061961iI3 Vlcarioua Llab
, r„Ar�OIaEa;ATf 63 000 000
UcTawr�O 1CP Cfrf 63.000,000
�.113MOATE MIT APPlJE9 i T
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Aurolwoen 1MAe1llry n L PHPKIC32304 0/1512013 ac1951z0'I
A BODILY INJURY tPorp4 mall 6
AUTO f;CHERULFD BQOIII WJURY(For mocsWalll 4
AUTOS AUTOS P PRIM I� S
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A Prof t.lebility 1PHPKi
Rota: 06110103 $3,pa0,000 Aggregate
DEBM"tON OF o MATIONS I I.0t;A11ON9111 'MJGLC 1AlUvIs ACORO 101,Addlt1oft!Rcm:ttks SWtadulo,it more opera Iz iuvradl
Certificate Halder Is Named as A01ti'oltai latsurcd 08 respactMS Senior In
Hame Care Project for the City.
G TIFICATIEHCItJ E CAC 'i 1%t
l; SHOULD ANY OF THI @ABOVE flEaCRIBEQ POLICMS I la CANGEI-I-L'D Bf!Fli
City of SI Segundo THE EXPIRATION UATO THEREOF, NQTICI= Wily 8I: OHLIV6RI:O IN
350 Main Street 0
ACCORDAN09 WITIJ THE POLICY
PROVISIONS.
El Segundo,CA 90245
1621A J
N AUrLtoRR60 RPRUB
Q 191, -2010 Ali CCRPQRATION re
.All rlghla aorved.
e
POLICY NUMBER: PHPK1032304
A F, GOMMERCIAL GENERAL LIABILITY
�
N& ')
CG 20 26 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED
PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person sj Or Organ izatio,n(s)
City of El Segundo
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
Section 11 — Who Is An Insured is amended to in-
clude as an additional insured the person(s) or or-
ganization(s) shown in the Schedule, but only with
respect to liability for "bodily injury", "property dam-
age" or "personal and advertising injury" caused, in
whole or in part, by your acts or omissions or the acts
or omissions of those acting on your behalf:
A. In the performance of your ongoing operations; or
B. In connection with your premises owned by or
rented to you.
CG 20 26 07 04 ISO Properties, Inc., 2004 Page 1 of 1 ❑
DATE(MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 03/26/2013 03:53 PM
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
'THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE
OR PRODUCER.,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the cerficate holder is an ADDITIONAL INSURED,the po Mcy(Mes)must be endorsed.If§UBROGATION 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).
PRODUCER CONTACT NAME:
Highpoint Risk Services LLC plglg ,pp,�1; (800)728-0623 F,,,�I,,c,,ol;(972)404-0380
5501 LBJ Freeway, Suite 1200
Dallas, TX 75240 11 ADDRESS:
INSURERS AFFORDING COVERAGE NAIC 0
INSURER A:Companion Property and Casualty Insurance Company 12157
INSURED: INSURER B:
Tiffany Homecare Inc dba Always Right Homecare INSURER C:
9700 Reseda Blvd., Ste 105 INSURER D:
Northridge, CA 91324
Phone: (818) 686-1602 Fax: O - INSURER E:
IN UR F:
C I'WERAGES CERTIFICATE NUMBER AC13-32601236-1178499 REVISION NUMBER: ELI'
NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR 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.LIMITS SHOWN
MAY HAVE BEEN REDUCED BY PAID CLAIMS.
N TYPE OF INSURANCE IAD RL O131t POLICY NUMBER POLICY EFF POLICY EXP LIMITS
D DATE IMM/DDIYYI DATE(MM/DD/YY)
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY oAmAep rofRiii
a
CLAIMS MADE [:] OCCUR ❑ ❑ MED EXP Any aperson) $
PERSONAL&ADV INJURY $
GENERAL AGGREGATE $
MEN L AGGREGATE LIMIT APPLIES PER` PRODUCTS-COMP/OP AGG
POLICY J R LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
(Ea accident) $
ANY AUTO
ALL OWNED AUTOS ❑ ❑
SCHEDULED AUTOS BODILY INURY(Per accident) $
HIRED AUTOS PROPERTY DAMAGE
(Per accident)
NON-OWNED AUTOS
UMBRELLA LIAB CLAIMS-MADE EACH OCCURRENCE 5
EXCESS UAB OCCUR AGGREGATE r5
DEDUCTIBLE p, El E $
RETENTION $ 5
X R
EMPL
X L I S
EMPLOYERS'LIABILITY
ANY PROPERIETOR/EXECUTIVE �YIN i EACH ACCIDENT la
1000000
OFFICER,MEMBER EXCLUDED? `I'
NIA CPCA16844 03/01/2013 03/01/2014 E,L.DISEASE-EA EMPLOYEE is 1000000
A (Mandatory in NH)
if yes, PROVISION below E,LDISEASE-POLICY LIMIT 3 1000000
es,describe under
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES(Attached ACORDI01,Additional Remarks Schedule,If more space is required
1. Waiver of Subrogation Endorsement Attached.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
City of E1 Segundo l
EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH
350 Main Street ) W"" THE POLICY PROVISIONS.
E1 Segundo, CA 90245
A � AUTHORIZED REPRESENTATIVE
MURD 26(2010106) O'd080-2IM 0 ACORD C606MION.Al right rerserve
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06
(Ed.4-84)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce
our right against the person or organization named in the Schedule. (This agreement applies only to the extent that
you perform work under a written contract that requires you to obtain this agreement from us.)
You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the
work described in the Schedule.
The additional premium for this endorsement shall be—5—%of the California workers'compensation premium
otherwise due on such remuneration.
Schedule
Person or Organization Job Description
City of El Segundo
350 Main Street
El Segundo, CA 90245
�r
This endorsement changes the policy to which it is attached and is effective on the date issued ulss otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective 3/1/2013 Policy No. CPCA16844 Endorsement No.
Insured Tiffany Homecare, Inc.dba Always Right Homecare Insurance Company Companion Property&Casualty
Countersigned by
WC 04 03 06
(Ed.4-84)
0 1998 by the Worker's Insurance Rating Bureau of California.All rights reserved.