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PROOF OF INSURANCE (2015) CLOSEDLIRMAU-1 OP ID: by CERTIFICATE OF LIABILITY INSURANCE F DATE (M MIDDIYYYY) 14 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 certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. 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 certificates holder in Ileu of such andorsomenti'sI, PRODUCER Brakke Schafnitz West - D License *0428915 100 Wilshire Blvd. # 940 Santa Monica, CA 90401 Darla Gray Phone: 800-464-360( Fax: Carole S. Mitchell 310-624-1357 949-313-3323 NAIC # . ......... . ... .,!us Lines Ins INSURED Dr, Maureen Sassoon MSURER B: — ----- P 0 Box 2028 Palos Verdes Peninsula, CA 90274 ..IN!SURE� _INSURER P,1 . ...... 1N§-URER E. -' - ------ KtVIbIUN INIUMbER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, T ERM 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS 7N,rSw, . ­_ __ -0-0-LT --- -wn­ ­­­ .­_.­­_._ LIS T YPE OF INSURANCE XP J= ima POLICY NUMBER IMMM=Y1 LIMITS GENERAL LIABILITY A X EACH OCCURRENCE _MWXM'T0 �1,000,00 COMMERCIAL GENERAL LIABILITY X X G24270427003 07/01/2014 07/01/2015 CLAIMS-MADE LK OCCUR akw Elp�w cc m�_L 'l MED EX Any one 5,00( X Add Insured X I INaiv ir­of Subro PERSONAL & ADV INJURY 1,000,00( N[EffALAqqR60AIt... S 2,000,00C GEN'L AGGREGArE LIMIT APPLIES PER: _1LOC LPR.92��CTS - q. qMf�IP A92- . ...... . .. — I 2,000,000 X POLICYFI �w!A Deductib: . ........ II AUTOMOBILE LIABILITY OWINE. SINGLE LIMIT- Ea a ANY AUTO BODI LY I NJ U RY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON-OWNED AUTOS A-W-A-G-9 .. . .... .. . ....... $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE A OED RETENTION WORKERS COM PEN SA13ON AND EMPLOYERS' LIABILITY YIN 0TI1- ANY PRO PRIETORIPARTN ERIEXECUTIVE. ❑ OFFICERIMEMSER EXCLUDED? F N/A E L, EACH ACCIDENT $ Mandatory In NH) if t4s, describe under E1 DISEASE - EAtIMPLOYEE $ D RIPTION OF O_PERATlONk1tLq�1. E L DiSEASIF - POLICY LAMP $ A PROFESSIONAL LIAB 624270427003 07/01/2014 07101[2015 �PROF LIAB $1mm/$2mm POLLUTION & ASBESTOS, CLAIMS-MADE �Ded. 5100t DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks schedule, if more space is required) Policy Pfovides, 30 days notice of cancellation except 10 days for nonDavment ­­w1uwx16b z-cr­Lcnea wnere requi-rea by written Contract C-ELSEG SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Julie DeZiel, HR Analyst ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street AUTHORIZED REPRESENTATIVE El Segundo, CA 90246 1988-2010 ACORD CORPORATION. All rights reserved, ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Named Insured Endorsement Number Dr. Maureen Sassoon Policy symboQ Poky Number r ochry,Period Effective Date or Endorsement ECP 07/01/2014 to 07/01/2015 07/01/2014 issued sy(Name of Insurance Company) Westchester Surplus Lines Insurance Company Insert the policy number, The remainder of the Information Is to be completed only when this endorsement Is Issued subsequent to the preparation ofthe policy„ THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ENDORSEMENT OWNERS, LESSEES OR CONTRACTORS—SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE CONTRACTOR'S POLLUTION LIABILITY COVERAGE SCHEDULE: Name of Person or Organization: Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you,wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. SECTION II -WHO IS AN INSURED is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds,the following exclusion is added: 2. Exclusions This insurance does not apply to bodily injury or property damage occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed;or (2) 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 subcontractor engaged in performing operations for a principal as a part of the same project. ENV-3100( -O r )Includes copyrighted material of Insurance Services Office, Inc.with its permission Page 1 of 1 Named Insured t Number Dr. Maureen Sassoon Endorsement ECP P ucaaber d�oldcy Fonod Effective Date of Endorsement 07/01/2014 to 07/01/2015 07/01/2014 Issued By(Name of Insurance Company) Westchester Surplus Lines Insurance Company Insert the policy number. The remainder of the information Is to be completed only when this endorsement is Issued subsequent to the preparatlon ofthe policy.. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ENDORSEMENT-OWNERS, LESSEES OR CONTRACTORS (PRIMARY AND NON-CONTRIBUTORY) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE CONTRACTOR'S POLLUTION LIABILITY COVERAGE SCHEDULE: Name of Person or Organization,, Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) SECTION II-WHO IS AN INSURED is amended to include: A. SECTION II -WHO IS AN INSURED is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds,the following exclusion is added: 2. Exclusions This insurance does not apply to bodily injury or property damage occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project(other than service, maintenance or repairs)to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) 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 subcontractor engaged in performing operations for a principal as a part of the same project. C. The coverage provided hereunder 'shall be primary and not contributing with any other insurance available to those designated above under any other third party liability policy. ENV-3101 (08-04) Includes copyrighted material of Insurance Services Office, Inc.with its permission Page 1 of 1 ADDITIONAL INSURED ENDORSEMENT—PRODUCTS-COMPLETED OPERATIONS HAZARD Neam d Insured _ Endorsement Number Dr. Maureen Sassoon POLY 5ytmbol plo4d¢y Numbtrn ollCy P"od Effective Date of Endorsement ECP 07/01/2014 to 07/01/2015 07/01/2014 Issuerct try(Nomo of Insurance company) Westchester Surplus Lines Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTOR'S POLLUTION LIABILITY COVERAGE PART SCHEDULE Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you,wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Sections II Who Is An Insured is amended to Include as an additional insured the person(s)or organization(s) shown in the Schedule, but only with respect to liability for bodily Injury or property damage caused,, in whole or in part, by your work performed for that additional insured and included in the product's-completed operations hazard. All other terms and conditions remain the same. ENV-3225(10-08) copyright©20080 Page 1 of 1 ADDITIONAL INSURED ENDORSEMENT—PRODUCTS-COMPLETED OPERATIONS HAZARD PRIMARY 8m NON-CONTRIBUTORY Named Mur d Endorsement Number Dr. Maureen Sassoon Poky syrr bW Policy Number PoEicy p a noat Effective Date of Endorsement ECP 07/01/2014 to 07/01/2015 07/01/2014 Nsued By(Name of insurance Company) Westchester Surplus Lines Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTOR'S POLLUTION LIABILITY COVERAGE PART SCHEDULE Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section II—Who Is An Insured is amended to include as an additicnaf insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for bodily Injury or property damage causes In whole or in part, by your work performed for that additional insured and included un the products-completed operations hazard. Furthermore, the coverage provided hereunder shall be primary and not contributing with any other insurance available to those designated above under any other third party liability policy. All other terms and conditions remain the same. ENV-3226(10-08) Copyright 0 20080 Page 1 of 1 Named Insured Endorsement Number Dr. Maureen Sassoon Policy SF17130 Policy Number -'Policy y Period Effective Date of Endorsement ECP G24270427 003 07/01/2014 to 07/01/2015 0710112014 Issucd-By(Name oft Insurmhco corripony) Westchester Surplus Lines Insurance Company Insert the policy number. The remainder of the Information is to be completed only when this endorsement is issued subsequent to the preparation ofthe policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART SCHEDULE Name of Person or Oraanizatiom Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations,and only at the specific written request of such person or organization to you,wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or your work done under a contract w4h that person or organization and included in the products-completed operations hazard, This waiver applies only to the person or organization shown in the Schedule above. All other terms and conditions remain the same. ENV-3143(03-05) Includes copyrighted material of Insurance Services Office, Inc,with its permission Page 1 of 1 ""Ktl'KIN I tU I•KUM 1 Ht AKL;HIVt. I Ht UKIUINAL I KANbAL;I IUN MAY INULUUt AUUI I IUNAL FUKMb .... POLICY NUMBER: A2074142 .� rty MutuA Company SAFECO INSURANCE COMPANY OF AMERICA AUTOMOBILE POLICY DECLARATIONS NAMEDINSURED: RENEWAL MAUREEN SASSOON PO BOX 2028 POLICY PERIOD FROM: SEPT 1 2014 PALOS VERDES PEN CA 90274-8028 TO: SEPT 1 2015 at 12:01 A.M. standard time at the address of the insured as AGENT: stated herein. NHC INSURANCE SERVICES INC AGENT TELEPHONE: 796 W 9TH ST (310) 221-0917 SAN PEDRO CA 90731-3602 RATED DRIVERS MS MAUREEN SASSOON 2008 BMW 328I SULEV 4 DOOR SEDAN ID# WBAVC53578FZ84867 1986 HONDA CIVIC 1500 4 DOOR SEDAN ID# JHMAK7430GS007927 Insurance is afforded only for the coverages for which limits of liability or premium charges are indicated. COVERAGES 2008 BMW LIMITS PREMIUMS 1986 HOND LIMITS PREMIUMS LIABILITY: BODILY INJURY $500,000 $ 211.30 $500,000 $ 131.80 Each Person Each Person $500,000 $500,000 Each Occurrence Each Occurrence PROPERTY DAMAGE $100,000 116. 50 $100,000 80.70 Each Occurrence Each Occurrence MEDICAL PAYMENTS $5,000 28. 50 $5,000 20.00 UNINSURED AND UNDERINSURED MOTORISTS: BODILY INJURY $500,000 121.40 $500,000 79.40 Each Person Each Person $500,000 $500,000 Each Accident Each Accident UNINSURED MOTORISTS: PROPERTY DAMAGE $3, 500 5.20 Each Accident COMPREHENSIVE Actual Cash Value 81.00 Less $250 Deductible COLLISION Actual Cash Value 272.30 Less $500 Deductible WAIVER OF COLLISION DEDUCTIBLE 17. 30 ADDITIONAL COVERAGES: LOSS OF USE $50 Per Day/$1200 Max 34.80 ANTI FRAUD FEE 1.74 1.74 ROADSIDE ASSIST 5.80 -- --- TOTAL $ 890.64 TOTAL $ 318.84 TOTAL EACH VEHICLE: 2008 BMW $ 890.64 1986 HOND 318.84 PREMIUM SUMMARY PREMIUM VEHICLE COVERAGES $ 1,209.48 -CONTINUED- P 0 BOX 515097, LOS ANGELES, CA 90051 08/18/2009 15:16 3105440752 DR 5AbSUUN rraut ni (f TI(E LAM- (8 ({'11 Ba z� 0TT mac,mph.mh providing management, health & safety services Lorraine Ward August 18, 2009 Human Resources Department City of El Segundo 350 Main Street El Segundo, California 90245 RE: Workers' Compensation lnstrrance Dear Ms. Ward: Due to the fact that Dr. Maureen Sassoon is self-employed and does not have any employees, Workers' Compensation insurance is not warranted and has not been obtained. Dr. Sassoon does maintain personal medical insurance through Kaiser Permanente. Cordially, OM Maureen Sassoon p.o, box 2028 Palos verdes peninsula ca, 90274 A