PROOF OF INSURANCE (2012) CLOSEDHpr 17 21.112 J:UbVM HH LHStKJLI FHX
page 1
CERTIFICATE OF LIABILITY INSURANCE T>r11!(MAMMO)YY)
THIS IS TO emnFY THAT THE POUCIEt
iNDICATED. *F"STANDINS ANY RT
CE1 ,FICATE MAY OE ISSUED OR MAY
EXCI. SIONSANDCONDMONOOFSUCH
A I oIIBRALUAYLITY
EXCESS LIAO
DED I I RETFNT10N4
OF totSU LISTEN BELOW HAVE BEEN IS ZO TO ME INSUIRED NAMED ABOVE FOR THE POLICY PERIOD
JUIREM MIT, TERM OR CONDITION OF ANY CONTRACT OR ^! THER OOCUMSNT VATH RESPECT TO WMICH THIS
1ERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,,
"OLICIP.S. /.SWATS 8HO N MAY HAVE BEEN REDUCED BY PAID CLAIMS.
12,9mm. LIMITS
✓ / P380001117 1 811 &2011 1 811512012 k EACH OCCURRENCE Q s __ 2 000,01
Sdroduled Al Endl
#PP83130610
Professional SeMCBs
pWonywd by fife In#Ured
are EXduded
177
A E cUTiYr IWAI f P
? I 1N Eodt OV4C410
308
A
Ce Holde! Is an AddIllboal It tmured
e, noW atwlWve. t d0i
s rs f w m, A oike!rs" +C wpsn l
In #w Scheftkl that mm 0851 to a Ca*dct that f"10110,
512011 18/1512012
911/2011 1 811&2012
8015/2011 18Y15J201Z
PERSONAL SADV I►IIURY
S
2,000,'
r3 AGORix?ATf
_.....'U.gOM..._PAdCi
#
4, m,
#
4,000.
s
#
T
Z001).
BODILY INJURY rw pram)
BODILY INJURY OW mo d§ M)
66
1•
1:
t
EACH OCCURRENCE
$
AGOREOATE
_
I
t
s
s
7SI, .M
E.L. DISEASE - FA EMPLOYE E
s
E.L DISEASE - w1 YUM1T
sFF
1 0
S2A00. r Claim
gmmfflxw�ao ltrad wlitl !flew Irawsured p�Tlar tost LA Per tiTrw ailBTwaw iX Ille 1� � �►rprl irwllla n eTore ICrffisr k6 CC
Sm Stebm 01 SHOUL)D ANY OF THE ABOVE DE9DRIBND POLICIES BE CANCBLI !D BEFORE
m O ICI $ s Ur11%O, II ACCORDANCE; WIN THE POLICY PROVIZIONCS IhM!•L BE DpLTVERED iN
Its 01i
THE EXPIRATION DATI' THE:R
El Segundo C�W 90245 AUTHORMOREPREBENrArA
A Pilcle K. [atom
0 1900 -2010 ACCORD CORPORAIrION. All righte mswved.
ACORD 28(2010106) The ACORD rwms and (ago are r"Isbened marks of ACORD
cover ?40.3 12660170 (ShO gabumm Eoater 4/16/2012 12 =06,28 PM Pmga 1 of I
Hpr 17 ?U12 J: UbHm HF LHbEKJL 1 I-HX page
Policy Number: PS130001177 RLI Insurance Company
Named Insured: Melvyn Green and Associates, inc.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE BEAD IT CAREFULLY.
RLIPaCk® FOR DESIGN PROFESSIONALS
SCHEDULED ADDITIONAL INSURED ENDORSEMENT
This endorsement modifies insurance provided under ttie Ibllowing:
BUSINESSOWNERS COVERAGE FORM - SECTION 11— LIABILITY
Schedule
Name of Person(s) or Orr��snIWIon(s): /
City of E1 Segundo, its czlals and
employees
1. SECTION II C. Who is An Insured is arnended to
include as an addltional insured the person or
organizaWn shown in 11hle schedule above, but only
respect vAth to Aabltlty for "bodily Injury -, "property
darn at or "personal and advartlsing lnjuf
caused In whole or in part by you or those acting on
your behalf:
a. In the perforrnanos of your ongoing operations;
b. in connection with premises owned by or rented
to you; or
c. In connection w9th "your worts" and included
within the "product-oompleted operations
h azae.
2. The Insurance provided to the additional insured by
this endorsement Is limited as follows:
a. This Insurance does not apply to the rendering
of or failure to render any "professional
selvIcee.
b. This endorsement does not increase any of the
limits of insurance stated In 0. Liability And
Medical Expenses Umils of Insurance.
3. The folloing is added to SECTION III H.2. Other
Insurance -- COMMON POLICY CONDITIONS
(BUT APPLICABLE ONLY TO SECTION II —
LIASILITY)
However, if you specifically agree in a Contract or
agreement that the insurance provided to an
,additional Insured under this policy must apply on a
ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED.
PPB 313 0610 Page 1 of 1
CLLR? MO., 19860170 (OAC) M&ecoa Poorer 6f16/ ?019 12.94,28 Pal Papa 9 of 3
Hpr 17 eU12 b:ubNM HH LHSLMjhI FHX Page j
WORKERS; COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 05
(Ed. n4�4j
`� WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT— CALIFORNIA
We have the right to r our psywwwmita fmM ar"ao Nklxla for an iniury comed by this policy. We will not enforce our right
against the pomon or organimban nomd, in the Schedule!. (rhlrl aorbament applies, only to the extantthet you perform work
under a vAlftn contract that requires you to obtain tltls agreenwrt from, uo.i
You must mttintain payroll records accurately segregating the remuneration of your empicyees while engaged in the work
described in the Schedule.
The additional premium for this endorser, ment shell be 2 of the California workers! compensation promium atherwise due on
such remuneratlon.
Schedule
Person or organization Job Oa cription
City of El Segundo, its officials and Jobs perf�orrned for any person or otganization that you have
employees agreed with in a wrWan c a *rict to provide this agreerrrent.
Thla endorsement changes the poloyto which It Is attached end is effective on the date issued unless otherwise stated.
{ruts Wormatlon below Is required dreg whwn this endomen wnt to Issued subsequent to prepwatlon al' Pie polkY.)
Endonemerrt Efredrve 811!2011 Polley No. PSWOD01142 Endorsement No.
Insured insursheeCormany. Ru Insurance Company
Melvyn Green and Associates, Inc.
.,
Countenlgnad By
=W1 No., 1266e17o rs&c) Aab"Ca r.-tar 4/16/2011 12256178 PH Page 3 of 3