PROOF OF INSURANCE (2015) CLOSEDOP III: DR
CERTIFICATE OF LIABILITY INSURANCE
DATE 104120Y4
i 12104!2014
THIS CERTIFICATE 18 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 endorsernent!'s).
PRODUCER
IS TO CERTIFY THAT THE POLICIES OF
U4rNTAUT
Alliance Mgt. A Insurance Sery
ISSUED TO
PH
PHONE
355 Via Verg Cruz #7
e
INDICATED.
iiL
CA Agent/Broker Lic# 0737966
San 92078
TERM OR CONDITION OF ANY
a
A a
OR OTHER DOCUMENT WITH RESPECT
RW�t
CERTIFICATE
usroMEaloN:
W YEN 1
N -1
INSURERB: .�......_..
INSURED yenn Associates INSURER A: First Mercury Insurance Co. 1
657
815 S Central Ave #ZO � .... ...... .
Glendale, CA 91204 - ............... ... _,., v.r... - .... ---
INSURER C z
!INSURER D
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.
i
�..._ TYPE OF INSURANCE ... _
1311
_..... _ ...........
POLICY NUMBER m .,.....
PYY Y.....
-- ...LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
S 1,000,00
A
X...
COMMERCIAL GENERAL LIABILITY X
SE-CGL -0000007013 -03
0310612014
03!06/2015
106,
CLAIMS-MADE fil OCCUR
CUR
MED EXP Any
f &
` "�`��"
-----------
X Errors 8 Omission
� S ADV INJURY
S 1, OOtI,O
Owners Sr Contract
GENERALAOGREGATE
$ 6,000.0
GEML AGGREGATE LIMIT APPLIES PER:
w
I PRODUCTS _C(MPIttlA00
CI In Al
In.I........_.
P O-
X POLICY LOC
s
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
$
(l J
ANY AUTO
(Es accident)
BODILY INJURY (Per person)
$
ALL OWNED AUTOS
BODILY INJURY( Per ecddent)
S
SCHEDULED AUTOS
PROPERTY DAMAGE
$
HIRED AUTOS
: (PEP! ACCIDENT)
NON -OWNED AUTOS
$
$
UMBRELLALIAB OCCUR
EACH OCCURRENCE
S
EXCESS LAB IM - MADE
.... ..
..................... _
p _
M.
- -----
$
DEDUCTIBLE
8
»., m .............................. �.. ....,...
5
RETENTION
$
WORKERS COMPENSATION
I WC STATU. OTH-
AND EMPLOYERS' LIABOJTY YIN',
Y_L1M1T8 ..__
.......................... - -....
ANYPROPRETOR)EXCLUDED?ECU'Tb'VL
�
EXCLUDED?
CH ACCIDENT
$
(Mandatory NH
atn
EL DI ASE FA EMPLOYE E
�
S
'
"fl' ��'�"r"
___...
....................._
D K VlP O OF OPERATIONS q �
I E,L. DISEASE, POLMY LIMIT
S
DESCRIPTION OF OPERATIONS) LOCATIONS I VE411CLES (Attach ACORD 101, Additional Remarks Schedule, It mom space Is required)
:ity of El Segundo its officere officiale,emtl loyees,,agents and
volunteers are named as additwi.o aal insured w th respect to the work
performed by the named insured.
[nvestigation, CA --
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS,
350 Main Street
El Segundo, CA 90245 ALRTiORQED REPRESENTATIVE
®1906 -2009 AGORD CORPORATION. All rights reserved.
ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: SE -CGL- 0000007013 -03
COMMERCIAL GENERAL LIABILITY
CG 20 26 07 04
ADDITIONAL INSURED - DESIGNATED
PERSON OR ORGANIZATION
This endorsement modilles insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
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" cau
in whole or in part, by your acts or omissions or e
acts or omissions of those acting on your behalf.
A In the performance of your ongoing operations;
B. in connection with your premises owned
by or rented to you.
CG 20 26 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDING /DELETING ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART
PRODUCTSICOMPLETED OPERATIONS LIABILITY COVERAGE PART
LIQUOR LIABILITYCOVERAGE PART
In consideration of a $50 additional premium, the following endorsement(s) are either added to, or deleted
from, the policy, the effective date as of the date shown below:
DED DELETED FORM NUMBER & NAME
CG 20 26 (07/04) - ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION
_,. _. .. City of Et Segundo 350_Maia_St EI_Segundo. CAS0245
TA MN'T
xlC ..k..� ,,.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
This endorsement forms a part of the Policy to which attached, effective on the inception date of the Policy unless
otherwise stated herein.
(The following information is required only when this endorsement is issued subsequent to preparation of the Policy.)
Endorsement effective 12/05/2014 Policy No. SE- CGL-0000007013 -03 Change No.1
Named Insured Unique Sports Accessories Inc (DBA) Wyenn & Associates
Countersigned by *gcok
FMIC -GL -2200 (11/2011) _ _ (Authorized Representative) Page 1 of 1
Shill in , Mona
From: Shilling, Mona
Sent: Wednesday, January 21, 2015 12:25 PM
To: Garcia, Angelina
Subject: Pending PSA #4796 w/Wyenn & Associates - Proof of Insurance Question
Angie,
This email is regarding pending Professional Services Agreement No. 4796 with Wyenn & Associates. You signed off on
the proof of insurance and the agreement. I just want to verify you waived the proof of Workers Compensation along
with the Waiver of Subrogation for the Worker's Compensation and the proof of Automobile Liability. Question thou. h
the vender crossed off the proof of Auto at 1M and put 500K? But the certificate indicates you have waived the r i d
proof? Also, are you waiving the proof of Professional Liability?
Thanks, �4 ,
Mona S
/a
Deputo C,-ty Cl erg
CLtu of EL SegL-twdo y V,
aLtU cl,eriz's a f ae p
35-0 MaLvL street '
aOz PhovLe Nkmbere (3:o) 5-24-2s07 �t a
1