Loading...
PROOF OF INSURANCE (2013) CLOSEDC CERTIFICATE OF LIABILITY INSURANCE °ATE`MM' ° °'YYYY' L -- 01/14/2013 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(ies) must be endorsed. If SUBR ,GA'TIOhN 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 I Ry!11ACT Steoha.nie Weiss. 715 - 246 -4257 RJF Minneapolis 7225 Northland Dr N #300 1rit / s —ra.. _ .... .. ..... I t�v� l wol. ADDRESS' cerisspec 'ialtylnsuranceagency,com ... .. OF Minneapolis, MN 55428 INSURERS) AFFORDING COVERAGE NAIC # THE INSURED INSURER A: Lexington Insurance Com�p �any - 19437 INSURED Performers of the U.S. and Club Members/ INSURER B :, mmmmmmm_ Phone: 715 - 246 -8908 Fax: 715 - 246 -4257 INSURER C : '-- Attn: Stephanie Weiss PO Box 24 INSURE.......... �W ........................................................................................................._..........,.-.............. ..................----......--- R __ ..... ... __........ _........ MAY BE ISSUED OR MAY New Richmond, WI 54017 INSURER E: ... THE POLICIES INSURER F: HEREIN IS SUBJECT TO ALL THE TERMS, 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. tNSR'. �'X"Y5'�L "... .�...�..._ . .. ....... .......... r't.7LICYEFF POLICY EXP ........_ -__ LTR, '', TYPE OF INSURANCE INSR WVQ POLICY NUMBER MM /DD /YYYY ) (MM/DDM= (MM/DD . LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 3,000,000 T 100'000 .COMMERCIAL GENERAL LIABILITY PREMISES,�Ea occurrence $ 5,000 CLAIMS -MADE OCCUR MED EXP (Any one person)mmmm $ 'X' A LX9776 08/04 X X 014245884 04/25/12 04/25/13 3,000,000 PERSONAL IADVINJURY $ X LX0404 GENERAL AGGREGATE .....,., . _ .. ............................... $ 5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 5,000,000... X PRO- POLICY POLICY JECT LOC $ AUTOMOBILE LIABILITY ....... COMBINEOSIRGLE .t-'� fa 'aa,cwdenll ANY AUTO BODILY INJURY (Per person) $ _... ALL OWNED SCHEDULED ................... ........... BODILY INJURY (Per accident) .._ $ AUTOS AUTOS ... ......... NON- OWNED .,.,c PEFYT'Y f.7AMAUE. $ HIREDAUTOS AUTOS (Pe.racoldent)�ITITITIT._.IT ...... ....................... _ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N "�"'�" '("'(" ') " " " " " " "" -ER- ANY ECUTIVE EACH EMB EXCLUDED? ❑ N/A ..... (Mandaory HR E L, EASECIEA EMPLOYEE $ If 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) PERFORMER IS A NAMED INSURED AS A MEMBER OF PERFORMERS OF THE U.S. (FORM LEXD00O21 LX0404): Jeffrey C. Parmer dba Great Magic Productions by Jeff Parmer Additional Insured: RE: Farmer's Market, January 17, 2013, The City of El Segundo, its officers, officials, employees, agents and certified volunteers are named as additional insured, but only insorfar as the operations under this contract are concerned. Finail• vramnc(niPlcanl Inrin nrn Attn- Citv CIPrk Q' CERTIFICATE HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE RE: Farmer's Market THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street, Room 5 ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 -3813 AUTHORIZED REPRESENTATIVE } ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 014245884 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. 'CI1ED Wf Name of Person or Organization: Any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. This insurance will be deemed "primary' such that any other insurance that may be carried by City of El Segundo will be excess thereto. This insurance will be on an "occurrence ", not a "claims made" basis or equivalent. (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, but only with respect to liability arising out of "your work" for that insured by or for you. CG 20 10 11 85 Copyright, Insurance Services Office, Inc. 1984 Page 1 of 1 01/10/2013 16:16 3106973395 JEFF PARMER PAGE 04/94 '1 v Interinsurance Exchange of the Automobile Club Automobile Insurance Policy Coverages and Limits Renewal Declarations We are pleased to offer you a renewal for your automobile insurance policy To renew your policy, send at least the minimum payment on or before the due date Insurance is in effect only for the vehloles, coverages, and limits of liability shown on this declarations page and as set forth in the insurance policy and endorsements These declarations, together with the contract and the endorsements in effect, completa your policy. If any change to your policy or to the information we have on file results in a premium decrease during the policy period, the Interinsurance Exchange reserves the right to apply any refund due to your outstanding balance. NAMED iNS RED Ind 1.1 PARMER, JEFFREY 18004 S HOBART BLVD GARDENA CA 90248 -3616 AUTO POLICY NUMBER; CAA 069046092 �CLII�Y PERiob (PACIFIC STANDARD TJ' POLICY EFFECTIVE DATE: POLICY EXPIRATION DATE: 0641.12 12:01 A.M. 0641 -13 12.01 A.M. VEHICLES Vehicle 1 Vehicle 2 VeNde 3 Comprehensive ACV ACV V E H CQR YEAR MAKE MODEL IDENTIFICATION VEHICLE GARAGE ANNUAL" VERIFIED NUMBER ACV NUMBER use ZIP CODE MILES ULEAGF. 1 2007 KAWA ZZ R600 JKAZX4JI67AC67283 PLEASURE 90277 1-2,500 VERIFIED 2 2000 BMW M ROAD CONV WESCK9341YLC03049 PLEASURE 90277 2,501 - 5,000 VERIFIED 3 2006 TYTA 4RUNNER SR5i5PORT JTP-ZU14RB60OW867 PLEASURE W277 10,001 - 15,000 VERIFIED COVERAGES AND OMITS ANNUAL PREMIUMS Coverage is not In effect unless a premium or the word "included" is shown. COVERAGES LIIATS Of LIABILITY Vehicle 1 Vehicle 2 Vehicle 3 Vehicle Vehicle Liabllify , Bodity Injury S1.000.00d each pera*N $1.000,000 each occurrence $110 i $202 A S318 J Properly Damage $250.000 each occurrence $26 5 117 $ 194 Excess Medial Payments SS,000 each person Physical Damage (Akm 1 east, value unlace alherMae aura, we dogmola) NA NA ftdily lniu(y -V9 -V * $600,000 *30 pervord 5500.000 each accident Uninsured b Underinsured Vehicles Uninswed Deductible Waiver Uninsured Collision Total Premium 1 a. i NA € $20 $21 M 9' i Vehicle Vehicle i $ 32 $ 88 $ 66 a $136 $ 429 $433 a I ; , NA NA NA $142 Included NA 14" see ' S107 i included Included i NA " NA PREMIUM DISCOUNTS "NA" indicates coverage not purchased. Please refer to the enclosed document entitled "Premium Discounts Applied to Your Automobile Polity." Total Annual Premium` a If at any time you choose to pay less than the full balance outstanding, finance charges of up to 1.5% per month of the balance outstanding will apply as explained in your billing statements, which are part of these declarations. To see the annual mileage for your expiring policy, please refer to the "!Notice of Annual MileagyeP pauge contalned in your renewal package, "udes all applicable drseounts_) $ 2501 Less Policyholder Savings Dividend $ 320 let ium" $ 2181 tit (ji'� PROCESS DATE 05 -02 -12 PLEASE ATTACK TO YOUR POLICY (SEI? REVERSE) Vehicle 1 Vehicle 2 VeNde 3 Comprehensive ACV ACV ACV (Leas Deductible) $Soo $500 SSW Collision ACV ACV ACV (Leas Deductible) 5500 $500 $500 Car Rental Expense NA NA ftdily lniu(y -V9 -V * $600,000 *30 pervord 5500.000 each accident Uninsured b Underinsured Vehicles Uninswed Deductible Waiver Uninsured Collision Total Premium 1 a. i NA € $20 $21 M 9' i Vehicle Vehicle i $ 32 $ 88 $ 66 a $136 $ 429 $433 a I ; , NA NA NA $142 Included NA 14" see ' S107 i included Included i NA " NA PREMIUM DISCOUNTS "NA" indicates coverage not purchased. Please refer to the enclosed document entitled "Premium Discounts Applied to Your Automobile Polity." Total Annual Premium` a If at any time you choose to pay less than the full balance outstanding, finance charges of up to 1.5% per month of the balance outstanding will apply as explained in your billing statements, which are part of these declarations. To see the annual mileage for your expiring policy, please refer to the "!Notice of Annual MileagyeP pauge contalned in your renewal package, "udes all applicable drseounts_) $ 2501 Less Policyholder Savings Dividend $ 320 let ium" $ 2181 tit (ji'� PROCESS DATE 05 -02 -12 PLEASE ATTACK TO YOUR POLICY (SEI? REVERSE)