PROOF OF INSURANCE (2011) CLOSEDACC>R" CERTIFICATE OF LIABILITY INSURANCE F DATE (MM/DDfYYYY)
1 03/30/2011
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 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).
IPRODUCER CONTACT
NAME:
� 111.1.11,111,111,111,'ll,���'ll""I'll""I'll",'ll1l.1— -111-11 ............ .................. ................... . . .. . . ...........
PHONE FAX
Dunlap Insurance Al lk�g.=_(714) 838-3158 AfC ..No 922-6157
(714)
. . . . ......
E-MAIL
700 West 1st Street, Suite #8 -ADDRESS, dean@ dunlapins. com. . ......... . .......... ....... .......... . . .
Tustin
INSURED
CA 92780
INSURERS) AFFORDING COVERAGE
A:Hartford Acc. & Indem
NAIC #
,57
Matrix Imaging Products, Inc. INSURER C:Hartf ord Acc. & Indem Co, 22357
3151 Airway Ave., Suite #H-1 INSURER D;Phi1.a�d-Ek1ph,ia_Ins.-Co.
INSURER E
Costa Mesa CA 92626 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.
. . ........
INSR '.ADDL SLek POLICY EFF POLICY EXP
iT,K TYPE OF INSURANCE INSH, 1MVP ... . . . ............. .(MYYPLP J WPPMyL " LIMITS_
A GENERAL LIABILITY X 72SBAUV3134 06/12/2010 06/12/2011 EACHOCCURRENCE. 1,000,000
X COMMERCIAL GENERAL LIABILITY 30O
,m000„
X OCCUR 10,000
PERSONAL & ADV INJURY $ 1,000,000
. .. . ........
GENERAL AGGREGA rp $ 2,000,000
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COM,PI/10P LAqq 2,1_000 , 000
-2taijal-] PRO. I t LOC $
. . ................... . . . ........... ....... . . . ..................................... ..... - -------
C AUTOMONY AUTO BILE LIABILITY 72UECKR1908 06/24/2010 06/24/2011 C OMBINED SINGLE LIMIT
person) 1
(Ea accident) ,000,000
A-- --- . . ........ ..
BODILY INJURY (Per $
ALL OWNED AUTOS . . . . .....................
SCHEDULED AUTOS BODILY INJURY (Per @ccidenO $
PROPERTY DAIMAGE-
HIRED AUTOS (Per accident)
NON-OWNED AUTOS
...... .... ..
A UMBRELLA LIABOCCUR 2SBAUV3134 06/12/2010 06/12/2011 EACHOCCURRENCE $ 4,000,000
. . .. . . ............. . .
EXCESS LIAB CLAIMS-MADE AGGREGATE S 4,000,000
DEDUCTIBLE
.............. . .. ...................I.........._
RETENTION $ X
WORKERS COMPENSATION 4024289978 12/01/2010 12/01/2011 X WCYSTATU- TH-
91 B AND EMPLOYERS' LIABILITY _ -- -ER... .-
Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE N/A�
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
Practices D Employment . ................ . D608293 03/12/2011 D3/12/2012
y
I Liabilit ---- Insurance
. ....................................... .......... ....... L
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
10 DAYS NOTICE OF CANCELLATION IN THE EVENT OF NON-PAYMENT OF PREMIUM.
THE CITY OF EL SEGUNDO IS NAMED AS AN ADDITONAL INSURED.
CERTIFICATE HOLDER
ATTENTION: CITY CLE
CITY OF EL SEGUNDO
350 MAIN STREET
EII SEGUNDO CA 90245-0989
CANCELLATION
E.L. EACH ACCIDENT
EL DISEASE - EA EMPLOYEE: S
E L DISEASE - POLICY LIMIT
500,000
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
ACORD 25 (2009109) (0 1988-2009 AGURD GURPOKATIUN, All rights reserve
INS025 (200909) The ACORD name and logo are registered marks of ACORD
MATRIX IMAGING PRODUCTS, INC
POLICY NUMBER: 72SBAUV3134
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
SCHEDULE
Name of Person or Organization:
The City of El Segundo, its officers, employees, agents, and volunteers
(If no entry appears above, information required to complete this endorsement will be
shown in the Declaration as applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to
organization shown in the schedule, but only with
work preformed for that insured,
include as an insured the person or
respects to liability arising out of your
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