Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
PROOF OF INSURANCE (2011) CLOSEDACODRO CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DD/YYYY)
112/27/2010
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 cartifica'te holder Is an ADDITIONAL INSURED, the policy(le) 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 NAIPldE: t1Tan0 ic.."lucber
Earl Bacon Agency, Inc. PHONE
P.O. Box 12039�tl
Tallahassee FL 32317 ADDRESS: nkluch@earlbacon.com
INSURED
MGT of America, Inc.
2123 Centre Point Blvd.
Tallahassee FL 32308
INSURER C:
COVERAGE II NAIC
CnVFRAnFS CFRTIFICATF KIIIMRFR•-1 nnAgSRSQ7 RFVISIr]N MIIMRFP-
20427
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.
IN5R. IT ........ ._. ........ _. ........ .......� ...........
LTR TYPE OF INSURANCE POLICY NUMBER MMI D YYY (MMIDDIYYYYI LIMITS
A
GENERAL
LIABILITY
Y
Y
2093390918
7/1/2010
,7/1/2011
EACH OCCURRENCE
$1,000,000
COMMERCIAL GENERAL LIABlUTY
X
__.
PREMISES 0I rr.rarne
$300, 000
CLAIMS -MADE OCCUR
.1.,�...w
_.....
MED EXP (An,one person)
....
$5,000
X
PERSONAL& ADV INJURY7
$1,000,000
A -XV Rating
_
GENERAL AGGREGATE
$2,000,000
-
GEN"L
AGGREGATE LIMIT APPLIES PER:
PRODUCTS- COMP /OPAGG
$2,000,000
X
POLICY 0 PRO- LOS:
$
B
AUTOMOBILE
LIABILITY
2093563501
7/1/2010
7/1/2011
COMBINED SINGLE LIMIT
$1,000,000
(Ea accident)
X
ANY AUTO
BODILY INJURY (Per person)
$
ALL OWNED AUTOS
..._..._ .._ -...
BODILY INJURY Per accident
$
SCHEDULEDAUTOS
PROPERTY DAMAGE
X
HIRED AUTOS
(Per accident)
$
X
NON -OWNED AUTOS
X
A -XV Rating
$
C
X
UMBRELLA LIAR X OCCUR
2093563496
7/1/2010
7/1/2011
EACH OCCURRENCE
$4,000,000
EXCESS LIAB CLAIMS -MADE.
AGGREGATE
$4,000,000
DEDUCTIBLE
.m.m�
._..,. M... ....... _.._,�.,.�..�...�..�
$
X
RETENTION $10,000.
$
A
WORKERS COMPENSATION
Y
3011086712
7/1/2010
7/1/2011
X WOSTATU- X OTH-
CA EL -Below
C
AND EMPLOYERS' LIABILITY Y/N
3011OB678B CA
7/1/2010
7/1 /2011
"IMI R
ANY PROPRIETORIPARTNER/EXECUTIVE
E.L. EACH ACCIDENT
$500,000
OFFICER/MEMBER EXCLUDED? ❑
NIA
(Mandatory In NH)
E.L. DISEASE -EA EMPLOYE
$500, 000
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
1 $500,000
D Professional Liab.(E &0) 104968324 7/1/2010 7/1/2011 'Limit $2,000,000
Claims -Made Form Aggregate $3,000,000
,7/5/95 Retro Date Deductible $25,000
DESCRIPTION OF OPERATIONS /LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
Umbrella:A -XV Rating. All other Workers Compensation and CA Workers Compensation: A -XV Rating, California
Employers Liability Limits: $1,000,000 each Accident /$1,000,000 Disease Policy Limit /$1,000,000 Disease
Each Employee.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
City of E1 Segundo
350 Main Street
El Segundo CA 902 AUTHORIZED REPRESENTATIVE
©1988 -2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER IN67RED NAME AND ADDRESS
P 2093390918 MOT OF AXERICA, INC.
2123 CENTRE POINT BLVD
TAUAAASSEE, FL 32308 -4930
POLXCY CWWQH0 - -
ENDORBEMENT RFFECTiVB. 12127110
This Change Endorsement changes the Policy. Please read it carefully.
This Change Endorsement is a part of your Policy and takes effect on the
effective date of your Policy,, unless another effective data is shorn.
The following Form(s) has (have) been added:
Form 4: G15115A Title:- Changes- Notice of Cancellation or
Material Coverage Change
Number of days: 30
City of El Segundo City Clear;
Attn.: Business Serv. Divi.s yin
350 Main Street, Room 5
E1 Segundo, CA 90245 --381
1
0
O
0
C
Chaiartan of the Board
G- 56015 -B (ED. 11/91)
secretary
MGT of America Policy#2093390918 Effective 7/1/10 -11
POLICY NUMBER: CG 24 04 10 93
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS
OF RECOVERY AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY OVERAGE PART
SCHEDULE
Name of Person or Organization
Refer to SCHEDULE CG24
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
The TRANSFER OF RIGHTS OF RECOVERY AGAINST
OTHERS TO US Condition (Section N -- COMMERCIAL
GENERAL LIABILITY CONDITIONS) Is amended by the
addition of the following:
We waive any right of recovery we may have against the
person or organization shown in the Schedule above
because of payments we make for injury or damage arising
out of your ongoing operations or "your work" done under a
contract with that person or organization and included In the
"products-completed operations hazard." This waiver
applies only to the person or organization shown in the
Schedule above.
CG 24 04 10 93 Copyright, Insurance Services Office, Inc., 1992
MGT of America, Inc. Policy#2 093390918 Effective 711/1 0-11
OVA
G- 17957 -G
(Ed. 01 /01)
IMPORTANT: THIS ENDORSEMENT CONTAINS DUTIES THAT APPLY TO THE ADDITIONAL
INSURED IN THE EVENT OF OCCURRENCE, OFFENSE, CLAIM OR SUIT. SEE PARAGRAPH
C.1. OF THIS ENDORSEMENT FOR THESE DUTIES.
ALSO, THIS ENDORSEMENT CHANGES THE CONTRACTUAL LIABILITY COVERAGE WITH
RESPECTS TO THE "BODILY INJURY" OR "PROPERTY DAMAGE" ARISING OUT OF THE
"PRODUCTS- COMPLETED OPERATIONS HAZARD ". SEE PARAGRAPH B.3. OF THIS
ENDORSEMENT FOR THIS COVERAGE CHANGE.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CONTRACTOR'S SCHEDULED AND BLANKET ADDITIONAL INSURED
ENDORSEMENT WITH LIMITED PRODUCTS - COMPLETED OPERATIONS
COVERAGE
This endorsement modifies insurn provided under the failowing:
COMMERCIAL GENERAL U ILITY COVERAGE PART
SCHEDULE
Name of Person or Organization: pesignated project:
The City of E1 Segundo, its Officers, Officials, Employees,
Agents & Volunteers
(Coverage under this-endorsement Is not affected by an entry or lack of entry In the Schedule above.)
A. WHO IS AN INSURED (Section 11) Is amended to 2. The Limits of Insurance applicable to the
include as an Insured any person or organization, additional Insured are those specified In the
Including any person or organization shown In the written contract or written agreement or in the
schedule above, (called additional insured) whom you Declarations of this policy, whichever is less,
are required to add as an additional insured on this These L.imb of Insurance are inclusive of, and not
policy under a written contract or written agreement, In addition to, the Limits of Insurance shown In the
but the written contract or written agreement must be: Declarations.
1. Currently In effector becoming effective during the 3. The coverage provided to the additional Insured
term ofihls policy. and by this endorsement and paragraph f, of the
2. Executed prior to the "bodily injlury," "property defiinNon of "Insured contract' under
damage," or "personal and advertising Injury'. DEFINITIONS (Section V) do not apply to "bodily
Injury" or "property damage" arising out of the
B. The Insurance provided to the additional Insured is "products-completed operations hazard" unless
limited as follows: required by the written contract or written
3. That person or organization Is an additional agreement When coverage does apply to "bodily
p g Injury' or "property danarge" arising out of the
Insured solely for liability due to your negildence products-completed operations hazard" such
specifically resulting from "your work" for the coverage Will not apply beyond:
additional insured which Is the subject of the
written contract or written agreement No a. The period of time required by the written
coverage applies to liability resulting from the sole contract or written agreement; or
negligence of the additional Insured.
G- 17957 -G Page 1 of 2
(Ed. (11101)
b. 5 years from the completion of 'your worm' on
the project which Is the subject of the written
contractor written agreement,
whichever Is less.
4. The insurance rovided to the additional Insured
does not apply too 'bod,,y Injurer," "property
damage," or 'personal and advertising Injury"
arising out of an architeds, engineer"s, or
survey-are, rendering of or failure to reader any
professional services including:
a. The preparing, approving, or falling to prepare
or approve maps, shop drawings, opinions,
reports, surreys, field orders, change orders
or drawings and specifications; and
b, Supervisory, or Inspection adlvities performed
as part of any related architectural or
engineering activities.
C. As respects the coverage provided under this
endorsement SECTION IV — COMMERCIAL
GENERAL LIABILfrY CONDITIONS are amended as
Ibllows:
1. The following is added to the duties In The Event
of Occurrence, Offense, Claim or Suit Condillorx
e. An additional Insured under this endorsement
will as soon as practicable:
G-1 7957-G
(Ed. 01101)
G- 17957 -G
(Ed. 01101 )
(1) Give written notice of an occurrence or an
offense to us which may result In a claim
or "suit" wxW this Insurance;
(2) Tender the defense and Indemnity of any
claim or 'suit' to any other Insurer which
also has Insurance for a loss we cover
under this Coverage part and
(8) Agree to make
Insurance which
has for a lose
Coverage part
available any other
the additional Insured
we cover under this
f. We have no duty to defend or Indemniry an
additional Insured under this endorsement
until we receive written notice of a claim or
°sine from the additional Insured.
2. Paragraph 4.b. of the Other Insurance Condition Is
deleted and replaced with the following:
Al. Other Insurance
b. Excess Insurance
This insurance Is excess over any other
insurance naming the additional insured
as an insured whether primary, excess,
contingent or on any other basis unless a
written contract or written agreement
specifically requires that this insurance be
either primary or primary and
noncontributing.
Page 2 of 2
b. 5 years from the completion of "your work" on
the project which is the subject of the written
contract or written agreement,
whichever Is less.
4. The insurance provided to the additional insured
does not apply to "bodily injury," "property
damage," or "personal and advertising injury"
arising out of an architect's, engineer's, or
surveyor's rendering of or fallure to render any
professional services including:
a. The preparing, approving, or failing to prepare
or approve maps, shop drawings, opinions,
reports, surveys, field orders, change orders
or drawings and specifications; and
b. Supervisory, or inspection activities performed
as part of any related architectural or
engineering activitles.
C. As respects the coverage provided under this
endorsement, SECTION IV — COMMERCIAL
GENERAL LIABILITY CONDITIONS are amended as
follows:
1. The following is added to the Duties In The Event
of Occurrence, Offense, Claim or Suit Condition:
e. An additional insured under this endorsement
will as soon as practicable:
G-1 7957-G
(Ed. 01101)
G- 17957 -G
(Ed. 01/01)
(1) Give written notice of an occurrence or an
offense to us which may result In a claim
or °suit" under this insurance;
(2) Tender the defense and indemnity of any
claim or "suit" to any other insurer which
also has insurance for a loss we cover
under this Coverage Part; and
(3) Agree to make available any other
insurance which the additional insured
has for a loss we cover under this
Coverage Part.
C We have no duty to defend or indemnify an
additional insured under this endorsement
until we receive written notice of a claim or
'sult" from the additional insured.
2. Paragraph 4.b. of the Other Insurance Condition is
deleted and replaced with the following:
4. Other Insurance
b. Excess Insurance
This insurance is excess over any other
insurance naming the additional insured
as an insured whether primary, excess,
contingent or on any other basis unless a
written contract or written agreement
specifically requires that this insurance be
either primary or primary and
noncontributing.
Page 2 of 2
MGT of America, Inc. Policy 3011086788 Effective 7/1/10 -11 -CA
CNA
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY
BLANKET WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS
G- 19160 -B
(Ed. 11/97)
This endorsement changes the policy to which it is attached.
It is agreed that Part One Workers' Compensation Insurance G. Recovery From Others and Part Two Employers'
Liability Insurance H. Recovery From Others are amended by adding the following:
We will not enforce our right to recover against persons or organizations. (This agreement applies only to the extent that
you perform work under a written contract that requires you to obtain this agreement from us.)
PREMIUM CHARGE -
The charge will be an amount to which you and we agree that is a percentage of the total standard premium for California
exposure. The amount is
G- 19160 -B Page 1 of 1
(Ed. 11197)
MGT of America, Inc. Policy 3011086712 Effective 7/1/10 -11 All Other
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
WC 00 0313
(Ed. 4 -84)
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.)
This agreement shall not operate directly or Indirectly to benefit anyone not named in the Schedule.
Schedule
ANY PERSON OR ORGANIZATION ON WHOSE BEHALF YOU ARE REQUIRED TO OBTAIN
THIS WAIVER OF OUR RIGHT TO RECOVER FROM UNDER A WRITTEN CONTRACT
OR AGREEMENT.
Y
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 Policy No. Endorsement No.
Insured Premium $
Insurance Company Countersigned by
WC 00 03 13
(Ed. 4 -84) Copyright 1983 National Council on Compensation Insurance.