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PROOF OF INSURANCE (2013) CLOSED' W?'" CERTIFICATE OF LIABILITY INSURANCE F10/19/2012 DATE (MM /DD 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 (he 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 endorsement(s), PRODUCER CONYYE.0 T Dove Sholk Hatter, Williams & Purdy Insurance ss (760)7�95p -2002 �i (760)929 -0534 2230 Faraday Ave EMAIL � dsholk @h insurance . com N PRODUCER 00015239 CUSTOMER 10 #: tn G # INSURED CoRACE NAIC Carlsbad CA 92008 INSURE 1NSURERA:Maxum Indemnity 4 t pany 26743 Vwvmr%m%3M0 t", rmIlr" rit ,i4.1t.9Y,t1.#4trb1.K:.1c --L.') Masr.er 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, EXCLUSION'S AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NNSR ..... TYPE OF INSURANCE _ ADDLy (l D POLICY NUMSER MMA17S?IYYYY) 9MM7DrNY AM ip LTR LIMITS GENERAL LIABILITY EACH OCCURRENCE $. 1,000,000 X, COMMERCIAL GENERAL LIABILITY DAMAGE R.) RENTED �'I�EMIISE�..r���ua�d�...r,an,) �... 100,000 4 eu A CLAIMS -MADE CI! OCCUR X E3C3G001.194408 7/1/2012 1/1/2013 MED EXP Art one remora) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 1,000,000 X POLICY PRO- ...... LOG $, mm AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate holder is named as Additional Insured per form CG2026 L,ri%Ilr`y4..AIr. r°1UILUtZK CANCELLATION' City of El Segundo, its off s officials, employees, agent , and volunteers 350 Main St El 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 REPRESENTATIVE Digitally signed by Dove Sholk DN: cn =Dove Sholk, o, ou, Dove Sholk ernail= dsholk@hwpinsu rance.corn, c =US )ove Sholk Date: 2012.10.1915:4737 - 07'00' wL,UKU zo (zuua /UU) ©1988 -2009 ACORD CORPORATION. All rights reserved. INS025 (200909) The ACORD name and logo are registered marks of ACORD (Ea accident) $ ANY AUTO ---- - BODILY INJURY (Per person) $ ALL OWNED AUTOS,._._... ''.... BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON -OWNED AUTOS $ .._..... .._.,. —. ......... UMBRELLA LIAB OCCUR .._._._ ....... .__. ...m- . -. -... _ EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE ....,,..... ... AGGREGATE $ DEDUCTIBLE .. RETENTION $ $ WORKERS COMPENSATION WC STATU- O�TH �TO,F3.Y..LLM AND EMPLOYERS' LIABILITY Y/N ,., -.,, T, I_tti..�, ,� -. ANY PROPRIETOR /PARTNER /EXECUTIVE E L EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? ... (Mandatory in NH) E L DISEASE - EA EMPLOYEE ". $ '.. It yes, describe under '.. -- -- -- DESCRIPTION OF OPERATIONS below _. '.... E.L, DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate holder is named as Additional Insured per form CG2026 L,ri%Ilr`y4..AIr. r°1UILUtZK CANCELLATION' City of El Segundo, its off s officials, employees, agent , and volunteers 350 Main St El 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 REPRESENTATIVE Digitally signed by Dove Sholk DN: cn =Dove Sholk, o, ou, Dove Sholk ernail= dsholk@hwpinsu rance.corn, c =US )ove Sholk Date: 2012.10.1915:4737 - 07'00' wL,UKU zo (zuua /UU) ©1988 -2009 ACORD CORPORATION. All rights reserved. INS025 (200909) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: BDG001194408 COMMERCIAL GENERAL LIABILITY 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 Person or Organization: City of El Segundo, its officers, officials, employees, agents, and volunteers 350 Main St El Segundo, CA 90245 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule as an insured but only with respect to liability arising out of your operations or premises owned by or rented to you. CG 2026 11 85 Copyright, Insurance Services Office, Inc., 1984 ACIORO � VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE DATE (MMIDD/YYYY) October 3, 2012 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. This form is used to report coverages provided to a single specific vehicle or equipment. Do not use this form to report liability coverage provided to multiple vehicles under a single policy. Use ACORD 25 for that purpose. PRODUCER -- T Elaine Farfan PAUL O'NEILL, AGENT LIC: # 0592873 209 W. SAN BERNARDINO ROAD COVINA, CA 91723 INSURED RENNER, ANDREW 1431 W CIENEGA AVE SAN DIMAS, CA 91772 YEAR MAKEI MANUFACTURER MODEL 2003 1 FORD I ECONOLINE DESCRIPTION 626 915-5666 1NSURERLSI AFFORDING COVERAGE State Farm Mutual Automobile Insurance Company C: 626 915 -0055 BODY TYPE VEHICLE IDENTIFICATION NUMBER VAN 1 1FDPE24L73HB51709 SERIAL NUMBER COVERAGES CERTIFICATE NUMBER: REVISION NUMRFR- 25178 THIS 15 TO CERTIFY THAT THE POLICY(IES) OF INSURANCE LISTED BELOW HASIHAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD('$) INDICATED, NOIWITHSTA14DINGa ANY' REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT" TO W41CH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE ,INSURANCE AFFORDED BY THE POLICY(IES) DESCRIBED HEREIN ISIARE SUBJECT TO ALL THE TERM'S, EXCLUSIONS AND CONDITIONS OF SUCH POUCY(IES). INSR AWL POLICY EFFECTIVE POLICY EXPIRATION iNSRD TYPE OF INSURANCI? POLICY NUMBER DATE (MMIDD/YYYY) DATE (MMIDDNYYY) LIMITS VEHICLE LIABILITY '.. COMBINED SINGLE LIMIT $ 117 3534FO6 -75 06106/2012 12/0612012 BODILY INJURY (Per person) „ $ 1,000,000 BODILY INJURY (Pet accident) $ 1,000,000 PROPERTY DAMAGE $ 1,000,000 GENERAL LIABILITY EACH OCCURENCE $ OCCURRENCE GENERAL AGGREGATE S CLAIMS MADE _u i INSR L0.9s POLICY EFFECTIVE POLICY EXPIRATION LTR PAYEE TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YYYY) DATE (MMIDDIYYYY) LIMITS I DEDUCTIBLE .. N LOSS O• V X EH COLLISI ACV....___ ❑ .u__�- ----- ,.._ E] AGREED AMT ,m._.µ ..,..m_....__. ............. ; LIMIT 117 3534F06 75 06/06/2012 12/06!2012 ❑ ❑ STATED AMT $ 500.00 DEC .. VEH COMP�.._. X VEH OTC ............ ❑ ACV ❑ AGREED AMT ; LIMIT —�� 117 3534F06 -75 06/06/2012 121OW012 ❑ ❑ STATED AMT $500.00 DED PROPERTY ❑ ACV ❑ AGREED AMT BA: BROAD ❑ RC ❑ STATED AMT S LIMIT DED DED .e.., SPECIAL .._�..,_.. . . . .. .................. . . . .. . . . . REMARKS (INCLUDING SPECIAL CONDITIONS I OTHER COVERAGES) (Attach ACORD 101, Additional Remarks Schedule, If more space Is requlred) ADDITIONAL INTEREST CANC'ELLATIO'N Select one of the following: SHOLILD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Y s O DELIVERED IN ACCORDANCE W THEREOF, NOTICE WILL BE l�e�aro$t Ih�a� hee'surermitlrcbed e� add the additional interest described below to the of cY (' ) WITH THE POLICY PROVISIONS The additional interest described below has been added to the policy(ies) listed herein by policy numbers _ BEFORE THE EXPIRATION DATE VEHICLE /EQUIPMENT INTEREST: LEASED FINANCED DESCRIPTION OF THE ADDITIONAL INTEREST NAME... .........'._ °__..._........._. .._.._......: - ........._.,_ __._. .._____ -..� AND ADDRESS OF ADDITIONAL INTIERESF ADDITIONAL INSURED LOSS PAYEE LENDER'S LOSS PAYEE LOANILEASE N''. 'ER AUTI RIZED 9SENTATIyV I0 / h-li 19 - trl 0 A 10 CORPORATIOIrAbLirights reserved. ACORD 23 (2010105) The ACORD name and logo are registered marks of ACOR 1004361 142987 09.30 -2011