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PROOF OF INSURANCE (2012) CLOSEDDATE (MM CERTIFICATE OF LIABILITY INSURANCE 0 5 /2 5 /DDNYYY) / 2 0 L 1 PRODUCER THIS CERTIFICATE IS ISSUED AS MATTER OF INFORMATION Joanne Bryant ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 2570 San Ramon Val -ley Blvd Ste A201 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR San Ramon, Ca 94583 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE ......... ...................... . . .......... . .................... . . . .......... - -------- - - ........ . . ..... . . . ................... C # INSURED 11114SURE.IR A: S ta Le Fa-r-m Gene.cal Insurance Coffln,�Y__, LIL 25151 NINA TARNAY INSURE . R B: ---- - — 453 32 ND STREET INSURER C: ............... MANHATTAN BEACH, CA 90266-3928 -INSURER D: INSURER E: 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INFSR A66ij___ ......................... ............. . POLICY EXPIRATION ....... L TRT IN TR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MNWDNY) LIMITS A X GENERAL LIABILITY 97BTX4496 0..x /25 201..1, 05/25/2012 EACHOCCURRENCE 1$ 1,000,000 X COMMERCIAL GENERAL tIABILITY PREMISES (Ea occurrence) 300,000 MED EXP An one arson .. . ........... I$ 10,000 CLAIMSMADE .,OCCUR ................ ............................... . PERSONAL & ADV INJURY 1$ 1,000,000 GENERAL AGGREGATE I$ 2, 06 0 , 0-0"0" l AGGREGATE umrr APPLIES PEP, COMINOPAGG $7 2, 000,000 POLICY LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA AGO $ ANY AUTO AUTO ONLY: AGG $ EXCES&UMSR ELLA LIABILITY EACH OCCURRENCE OCCUR E] CLAIMS MADE !AGGREGATE_.. DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND STFA_`T7U_ OTH- EMPLOYERS' LIABILITY ORY L" S TORY LIMITS ER . .... ANY PROP RI ETOR/PARTN ER/EXEC UTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER. EXCLUDED? El, DISEASE - EA EMf,�PXKE. If yes, describe under � . ....... SPECIAL. PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS VEHICLES EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS *10 Day Notice of Cancellation in the event of Non-Payment of Premium *The City of El Segundo is named as additional insured UhH I 111-1(;A Ih HULDEH CANCELLATION CliLy Of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION ALtn City Clerk DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN 350 Ma..tn Str.eeL NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL El Segundo, Ca 90245-098 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE 11 Brendan Chi.ite, Agency ReT.:) 132849 03. IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(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 amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001/08) HHDU Policy No.: 97 BTX4496 FE -6609 ,7 n � 1 SECTION II ADDITIONAL INSURED ENDORSEMENT Policy No.: 97 BTX4496�� Named Insured: NINA TARNAY Additional Insured (include address): THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS AND VOLUTEERS 350 MAIN STREET EL SEGUNDO, CA 90245 -0989 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.S A. Interinsurance Exchange of the Automobile Club Automobile Insurance Policy Coverages and Limits Renewal Declarations ,Ve are pleased to offer you a renewal for your automobile insurance policy. To renew your policy, send at least the minimum zz payment on or before the due date. Insurance is in effect only for the vehicles, 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, complete 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 INSURED (Item 1.) TARNAY, MICHAEL A AND NINA 453 32ND ST MANHATTAN BEACH CA 90266 -28 VEHICLES YEAR AUTO POLICY NUMBER: G 6303457 HULIGY PERIOD (PACIFIC STANDARD TIME) POLICY EFFECTIVE DATE: 05 -30 -11 12:01 A.M. POLICY EXPIRATION DATE: 05 -30 -12 12:01 A M. COVERAGES AND UMITS ANNUAL PREMIUMS Coverage is not in effect untess a premium or the word ' IncWded" is shown. COVERAGES LIMITS OF LIABILITY Vehicle 2 Vehicle 3 Vehicle Vehicle Vehicle Liability Bodily Injury $250,000 each person/ $500,000 each occurrence Properly Damage $100,000 each occurrence Medical '=xcess "1lediva pa)�Ments $10.000 each person Physical Damage -.___ ..__.. _ ,e _ _-- __ > -s:= =;y =_ :_ =5 _�a� :::_: $116 Vehicle 2 Vehicle 3 Vehicle Vehicle Comprehensive NIA KE MO-EL IDENTIFICATION T VEHICLE $250 ANNUAL VERIFIED D .......�.... .........._- _�.._...... (Less Deductible) ZIP ODE ES MILEAGE A� w �C� SIE:NN X�= �_ �:�',.° =D 5TDZA22C78S5218 "oi �.............._.. COMMUTE 95266 �_.. 5,001 - 7.500 ..�..... VERIFIED 2HNYD1&Q15H542107 COMMUTE 90286 1 -2.500 VERIFIED COVERAGES AND UMITS ANNUAL PREMIUMS Coverage is not in effect untess a premium or the word ' IncWded" is shown. COVERAGES LIMITS OF LIABILITY Vehicle 2 Vehicle 3 Vehicle Vehicle Vehicle Liability Bodily Injury $250,000 each person/ $500,000 each occurrence Properly Damage $100,000 each occurrence Medical '=xcess "1lediva pa)�Ments $10.000 each person Physical Damage -.___ ..__.. _ ,e _ _-- __ > -s:= =;y =_ :_ =5 _�a� :::_: $116 Vehicle 2 Vehicle 3 Vehicle Vehicle Comprehensive ACV ACV (Less Deductible) $250 $250 Collision ACV ACV (Less Deductible) $500 $500 Car Rental Expense (Per Day) $45 $45 U dMt 't $161 ;`$126 $116 '$20 :$15 Vehicle $47 x:$68 $ 332 $ 302 i$58 $52 n�nsure o orrs Bodily Injury $100,000 each person/ $300,000 each accident $ 51 $ 41 Uninsured & Underinsured Vehicles Uninsured Deductible Waiver Included Included Uninsured Collision NA NA Total Premium $ 785 $ 693 PREMIUM DISCOUNTS "NA" indicates coverage not urchased. Pp y .! _ Please refer to the enclosed document entitled "Premium Discounts Applied to Your Automobile Policy Total Annual Premium' $ 1478 *If at any time you choose to pay less than the full balance outstandin (Includes all applicable discounts,) g, Less Policyholder Savings Dividend $ 232 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. m , Net Premiu $ 1246 ITS00 A PROCESS DATE 04 -25 -11 PLEASE ATTACH TO YOUR POLICY (SEE REVERSE) 042511 Nina Tarnay 46932 nd Street Manhattan Beach, CA 90266 (310) 918 -1029 May 16, 2011 Stephanie Katsouleas Director of Public Works City of El Segundo 350 Main Street El Segundo, CA 90245 Re: Professional Services Dear Ms. Katsouleas: Please be advised that I am a sole proprietor, have no employees and shall render my services directly to the City of El Segundo under the Professional Services Agreement for Design Services dated May 16, 2011 between the City and me. Please contact me if you have any questions. Sicery Nina Tarnay �� `� �� . � �� r � `, w�