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PROOF OF INSURANCE (2015) CLOSEDClient#: 5688 50TIFFAHOMEC ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(N lYY" 7116f2014 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 oalllflData hoidar Is an ADDITIONAL NNSURED„ the pallcy {lee) moat tae endorsed. If SUBROGATION IS YIfAIVED, sutlTjeot 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 ondors'emont(s), PRODUCER N Carol Morris Livermore & Assoc Ins Sery -- 1 909 . CA lic #0425149 909 466 Np). $4'3.0825 9570 Center Ave ,. _ INSURERS AT'FtYt COM COVERAGE NAIC k Rancho Cucamonga, CA 9 1730 INSURER A, Philadelphia Indemnity Ins ... INSURED ENSUIEER a ' Tiffany Home Care Inc INSURERC dba Always Right Home Care -- -•• • - - ..•..•._.. 9700 Reseda Blvd Ste 105 INSURER D Northridge, CA 91324 ±NauRER 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 NA4MED ABOVE FOR THE POLICY PERIOD INDICATED, 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, S, OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, EXCLUSIONS AND CONDITIONS y� I TYPEOF WSURANCE I,tl 0 ' = POLICY N91MaElr pII4! 1 YW Y P I ,�_..... .....,�.w,� ...HMm...» _..�m „,.,..,..W ..... I' Ir DXY�'W9 LIMITS A COMMERCIAL GENERAL LIABILITY _x] E E .. OCCUR Retro Date: 06/15/03 GEN'L AGGREGATE LIMIT'APPLIES PER: P4J�PCY PRO Ll1C A AUTOMOBILE LIABILITY ANY AUTO ALLOWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS UMBRELLA LU1B OCCUR EXCESS LIAa .CLAIMS -MADE AND EMPLOYERS' LIABILITY /A (Mandatory In It . destr" A Prof Liability Retro: 06 /15/03 PHPK1184535 PHPKI 184535 PHPK1184535 I W2014 {' 0 611 512 01 4 EACH OCCURRENCE I t 1,0001004 DESCRIPTION OF OPERATIONS F LOCATIONS /VEHICLES (Attach ACORD 101, Addlllonal Rent Schedule, Schule, IT more space to required) Certificate Holder is included as Additional Insured as respects Senior In Home Care Project for the City City of El Segundo 350 Main Street EI Segundo, CA 90245 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED TtvE 0 ©1988.2010 ACORD CORPORATION. All rights reserved, ACORD 25 (2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S29995/M29786 CAROM CNTED PERSONALSADVIN,IIJRY S"I,000', IiiO(I GENERALApGREGATE $31)00000 PRODUCTS - COMPIOPAGO 53,000 DOO S __ i5d2014 _ 06115120151 INS " ' t1,000100 BODILY INJURY (Per person) 5 BODILY (PerarrJdenl) S EACH OCCURRENCE $ Or w E.L EACH ACCIDENT S'.. E.L. DISEASE. EA EMPLOYEE. 5 _ , El, DISEASE. POLICY LIMIT S 5/2014 06/15/201 . $1,000,000 Ea Inc Inci'de ' 3,000,000 Aggregate DESCRIPTION OF OPERATIONS F LOCATIONS /VEHICLES (Attach ACORD 101, Addlllonal Rent Schedule, Schule, IT more space to required) Certificate Holder is included as Additional Insured as respects Senior In Home Care Project for the City City of El Segundo 350 Main Street EI Segundo, CA 90245 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED TtvE 0 ©1988.2010 ACORD CORPORATION. All rights reserved, ACORD 25 (2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S29995/M29786 CAROM fi POLICY NUMBER: PHPK1184535 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 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 A. Section 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"" "property damage" 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: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 9. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 26 0413 Q Insurance Services Office, Inc., 2012 Page 3 of 9 POLICY NUMBER: PHPKI032304 COMMERCIAL GENERAL LIABILITY 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 Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s) or or- ganizations) 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; r B. In connection with your premises owned b or rented to you. CG 20 26 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ PRODUCER Douglas J Carlson 1820 S. Elena Avenue, Suite H Redondo Beach, CA 90277 INSURED COVERAGES CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD/YYYY) 02/03/2014 THIS CERTIFICATION 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. Tiffany Homecare Inc. dba Always Right Home Care 9700 Reseda Blvd. Ste 105 Northridge, CA 91324 INSURERS AFFORDING COVERAGE NAIC # INSURER A: Companion Property and Casualty 12157 INSURER B: INSURER C: INSURER D: _ INSURER E:. 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 POLICY EFFECTIVE POLICY EXPIRATION LTR INSR TYPE OF INSURANCE POLICY NUMBER DATE MMlDDlYI' DATE M.M/DD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ , 'r0'tl;Et+T U COMMERCIAL GENERAL LIABILITY PREMISES Ea dCG4dq'ndiM S CLAIMS MADE D OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP /OP AGG S GEN'LAGGREGATE LIMIT APPLIES PER: $ POLICY JPE CCT' LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ BODILY INJURY ALL OWNED AUTOS SCHEDULED AUTOS (Per person) $ - HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE S (Per accident) GARAGE LIABILITY ''AUTO ONLY - EA ACCIDENT S ANY AUTO OTHER THAN EA ACC $ $ AUTO ONLY: AGG EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ S� DEDUCTIBLE $ RETENTION S $ YC OTH A WORKERS COMPENSATION AND WG- CC- WC- 0000324 -05 03/01/2014 03/01/2015 TORY LI ITS ER EMPLOYERS' LIABILITY EL L. EACH ACCIDENT $ 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE ...... -.. OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,000 OTHER DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES/ EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS includes WC D40306 Waiver of Subrogation %,t:IK I III'IL«•A I I. MULUI: K City of El Segundo 350 Main Street El Segundo, CA 90 5 'I Imo' �"'"In0", SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE WY ACORD 25 (2001/08) ORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statment 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. ACORD 25 WORKERS COMPENSATION ANb �nAPLOYERS 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 _ LOCATION: CITY OF EL SEGUNDO CA 8827 $13,000 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: 3/1/2014 Policy No.WG- CC -WC- 0000324 -05 Endorsement No. Minimum Premium: $100 Insured: Tiffany Homecare Inc. 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.