No preview available
PROOF OF INSURANCE (2011) CLOSEDTo; Froo:Stato Farm Fax.State Fero KOFAp? at_JAN -27 11 -16:41 Doc-342 Pagn:004 DATE (MM OD/YYYYI AC4CYRJ6 CERTIFICATE OF LIABILITY INSURANCE 01/27/2011 ^" TH &S CRTIFNrATE IS ISSUEI3 A6: MATTER O IN'FOR�TATION PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MORTON V ROBERTS RJR LICENSE# 0035481 HOLDER. TH18 CERTIFICATE DOES NOT AMEND, EXTEND OR 3306 HELMS AVE ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. CULVER CITY, CA 90232 INsJRED KIP,F; WO:LFSBERGER DBA KIRK FLOORING 105 w MOLLY AvE EL SEGUNDO, CA 90245 INSURERS AFFORDING COVERAGE f,j!UIERA rare Farm G4ne'r,Ea1 Insurl n NAIC# 25143 INSURER E: THE FoLpES OF INSURANCE LISTED BELOW HAVE 13EEN ISSUED To THE INSURED NAMED ABOVE FOR COVERAGE'S ANY REOUIREMEN TERM OR CONDRTION OP ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TTO WHICH THIS CERTIFICATE MAY ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE WWI S SHOWN I— HAVE BEEN REDUCED BY PAID CLAIMS INS!P adG. POLICY L- FFECTIVE POLICY EYFaR,ATION LTi9 III3I %6Y TYPE OF INSUR4NCE POLICY NVIABER DATE w�wuszCYrfY DATE MHre%�ONY A X I,ENERALLIABILITY 92 -Qv- 7297 -4 09 -01 -2010 09 -01 -2011 X rOr» AERCIAL 4sN'ER LLAaw„rrY CLAIMS MADE LJOCCUR x NCrIi 0ItIED AUTOS HIRED AUTOS GOJL AGGREGATE LIMIT AFF'Le9 P% )MOOke LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON- O\M,IEO AUTOS LIABILITY AUTO CLAMS MADE LJDEDUCTIBLE RETENTION E WORKERS coMPENSATION AND EMPLOYERS, LIABILITY ANY PROPRIETOWPARINERAEY CuTIVE OFFICER MEMBER FYCLUDED9 OTHER LtlMITB 9ACH PjC'�.URRSIpi^.d: 1, 001 , 000 f ,S r rrrA PPerVO E ;O },ODD I K 1000 P ERSOI AL 4 AIN %N AY D D D DOD GENERA_ AG R /,ATE 000, (100 MOD. J s- COMP,OPA00 2, 000, 000 COMBINEDSINGLELIMIT S (Ea amidanl) BODILY INJJRY (vor oar:or11 GODLY INJJaY 1 (Per ewclont) PRORF.PTVDAMAGE T (P¢raed 'an 0 x 'TR I,r{.V , EA A ICE)jT OTHER THAN EA. /,Cr•: AUTO 0141.Y F RO PL- AR- EIII"IF ..... .... .. ieOORCO "I T'i7•. t WC STATU• 0TH- . DRV LIMITS. ER E L FA(,,H ACCIDENT S.. ELDISEASF- F�FMPL.OVEE 4 ,,,, EI.0)SEASE - POLICY LIMIT t DESCRIPTION OF OrNAATIONS i LOCATIONS / VEHICLES i Gl(CLUSIONe ADDED BY ENDORSFUENT /SPECIAL PROVISIONS CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGF,'NTS AND VOLUNTEERS C/O CI'rY CLERK 350 MAIN STREET, ROOM 5 EL, SEGUNDO, CA 90245 -8313 CERTIFICATE HOLDER CANCELLATION CITY OF EL SEGUNDO, ITS Of FI.C'ERS, OFF C„".IA,LS,, 9iOULO ANY OF THE ABOVE 00cmoCD POLICIES BE CANCELLED BEFORE THE E?PIRATION EMPLOYEES, AGENT'S AND VOLUNTEERS DATE THEREOF, THE Ie6UINC INSURER WILL ENDEAVOR TO MAIL _U- OAYB WRI'irEN (7/0' CITY CLERK NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL 350 MAIN STREET, ROOM 5 IMPOSE NO OBLIGATION OR LIABILR'Y OF ANY KIND UPON THE INSURER ITS AGENTS OR EL SEGUNDO, CA 90245 -8313 RfPRESEFdiATIVE'S. AIJITINORuzED REPRESEb^ITAT %VE !MORTON V ROBERTS, ACORU lS �2UUIIOU) I ILI„ EuR'da4l%awI O 194 F4 01 EWMwwz , P A . , .,. .. , .._... Q Aj I rig rfm to 132849 03-13-2007 To= From: State Fare Fax-State Ferro KOFAXA) at- jAN-27- 2011 -16:41 DOC:342 Page: = Policy No.: 92- QV- 7297 -4 SECTION 11 ADDITIONAL INSURED ENDORSEMENT Policy No.: 92- QV- 7297 -4 Named Insured: KIRK WOLFSBERGER DBA KIRK FLOORING 105 W HOLLY AVE EL SEGUNDO, CA 90245 Additional Insured (include address): CITY OF EL SEGUNDO, ITS OFF S, OFFICIALS, EMPLOYEES, AGENTS AND VOLUNTEERS C/O CITY CLERK 350 MAIN STREET, ROOM 5 EL SEGUNDO, CA 90245 -8313 FE -6609 A WHO IS AN INSURED, under SECTION II DESIGNATION OF INSURED, is amended to include as an insured the Additional Insured shown above, but only to the extent that liability is imposed on that Additional Insured solely because of your work performed for that Additional Insured shown above. Any insurance provided to the Additional Insured shall only apply with respect to a claim made or a suit brought for damages for which you are provided coverage. The Primary Insurance coverage below applies only when there is an "X" in the box. ® Primary Insurance. The insurance provided to the Additional Insured shown above shall be primary insurance. Any insurance carried by the Additional Insured shall be noncontributory with respect to coverage provided to you. All other policy provisions apply. FE -6609 Printed in U.SA Tae Frw State Farm Fax:5tate Fare KoPA". at: dA1 -27 11 -16:41 Doc: 342 Page: 003 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the polloy(ies) must be endorsed. A statement 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 emend, extend or alter the coverage afforded by the policies listed thereon. ACORD 23 (2001108) ZAH CERTIFICATE OF LIABILITY INSURANCE R054 1 DATE (MM /DD/YYYY) 01 -31 -2011 THIS CERTIFICATEIS 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 SUBROGATIONIS 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 CONTACT NAMEi PACIFIC (866)467N8730CF: (877)905 -0457 u,C _(,866)467 X730 (A /c „Nod; (877) 0457 ADDRESS PO BOX 33015 PR"ObUC k ......... ........ ............. ..... - SAN ANTONIO TX 78265 CUSTOMER ID #... __ --------- _ . INSURERS) AFFORDING COVERAGE NAIC # INSURED INSURER A: Hartford Underwriters Ins CO 30104 KIRK WOLFSBERGER D /B /A KIRK FLOORING INSURER e „ 105 W HOLLY AVE INSURER C EL SEGUNDO CA 90245 INSURER D INSURER 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 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. / SR ODL SLfBR ...... ___ r..."'” .�l�CfCV i=XV�. LTR TYPE Of INSURANCE WVD POLICY NUMBER /MMJDD/YYYYI (MM/DD/YYYY/ LIMITS .__..�. .... .... ....... ...._......... . ...... GENERAL LIABILITY EACH OCCURRENCE �S DAMAGE "I C REN`TE�i LIABILITY ,a,arrrrrucal $ COMMERCIAL GENERAL PREMISES IEa ort .� CLAIMS -MADE [ ] OCCUR MED EXP (Any one ersonl . ,. S PERSONAL & ADV INJURY $ GENERAL AGGREGATE S LOC . �; iaOL >CYE LIMIT .AfM,R......WW..... PRODUCTS COMP /OPAGG.., $ ......... I RO• AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ,,,,, ......... ,� .... ..............A BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMA . ..GE $ HIRED AUTOS (Per accident) ..,,, - ------._ .................�_.... NON -OWNED AUTOS $ u .. ®. $ CMS MADE LAI ....... -- .. __ ------------ -------------------------- OCCUR _... �.... �.., UMBRELLA LIAR EACH OCCURRENCE, $ EXCESS L /AB AGGREGATE $ DEDUCTIBLE S RETENTION $ _ $ ANY MPLO BLRS'LABILTY N _ww..wwwww TOR.YLIMITS., 0TH COMPENSATION X WC STATU ER AOFFICER/MEMBER EXCLUNERIEXECt)TIVE." E.L. EACH ACCIDENT _ ASE -EANT $ 1, OOOr 000 72 WEC LX0439 08/01/2010 08/01/2011 E.L. DISE 'D' (Mandatary in NH) DED, �,,,,,,,,,,,,,,,,,,,,,,,,,,,� N/A EMPLOYE $ 1, 000, 000 If DESCRIPTION OF OPERATIONS below E L. DISEASE POLICY LIMIT yes, describe under - -------- ............................... w ............... .s...l'. ! 000 DESCRIPTION Of OPERATIONS /COCA TONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedu /e, If more space is required) Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION City Of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Its Officials and Employe O BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE City Clerk DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 MAIN ST RM 5 AUTHOR /ZED REPRESENTATIVE EL SEGUNDO, CA 90245 7a-z- �.._.... .._......_ _ ..... . ........ ............. © 1988 -2009 ACORD CORPORATION. All rights reserved, ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD PACIFIC UNIFIED INS AGCY INC /PHS PO BOX 33015 SAN ANTONIO TX, 78265 City Of E1 Segundo Its Officials and Employees c/o City Clerk 350 MAIN ST RM 5 EL SEGUNDO, CA 90245 ACORD 25 (2009/09) Jan, 20, 2011 4; 24PM. /,No 4139 F P. 1 1/4 E R S 29-66-30 Memorandum of Automobile Insurance Policy Number: 16267 - 60 - 76 Subscription Agreement - California Print Date: 01/20/2011 Effective Date: 01/20/2011 This policy is being underwritten [)asecl,, iu part, oti the information you are providing to us, Term Length: 6 mo nus which is in this Meiinorandurn of Automobile Insurarice — California (Memorandum). If you misrepresent or s�onceal any tnnaterial facts, Nye may have the right to deny coverage or to rescind this binder or your policy, Agent: Mark Hebson Name and Address of Insurer: 22925 Arlington 01 FARMERS INSURANCE EXCHANGE, LOS ANGELES, CALIFORNIA Torrance, CA 90501 NORTHWEST SERVICEPOINT Phone: (310)530 -9662 Fax: (310)530 -0081 23175 NW Bennett Street, Hillsboro, OR 97124 Named Insured: KIRK WOLFSBERGER 350 CONCORD ST EL SEGUNDO, CA 90245 -3741 Description of Vehicles: Veh. I Year Make Model VIN Rsstun Poirn's ationsl'Aaxldenis W Major Minor Accidents 1 2004 CHEVROLET SILVERADO 1500 XCAB 2WD H 2GCEC13T341428535 0 0 0 Coverages Premium Limit/Deductible tide # Vehide # Vehicle # Vehicle # Liability Each Person Each 0t4 ren Bodily Injury $100! 000 $300,11 0 $249.00 Property Damage $50,000 Included UNINSURED MOTORIST Each Person Each Occurrence Bodily Injury $30,000 $60,000 $41.50 Property Damage Included Medical /No -Fault Not Covered Vehicle 1 $1,000 Deductible $22.90 Comprehensive Deductible Vehicle 1 $1,000 Deductible $109 „90 Collision Deductible Towing Not Covered Other $2.30 Vehicle 1 Not Covered Additional Equipment Total Premium $425.60 Premium Per Vehicle $425.60 Total State Charges $0,00 State Charge Per Vehicle $0.00 Total Fees $0.00 Fees Per Vehicle $0.00 Total $425.60 Coverages included in the Other premium above 31- 5252„ SUB 12 -10 1 are described at the bottom of the following page. Jan .20, 2011 4:25PM No, 4139 P. 2/4 Policy IN umber:.1620/ - ou - 76 Declaration of Household Members - All persons who reside with you must be identified with no exception; including persons of all ages, whether or not they are drivers or licensed to drive; whether or not they are related to you by blood, marriage, or adoption; student attending school away from home; and whether or not they are insured by another insurer. Excluded drivers will be listed wpar4nely. Fla to —e Gender Marital Status DOB Driving 1xperien(e Drivers License Household llelot!Rnshi . ............ . KIRK WOLFSBERGER Male Single **/**/1956 38 Years ******04 Insured LEEANN WOLFSBERGER � , ---, I . . .. . . . . . . . Female SiMJ q **/**/1989 3 Years '"'45 Dau2hter MONICA. WOLFSBERGER Female Married **/**/1962 32 Years ******81 Resident Relative .. . . ...... . . ...... Other Vehicle Information Vehicle # I Vehicle # Vehicle # Vehicle # Year, Make & Model Year' Malce Model Year, Make Si Model Year, Make Model 2004, CHEVROLET, SILVERADO 1500 XCAB 2WD H VIN VIN VIN VIN 2GCEC13T341428535 Rated Driver Rated Driver Rated Driver Rated Driver MONICA WOLFSBERGER Occupation Occupation Occupation Occupation OTHER Work/School Address (City, ZIP) Work/School Address (City, ZIP) Work/School Address (City, ZIP) Work /School Address (City, ZIP) EL SEGUNDO, 90245-3507 Miles to Work Commute days per week 1 Miles to Work Commute days per week 1 Miles to Work Commute days per week 1 Miles to Work Commute days per week 1 2 Garaging ZIP Code Annual Mileage: Garaging ZIP Code Annual Mileage: Garaging ZIP Code Annual Mileage: Garaging ZIP Code Annual Mileage: 90245 -3741 9,332 Odometer Reading Date Odometer Reading Date 1 Odometer Reading Date Odometer Reading Date 60,235 08/13/2010 1 Car Symbols Car S 7mbols Car Symbols (3,arSyntbols BI/Po MED/PIP Physical Damage 118 1 BI /PD M[D/PlP Physical Damage I BI /PD MID/PIP Physical Damage I I Physical Damage I 19 X !�= Discounhi/Surchargas Discounts/Surcharges Discounts/Surcharges Discounts /Surcharges AB-ANTI LOCK BRAKES AT - ANT:[. T11EFT DEVICE GD-GOOD DRIVER ,kF AUT 0/1 [01AE D:[ S C 0 UNT MA MULTI CAR DISCOUNT ACROSS COMPAN.Y Z9PER',1tS'1TNCY- D[SC - 91 ?R.] Other i Other I Other I Other (TIASS IXEDUCTIBLE BUYBACK Mileage Statement: I declare that the mileage and usage information above is true and correct. I agree to contact my agent if the estimated mileage shown above changes more than 2,500 miles. Applicant lnitials#% 31-5252 SUB 12-10 2 Jan, 20, 2011vi 4: 2 7 P 9REMIUM IS PAID EVIDENCE OF INSURANCE - STATE OF CALIFORNIA Named insured KIRK WOLFSBERGER 350 CONCORD ST EL SEGUNDO, CA 90245 -3741 No.4140 P, 1/2 FARMERS Policy number: 162676076 Effective date: 01/20/2011 Expiration date: 08/13/2011 NAIC number: 21652 FARMERS INSURANCE EXCHANGE, LOS ANGELES, CALIFORNIA , an authorized California Insurer, in compliance with the California Financial Responsibility Act, certifies that it has issued a policy in an amount not less than that required by the California Financial Responsibility Law for the described motor vehicle(s). Vehicle description: Registered Owner: 2004 CHEVROLET SILVERADO 1500XCAB 2WD12GCEC13T341428535 KIRK WOLFSBERGER Agent name: Mark V Hebson Phone no: (310)530 -9662 25 -6408 4 -09 Keep this certificate in your vehicle at all times. A6408111 READ CAREFULLY '111L CALIFORNIA FINANCIAL RLSPONS1B1L11Y AC'1, (SLC'110N 16020) OF 'I11L. VL111CLL. CODE. RLQUIRLS LVLRY OWNLR OR OPERATOR OF A VLl11CLL SUBILC'1 '10111E RLQUIRL;MLK'1S OF 'III5 FINANCIAL RLSP0NS1131Lr1Y AC'I SHALL CARRY LV1L)LNCL. OF FINANCIAL RLSPONS1131LAY IN 'I11L: VL111CLL: Al ALL '111ViLS. UNL)LR VLl11CLL. COOL. (SL'CHON 16025) LVLRY DR1VLR 1NVOLVLL) IN AN ACCIDENT MUSI PROVIDE L:VIL)LNCL OF FINANCIAL RLSPOKS1B1LrIY Al '111L. SCLNL. FAILURL'10 COMPLY 1S AN 1NFRACI ION AND SI LALL BL PUN1Sl1ABLL BY A FINE OF NO'1 MORE IlIAN'1 WO 11UN URLll k1FI Y DOLLARS ($250). What to do in case of accident 1. Stop and check for injuries. Call an ambulance, if anyone is injured. 2. Warn other drivers to prevent further damage. Set flares. Signal with flashlight at flight. 3. Notify the police. Many times a passing driver or bystander will do tills for you. 4. Gather the facts. Be sure to get the names of witnesses, as well as other pertinent information. (i.e. driver's license number, Insurance information and description of the other vehicle) 5. Be careful what you say. Don't admit responsibility. Investigation may show you were not responsible. 6. Report to proper authorities. Each state has its own requirements for such reports. Know the law for your state and comply. 7. CONTACT HELPPOINT' IMMEDIATELY! FOR 24 -HOUR CLAIMS SERVICE, CALL US TOLL FREE AT 1- 800 - HELPPOINT (1- 800 - 435 -7764) FOR ASSISTANCE. PARA ESPANOL LLAME AL 1- 877 - RECLAMO (1- 877 - 732 - 5266). FARMERS INSURANCE GROUP OF COMPANIES a 4680 0[SHIRE BLVD, LOS ANGELES,CA 90010 Jan, 20, 2011N, 4:27P %EMIl1MISPAID EVIDENCE OF INSURANCE - STATE OF CALIFORNIA Named insured KIRK WOLFSBERGER 350 CONCORD ST EL SEGUNDO, CA 90245 -3741 No.4140 P, 2/2 µ;Vi FARMERS Policy number: 162676076 Effective date: 01 /20/2011 Expiration date: 08/13/2011 NAIC number: 21652 FARMERS INSURANCE EXCHANGE, LOS ANGELES, CALIFORNIA , an authorized California Insurer, in compliance with the California Financial Responsibility Act, certifies that it has issued a policy in an amount not less than that required by the California Financial Responsibility Law for the described motor vehicles). Vehicle description: Regislered Owner: 2004 CHEVROLET SILVERADO 1500 XCAB 2WD I2GCEC13T341428535 KIRK WOLFSBERGER Agent name: Mark V Hebson 25 -6400 4 -09 Keep this certificate in your vehicle at all times. Phone no: (310)530 -9662 DMV REGISTRATION COPY A6408142 The California DEpartinent of Motor Vehicles (DMv) requires proof of insurance when registering your vehicle. Above is the DMVs upy of the Evidence of Insurance form. Please provide this form to the DMV when registering your vehicle. rsu�irlr, euwx aea FARM E + Binder The insurance has been applied for and is bound for 60 days from the Effective Date pending issuance of a policy to the Named Insured. This certificate or verification of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with respect to which this certificate or verification of insurance may be issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms, exclusions and conditions of the policies. Subject to the provision of insurance Code Section 11580, 1(d), I release and agree to the exclusion of all coverage provided by this policy arising from any use or operation of negligent entrustment of a motor vehicle insured by this policy by the following designated persons: The quoted premium is subject to verification and change (increase or decrease), when necessary, by us. It may also be subject to inspection of your vehicle. Rates quoted reflect the rates in effect as of the date of the application. Rates are subject to revision. We reserve the right to accept, reject, or modify your application, this Memorandum, and /or its quotes /rates /premium after investigation and review of all underwriting information. The undersigned represents that he /she has applied for the insurance coverage(s) as set forth above, and has supplied the information stated in this Memorandum and entered into our computer records, and hereby confirms and represents that all such information is true and correct. If you do not provide complete information, or if we do not receive this signed form from you, we may issue your policy using alternative sources of information as permitted by law. The undersigned represents that he /she has read this Memorandum and understands that any discovery of misrepresented or concealed material information may result in a loss of coverage for all insureds under the policy, and the policy could be rescinded. Loss of coverage and rescission of the policy may result even if a claim is already pending or has been reported. Note: Failure to provide requested information at this time or during the policy term, within the time required, or data developed from that information, may result in the cancellation or non - renewal of your policy. Acknowledgement: FOR YOUR PROTECTION, CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS, OR KNOWINGLY PRESENTS FALSE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD AN INSURANCE COMPANY, OR PROVIDES FALSE INFORMATION CONCERNING A MATERIAL FACT ON AN APPLICATION FOR INSURANCE, OR HELPS ANY OTHER PERSON COMMIT SUCH ACTS, MAY BE GUILTY OF INSURANCE FRAUD, AND MAY BE SUBJECT TO SUBSTANTIAL CIVIL AND CRIMINAL PENALTIES, PURSUANT TO THE LAWS OF THE STATE IN WHICH THESE ACTS OCCUR MY SIGNATURE ON THIS MEMORANDUM OF INSURANCE INDICATES THAT THE INFORMATION PROVIDED IS COMPLETE, TRUE, AND CORRECT, AND INDICATES IN PARTICULAR (A) THAT I HAVE COMPLETELY, TRULY AND CORRECTLY IDENTIFIED ALL MOTOR VEHICLE ACCIDENTS IN WHICH ANY MEMBER OF MY HOUSEHOLD HAS BEEN INVOLVED FOR THE LAST THREE YEARS, AND (B) THAT I HAVE COMPLETELY, TRULY AND CORRECTLY IDENTIFIED ALL MEMBERS OF MY HOUSEHOLD, INCLUDING PERSONS WHO RESIDE WITH ME. I ACKNOWLEDGE, UNDERSTAND, AND AGREE THAT IF I DO NOT IDENTIFY ALL MEMBERS OF MY HOUSEHOLD ON THIS MEMORANDUM OF INSURANCE, MY POLICY MAY BE RESCINDED AND COVERAGE UNDER MY POLICY MAY BE DENIED. I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT. 31 -5252 SUB 12 -10 Jan, 20, 2011 4:26PM 29-66-30 No.4139 P. 4/4 Policy Number: 162 „67_ 60 - 76 I represent that I have read, understood and agree to the terms and conditions of both the above Memorandum of Insurance and the Subscription Agreement. Subscribed to this day o I - --- -------------------------- , Year Signature (if applicant is a minor, parent or guardian Must GISD sign) Please keep a copy for your records. 31-5252SUB 12-10 4 ,fan 20 2011 15:18:47 EST FROM: FZM/13449036337 MSGtt 44712488 -807 -1 .,wry The Hartford FAX COVER PAGE To: From: The Hartford Date: 01/20/1103:17.58 PM Re: Total Pages: # 3 including cover page ME 901 OF 083 PRIVILEGED AND CONFIDENTIAL: This eler ttolle eommunicaboh, including attachments, is for the eydusive use of addressee and may contain pmpdenry, conldental andlor privilaged infofmatIon. If you are hot Me intended recipient, any use, copying, disdoeure, dislseminetion or disMiiulfon is stricUy prohlbited. If you are not the intended redpient, please notify sender immediately by phone, destroy this communleatlon and all copies. Roschellc Aguilar >Policy Service Specialist >13usiness Insurance Service Operations >Phone: 869-467 -8730 >Email: agency .services @thehartford -com >You can now order a Certificate of insurance or Auto In card online at http : / /www.thehartford.com by clicking the Business tab, and then follow the Business service Center link, 5-We care about meeting your service expectations. Bid I provide you with a great Haxtford 5xperience? Pleane feel free to send any feedback on my service to 1.ocky'.cosiglinno@ThcHart £ ord.com Jan 29 2011 15:10:58 SST FROM; F2M/ 13449836337 MSG# 447124Q8 -807 -1 PAGE 802 GF 003 PACIFIC UNIFIED INS AGCY INCIPAS PO BOX $3016 SAN ANTONIO TX, 78285 City of El Segundo Safety Department 333 MAIN ST UNIT A EL SEGhUNDO, CA 90245 ACORD 215 (2009/09) To:StreemCenter(tm) From:State Farm Fax:State Farm KOFAW" at:JAN -21 -2011 -11:35 Doc:179 Page:001 Facsimile Cover Sheet Caratula de facsimil 3103222756 @fax.tc To /A Office /Address / Oficina/Direcci6n Telephone number/ Numero de telefono Insured /Asegurado(a) RTAT! lARM INSURA NCI Confidential Business State Farm® Confidencial Empresarial Providing Insurance and Financial Services Su Compaffia de Seguros y Senricios Financieros Home Office, Bloomington, Illinois 61710 Oficina Centrale, Bloomington, Illinois January 21, 2011 _...... ----------------------- -- ---------- - - - ----------- - - - - - -. _..__.. m . ............... Date / Fecha 3103222756 5 Fax number / Numero de fax Total pages/ Cantidad de paginas Claim number/ Numero de reclamo Policy number/ Numero de p6liza Notice: Confidential Business The information contained in this facsimile message information, or the taking of any action in and any attachments contains confidential reliance on the contents of this transmission, business material intended for the sole use of without the express written consent of State the individual(s) named above. If you are not Farm @, is STRICTLY PROHIBITED. If you have an intended business recipient listed above, or received this transmission in error, please notify an employee or agent of such recipient who is the sender immediately by telephone, so the responsible for delivering this material to them, return of this material can be arranged at no you are hereby notified that any disclosure, cost to you. duplication, distribution, or other use of this Aviso; Confidencial de la Empresa Adriana Jimenez From / De Office /Address /Location / Oficina/Direcci6n /Lugar Telephone number/ Numero de telefono Message / Mensaje Certificate of Insurance 190 -6580 a.6 Printed in U.S.A. Rev. 12 -03 -2004 La informaci6n qua se encuentra an el mensaie de este facsimil y cualquier documento adjunto contiene material confidential de la empresa para use exclusivo de la(s) personals) nombrada(s) anteriormente. Si usted no as el destinatario mencionado anteriormente, o un empleadoo agentede dicho destinaterioquesea responsable de entregar este material al mismo, por la presente se le notifica qua cualquier divulgaci6n, duplicaci6n, distribuci6n, u otro Fax number/ Numero de fax use de esta informaci6n, o cualquier medida qua se tome basada an el contenido de esta transmisi6n, sin el expreso consentimiento por escrito de StateFarmC, esta ESTRICTAMENTE PROHIBIDA. Si usted recibi6 esta transmisi6n por equivocaci6n, per favor notifiquenos inmedietamente portelefano pare qua podamos hater los arreglos necesarios para que nos devuelva este material sin costo alguno pare usted. To.StreemCenter ( tm) From:State Farm Fax:State Farm <<CITY OF EL SEGUNDO.pdf>> <<ADDITIONAL INSURED - CITY OF EL SEGUNDO.docx>> Please inform me of any changes if needed. Adriana Jimenez State Farm Morton V. Roberts, Jr 3306 Helms Ave Culver City, CA 90232 310.842.7679 Fax 310.842.7683 KOFAVO at:JAN -21- 2011 -11:35 Doc:179 Page :002