PROOF OF INSURANCE (2015) CLOSEDSPCAL -2 OP ID: LG
DATE (MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 08128/2014
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 WANED, 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
PRODUCER
Grossllght Insurance, Inc.
License # 0247283
1333 Westwood Blvd
Los Angeles, CA 90024
Gil Grossllght
INSURED spcaLA etal
Elizabeth De La Rosa
5026 W. Jefferson BI
Los Angeles, CA 90016
COVERAGES CERTIFICATE NUMBER:
/nn Grossli ht
310- 4739611 rase. New: 310- 312 -4993
INSURERS AFFORDING COVERAGE NAIC 0
INSURER A: Great Am Ins Co 16691
INSURER B :
INSURER C :
INSURER D :
F:
REVISION NUMBER:
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, 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
5R ADD ldB ICP
.,.-
LTR TYPE OF INSURANCE POLICY NUMBER
LIMITS
A X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,00
CLAIMS -MADE OCCUR X PAC5603474 09/01/2014 09/01/2015
PREM{ E ea accurr'es eel
$_ 300,00
MED EXP (Any one person)
$ 10,00
PERSONAL & ADV INJURY
$ 1,000,00
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,00
POLICY OJECT PRO-- [9] LOC
PRODUCTS - COMP /OP AGG
$ 2,000,00
OTHER
Emp Ben.
$ 1,000,00
AUTOMOBILE LIABILITY
En ace °d rfi d Li A
$
BODILY INJURY (Per person)
$
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident)
$
NON -OWNED
P p
HIRED AUTOS AUTOS
Per acr,IclrrR
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
$
EXCESS LIAB
CLAIMS -MADE
AGGREGATE
$
DIED I li RETENTION
WORKERS COMPENSATION
H
STATUTE ER
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORIPARTNERIEXECUTIVE
E L, EACH ACCIDENT
$
OFFICER IMEMBER EXCLUDED?
NIA
E L, DISEASE - EA EMPLOYEE $
(Mandatory In NH)
If es, describe under
DESCRIPTION OF OPERATIONS below
El, DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS f LOCATIONS f VEHICLES (ACORD 101, AddMonal Remarks Schedule, may be attached H more space Is required)
Cert holder is added as Additional Insured (ATIMA). * *See form #CG8224
(12/01) #1.5.c* ( *)Cancellation for non - payment of premium is ten (10)
days. Cancellation for all other is thirty (30) days.
CERTIFICATE H -OLDER _ _ CANCELLATION
ELSEGUN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE HALL BE DELIVERED IN
City of El Segundo
ACCORDANCE NTH THE POLICY PROVISIONS.
kR �r
City Clerk's Office
Attn: Mona Shilling
AUTHORIZED REPRESENTATIVE
350 Main Street ue 1 7
V Segundo, CA $0245-3895
®1988.2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
Administrative Offices
580 Walnut Street
Cincinnati, OH 45202
513.369.5000 ph
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CG 82 24
(Ed. 12 01)
SOCIAL SERVICE AGENCY GENERAL LIABILITY BROADENING EN ORSEI IEN C_
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
1. The following provision is added to SECTION
II - WHO IS AN INSURED
5. AUTOMATIC ADDITIONAL INSURED(S)
a. Additional Insured - Manager or
Lessor of Premises
(1) This policy is amended to include
as an insured any person or or-
ganization (hereinafter called Ad-
ditional Insured) from whom you
lease or rent property and which
requires you to add such person
or organization as an Additional
Insured on this policy under:
(a) a written contract; or
(b) an oral agreement or con-
tract where a Certificate of
Insurance showing that per-
son or organization as an
Additional Insured has been
issued;
but the written or oral contract or
agreement must be an "insured
contract," and,
(1) currently in effect or be-
come effective during the
term of this policy; and
(II) executed prior to the "bodily
injury," "property damage,"
"personal and advertising in-
jury"
(2) With respect to the insurance af-
forded the Additional Insured
identified in Paragraph A.(1) of
this endorsement, the following
additional provisions apply:
(a) This insurance applies only
to liability arising out of the
ownership, maintenance or
use of that portion of the
premises leased to you.
(b) The Limits of Insurance ap-
plicable to the Additional In-
sured are the lesser of those
specified in the written con-
tract or agreement or in the
Declarations for this policy
and subject to all the terms,
conditions, and exclusions
for this policy. The Limits of
Insurance applicable to the
Additional Insured are inclu-
sive of and not in addition to
the Limits of Insurance
shown in the Declarations.
(c) In no event shall the cov-
erages or Limits of Insurance
in this Coverage Form be in-
creased by such contract.
(d) Coverage provided herein is
excess over any other valid
and collectible insurance
available to the Additional In-
sured whether the other in-
surance is primary, excess,
Includes copyrighted material of Insurance Service Office with its permission.
F8972CP101) Copyright, Insurance Services Office, Inc., 2001
CG 82 24 (Ed. 12/01) XS (Pace 1 of 4)
contingent or on any other
basis unless a written con-
tractual arrangement specifi-
cally requires this insurance
to be primary.
(3) This insurance does not apply to:
(a) Any "occurrence" or offense
which takes place after you
cease to be a tenant in that
premises.
(b) Structural alterations, new
construction or demolition
operations performed by or
on behalf of the "Additional
Insured."
b. Additional insured Funding
Sources
(1) This policy is amended to include
as an Insured any Funding Source
which requires you in a written
contract to name the Funding
Source (hereinafter called Addi-
tional Insured) as an Insured but
only with respect to liability aris-
ing out of your premises, "your
work" for such Additional Insured,
or acts or omissions of such Ad-
ditional Insured in connection with
the general supervision of "your
work" and only to the extent set
forth as follows:
(a) The Limits of Insurance ap-
plicable to the Additional In-
sured are the lesser of those
specified in the written con-
tract or agreement or in the
Declarations for this policy
and subject to all the terms,
conditions, and exclusions
for this policy. The Limits of
Insurance applicable to the
Additional Insured are inclu-
sive of and not in addition to
the Limits of Insurance
shown in the Declarations.
(b) The coverage provided to
the Additional Insured(s) is
not greater than that cus-
tomarily provided by the
policy forms specified in and
required by the contract.
(c) In no event shall the cov-
erages of Limits of Insurance
in this Coverage Form be in-
creased by such contract.
c. Additional Insured - Contractual
Obi igations
(1) This policy is amended to include
as an Insured any person or or-
ganization (hereinafter called Ad-
ditional Insured) that you are re-
quired by a written "insured con-
tract" to include as an Insured,
subject to all of the following
provisions:
(a) Coverage is limited to liability
arising out of:
(1) your ongoing oper-
ations performed for
such Additional Insured;
or
(ii) that Insured's financial
control of you; or
(iii) the maintenance, opera-
tion or use by you of
equipment leased to
you by such Additional
Insured; or
(iv) a state or political sub-
division permit issued
to you.
(b) Coverage does not apply to
any "occurrence" or offense:
0) which took place be-
fore the execution of,
or subsequent to the
completion or expira-
tion of, the written "in-
sured contract ", or
(ii) which takes place after
you cease to be a ten-
ant in that premises.
Includes copyrighted material of Insurance Service Office with its permission.
Copyright, Insurance Services Office, Inc., 2001
CG 82 24 (Ed. 12/01) XS (Paae 2 of 4)
(c) With respect to architects,
engineers, or surveyors,
coverage does not apply to
"Bodily Injury," "Property
Damage," "Personal and Ad-
vertising Injury" arising out
of the rendering or the fail-
ure to render any profes-
sional services by or for you
including:
(1) the preparing, approv-
ing, or failing to pre-
pare or approve maps,
drawings, opinions, re-
ports, surveys, change
orders, designs or
specifications; and
(ii) supervisory, inspection,
or engineering services.
If an Additional Insured endorsement is at-
tached to this policy and specifically names a
person or organization as an Insured, then the
coverage in Section II - WHO IS AN
INSURED 5. Automatic Additional Insured(s)
does not apply to that person or organization.
2. BLANKET WAIVER OF SUBROGATION
SECTION IV - COMMERCIAL GENERAL
LIABILITY CONDITIONS, Item 8. is replaced
with:
8. Transfer of Rights of Recovery Against
Others to us and Blanket Waiver of
Subrogation
a. If an Insured has rights to recover all
or part of any payment we have made
under this Coverage Part, those rights
are transferred to us. The Insured must
do nothing after loss to impair them.
At our request, the Insured will bring
"suit" or transfer those rights to us and
help us enforce them.
b. If required by a written "insured con-
tract", we waive any right of recovery
we may have against any person or
organization because of payments we
make for injury or damage arising out
of your ongoing operations or "your
work" done under a contract for that
person or organization and included in
the "products- completed operations
hazard"
3. NON -OWNED OR CHARTERED WATER-
CRAFT
Section I - Coverages, Coverage A, Item
2.9.(2) is replaced with:
(2) A watercraft you do not own that is:
(a) less than 51 feet long; and
(b) not being used to carry persons or
property for a charge.
4. BROADENED PERSONAL AND ADVERTISING
INJURY
Unless "Personal and Advertising Injury" is ex-
cluded from this policy:
SECTION V - DEFINITIONS Item 14. is re-
placed by:
14. "Personal and Advertising Injury" means
injury, including consequential "bodily in-
jury," arising out of one or more of the
following offenses:
a. false arrest, detention or imprison-
ment;
b. malicious prosecution;
c. the wrongful eviction from, wrongful
entry into, or invasion of the right of
private occupancy of a room, dwelling
or premises that a person occupies by
or on behalf of its owner, landlord or
lessor;
d. oral, written, televised, videotaped, or
electronic publication of material, in
any manner, that slanders or libels a
person or organization or disparages a
person's or organization's goods, pro-
ducts or services;
e. oral, written, televised, videotaped, or
electronic publication of material, in
any manner, that violates a person's
right of privacy; or
Includes copyrighted material of Insurance Service Office with its permission.
Copyright, Insurance Services Office, Inc., 2001
CG 82 24 (Ed. 12/01) XS (Paae 3 of 4)
f. mental injury, mental anguish, humili-
ation, or shock, if directly resulting
from Items 14.a. through 14.e.
g. the use of another's advertising idea in
your "advertisement "; or
h. infringing upon another's copyright,
trade dress or slogan in your "adver-
tisement"
5. MENTAL INJURY, MENTAL ANGUISH,
HUMILIATION, OR SHOCK INCLUDED IN
BODILY INJURY DEFINITION
Section V - Definitions, Item 3. is replaced
with:
3. "Bodily injury" means physical injury, sick-
ness, or disease, including death of a per-
son. "Bodily injury" also means mental in-
jury, mental anguish, humiliation, or shock
if directly resulting from physical injury,
sickness, or disease to that person.
6. MEDICAL PAYMENTS
A. The Medical Expense Limit in Paragraph 7.
of SECTION III - LIMITS OF INSURANCE
is replaced by the following Medical Ex-
pense Limit.
The Medical Expense Limit provided by
this policy shall be the greater of:
a. 510,000; or
b. The amount shown in the Declarations
for Medical Expense Limit.
B. This provision 7. is subject to all the terms
of SECTION III - LIMITS OF INSURANCE.
C. This provision 7. does not apply if
COVERAGE C. MEDICAL PAYMENTS is
excluded either by the provisions of the
Coverage Part or by endorsement
7. DAMAGE TO PREMISES RENTED TO YOU
LIMIT
A. SECTION III - LIMITS OF INSURANCE,
Item 6. is replaced with:
Subject to 5. above, the Damage to Prem-
ises Rented to You Limit is the most we
will pay under Coverage A for damages
because of "property damage" to your
building, or to personal property of others
in your care, custody and control while at
premises rented to you or temporarily
occupied by you with permission of the
owner, arising out of any one fire.
The Damage to Premises Rented To You
Limit is replaced by the following Damage
to Premises Rented To You Limit.
The Damage to Premises Rented To You
Limit is the greater of:
(1) $300,000; or
(2) the amount shown in the Declarations
for Damage to Premises Rented to
You Limit.
B. This provision is subject to all the terms
of SECTION III - LIMITS OF INSURANCE.
C. This provision 5. does not apply if Damage
to Premises Rent to You Liability of COV-
ERAGE A (SECTION 1) is excluded either
by the provisions of the Coverage Part or
by endorsement.
S. SUPPLEMENTARY PAYMENTS
A. In the SUPPLEMENTARY PAYMENTS -
COVERAGES A and B provision, Item 1.b.,
and 1.d are replaced with:
1.b. Up to $500 for cost of bail bonds
required because of accidents or traf-
fic law violations arising out of the use
of any vehicle to which the Bodily In-
jury Liability Coverage applies. We do
not have to furnish these bonds.
1.d. All reasonable expenses incurred by
the Insured at our request to assist us
in the investigation or defense of the
claim or "suit," including actual loss of
earnings up to $500 a day because of
time off work.
This endorsement does not change any other
provision of the policy.
Includes copyrighted material of Insurance Service Office with its permission.
Copyright, Insurance Services Office, Inc., 2001
CG 82 24 (Ed. 12/0 1) XS (Paae 4 of 4)
� SPCAL -2 OP ID: LG
CERTIFICATE OF LIABILITY INSURANCE DATE( F0812812014
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 pollcy(les) must be endorsed. If SUBROGATION IS WANED, 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 I
Grossllght Insurance, Inc.
License 4 0247283
1333 Westwood Blvd
Los Angeles, CA 90024
GII Grossllght
INSURED spcaLA etal
Elizabeth De La Rosa
5026 W. Jefferson BI
Los Angeles, CA 90016
COVERAGES CERTIiFICATE', NUMBER,
310 -473 -9611
INSURER(S) AFFORDING COVERAGE
INSURERA: Great Am Ins Co
INSURERS:
INSURER C :
INSURER D :
INSURER E :
INSURER F :
1:7 ��1�3C•77� lq,T,l -1=1.4
310 -312.4993
N i
16691
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, 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
w
IN
TYPE OF INSURANCE IADOL SUB
iNan Yon POLICY NUMBER
LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$
CLAIMS -MADE 1:1 OCCUR
PREM2SEES EeoccMurrence,
$
MED EXP (Any one person) _
$
PERSONAL & ADV INJURY
$
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$
PRO-
71 7
POLICY
POLICY LOC
PRODUCTS - COMP /OP AGG
$
OTHER:
$
AUTOMOBILE LIABILITY
Ea aCGidenq L
$
A
X ANY AUTO
CAP5603475
09/01/2014
09/01/2015
BODILY INJURY (Per person)
$
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident)
$ 1,000,00
X X
_••
,_
$
HIRED AUTOS AUTOSED
Per accident
UMBRELLA LIAB OCCUR
EACH OCCURRENCE
$
EXCESS LIAB CLAIMS MADE
AGGREGATE
$m
DEQ RETENTION
$
WORKERS COMPENSATION
OT H
AND EMPLOYERS' LIABILITY YIN
STA? JTE ER
E L EACH ACCIDENT
..
$
ANY PROPRIETORIPARTNERIEXECUIIVE
EXCLUDED?
NIA
—
Mandatory In NH)
(Mandatory
E L DISEASE - EA EMPLOYEE'
If yes, describe under
DESCRIPTION OF OPERATIONS below
EL DISEASE -POLICY LIMIT
$
DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached N more apace Is required)
( *) Cancellation for non - payment of premium is ten (10) days. Cancellation
for all other is thirty (30) days.
ELSEGUN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of El Segundo ACCORDANCE MATH THE POLICY PROVISIONS.
City Clerk's Office
Attn: Mona Shilling AUTHORIZED REPRESENTATIVE
Main Street
=1 ,��feAsy
CI CenunAn r!A On9dR_911110e2
It 1988 -2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
CERTIFICATE OF LIABILITY INSURANCE
SPCAL -2
DATE (MMIDDIYYYY)
1112012014
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
certificate holder In lieu of such endorsernentlsl.
PRODUCER
"� """'"'
NAIMIE: viii rOSs
Grossllght Insurance, Inc.
License # 0247283
PHONE �
W. FAX
I(u :310 73 -9611 c NoIIT 310 - 312 -4993
1333 Westwood Blvd
AD1� L s, lynnfgrosslight.conl
Los Angeles, CA 90024
__...
Gil Grossllght
IINSUREFt(S AFFORDING COVERAGE
NAIC s
INSURERA: Redwood Fire & Cas Ins Co
11673
INSURED spcaLA etal
INSURERS:
Elizabeth De La Rosa
5026 W. Jefferson BI
INSURER C:
-- -�
Los Angeles, CA 90016
INSURER D:
INSURER E ; . -
INSURER F :
COVERAGES CERTIFICATE NUMBER:
REVISION NUMBER:
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, 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
____
TYPE OF INSURANCE POLICY NUMBER
iTii 5r EF
LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$
CLAIMS -MADE D OCCUR
P'REMIS'ES 6'arturf6nceL
$
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$
POLICY EI PRO- F7 LOC
ECT
PRODUCTS - COMP /OP AGG
$
OTHER
$
AUTOMOBILE LIABILITY
Eo &rcCtM1'rp
$
ANY AUTO
BODILY INJURY (Per person)
$
„M„•.,.� „•
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident)
- -,,,,�
$
HIRED AUTOS AUTTOS ED
(Paa CCa l mi)
$
UMBRELLALIAB OCCUR
EACH OCCURRENCE
$
EXCESS LIAB CLAIMS -MADE
AGGREGATE
$
DED RETENTION
WORKERS COMPENSATION
X STATUTE ER
AND EMPLOYERS' LIABILI
A ANY PROPRIETORIPARTNERIEXECUTIVE YIN N 1 A x 00015212
09/30/2014 09/30/2015 E L EACH ACCIDENT
° " " "....
$ 1,000,00
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH)
E.L. DISEASE -EA EMPLOYEE $ 1,000,00
0 SCRIPTIrN under OPERATIONS below
E,L, DISEASE - POLICY LIMIT
$ 1,000,00
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached K more space Is required)
Cert holder is named on Waiver of Subrogation endorsement (#WC990402B -Ed 7-
07 - attached) ( *)Cancellation for non - payment of premium is ten (10) days.
Cancellation for all other is thirty (30) days.
ELSEGUN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
L ACCORDANCE WITH THE POLICY PROVISIONS.
City of El Segundo�� , Y
City Clerk's Office
' AUTHORIZED REPRESENTATIVE
Mona Shilling
350
350 Main Street
191 92gM049. CA 90245,3695
®1988 -2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 04 02B (Ed 7 -07)
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 by 5.00 % of the total policy premium otherwise due on such
remuneration subject to a policy maximum charge for all such waivers of 5.00 % of total policy premium.
The minimum premium for this endorsement is $ �Sy_
Person or Organization
City of El Segundo
City Clerks Office 350 Main St. El Segundo, CA 90245
Schedule
�kW
Job Description
Housing animals
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below Is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective 09/30/2014 Policy No. 4400015212 -141 Endorsement No. 1
Insured SPCALA Premium $
Insurance Company Countersigned by
Redwood Fire and Casualty Insurance Company
WC 99 04 02B
(Ed 7 -07)