PROOF OF INSURANCE (2013) CLOSEDDAT )Y
E (MMIDnIIr
�- CE TIFI: TE OF LIA��l MY 1NSW..A E 05/1812012
THIIStICERTIFICATE T E I NOT ISSUED N A MATTER OF INI d`TION O!NILY ANDY CONIFERS NO IRIGM. UPON "I"1r1 ERTIFICAT t'f E�4Di:1� T141:9
I,Y OR MEGA if AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THI; POLICIES
BELOW. THIS CEMIFICATV OF INGURANIX WE$ NOT 00N3TrrUTE A CONTRACT SI"'I`iMtN THE ISSU 11110 INSURERIS), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE ICERTI Tl HOLDM
IMPORTAi+ . If the certificallts holder Is an ADDITIONAL INSUMD. M j0ICY(;—WJ must Fe endon>ted. If SUMft0dffION IS WANE .subject to
the tornre and conditions of the poltcy, certai m
n poticlee Rmy requIM an endarseent. A statsrttent on this cartIfleate does not confer rights to the
certHlcate holder In Ilou of such endorsemaros�
PRODUCER NA Suml $Mini
Shorr Agency, Inc.
, (ti ) 798.8644
Na ,
(562)
799.4244
5500 Atherton St. #320
S„ susan(�sirorr.us
Long Beach, CA 90615
IMWI" AF RDINO COVERAGE
NAIL k
INSURER A: Aswdated Industrft
Ins, Co.
INli.0 0.3 INSURER e
Harold Hofmann INSURER o :
DBA: Hofmann & Son INSUFMR D:
4443 VW. 161 st Surat INSURER E:
Lawndele, CA 90260 INSURER F :
GOVERAGIES CERTIFICATE N ER.a
REVISION NUMBER -,
THIS IS TO CERTIFY THAT" THE POUCIES OF IMUMM ISTED 5ELO'W I vt" 09914 IS IJED 73 THE INSURED IMAM
I R'TH5 PO ICY PERIOD
INDICATED. NOT 41THSTANDING ANY REQUIREMENT, TERM OR CONDITION OP ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE, INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSION& AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN RECUCED BY PAID CLAIMS,
TYPE OP INSURANCE �'NRR ry v%) POkVDYNBNIISSR P
LINrtS
GENERAL L)AI' LITY
EACH OCCURRENCE
s
1,000,000
CO EROIAL OENERAL LIAI nsry'
PitEMlilaaE$I p tlyl r, l
100,000
CI.AMWAOE 21 "OUR
MED P P (Any ane pman
I< ..�
Excluded
A X AES1022852 05/1712012 05!7712013
.,
PERS131NAL i1 ADV INJURY
$
1,000,000
OEXERALACCREICATE
$
2,000,000
GSN'LACSRE4ATE LIMITAPPLIES PER;
PROOUCTS - COMPIOP ACC
$
2,000,000
P
POLICY „ 9 LOC
AVTOMOWLE LAMI„1"1"y
NIN
ELI a Ian!
ANY AUTO
BODILY INJp�
URY (Per person)
S
"
AUTOS NED AUTOBU�O
BODILY' INJURY (Fw aoddenl)
S
ON
HIRMAUT05 ALMO•QSWNED
Ieeultl nl.
$
$
UMBRELLA LL49 OCCUR
EACH OCCURRENCE
$
EXCESS LIAR CLAIMS-MADE
AGGREGATE
])ED RETENTIONS
$
WORKERS O RIPEN 11ION
k
11
AND EMPLOYERS' LIAMLITY YIN
T(N? L PIrI [
ANY PROPRIMRIPARTNEROXECLITIV6
OFFIC[RIMEMEGREXCLUDED7 NIA
E L. EAC H ACCIDENT
$
fN nUOM In NH)
C, L.DMEASE CA EMPLOYE
$
II (Im7 is under
l� RI'P ON OF OPERATIONS
TI aglow
,S
E.L. DISEASE -1?41I.IiT"r LIMIT-12
DESCRIPTION OF OP'SRAIRONS I L N$I I VEHICLES (Afineh ACORO 161, Aftoonol RamellN Wh9duls„ R moro "m le reglolrad)
Sorvlce & Repair PlumbInglSeymm
See City of FI Segundo Addltlional Insured endorsement attaatled,
30 days nGdes of cancellation.
IAES1022652 I
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11, 1"M Commercial General Liability
1% Ufflft orUp 10ar. $1,040,000 Occurrence /2,000,000 Aggregate
tali ftftft*d : 5 7 Tw, 17/ 13
14, {�
OF 2 500 t�+ ara X) Pw ompow.
is *@ME plaww gar;
1m. zuso m=ww4m wa: Harold Hofmann OSA: Hofmann & Son, 4443 W. 161st St.,
17. Associated Industries Ins. Co. La,wnda,l e, CA 90260
w Pwftl' e.I . AES1022652
19. EwMw8wMftfft~. .
20. GNMa na ftet ej I. as�w, 5/17/12
Pis R"Gf 2
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CERTHOLDER COPY
SC
P.O. BOX 420807, SAN FRANCISMCA 94142,0807
OERTIFICATI: OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 05 -03 -2012 GROUP: 000318
POLICY NUMBER: 0000128 -2011
CERTIFICATE It> 185
CERTIFICATE EXPIRES: 07-01 -2012
07- 01- 2011107- 01 -2012
CITY OF EL SEGUNDO
PUBLIC WORKS DEPT, EL SEGUNDO CITY
330 MAIN ST
EL SEGUNAO CA 80245 -3813
This Is to certify that we haute issued a valid LCornpensation insurance policy In a form approved by the
California Insurance Commissloner to the employer named below for the policy period Indlcatec!_
This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer,
We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance Is not an insurance policy and does not arnpnd, extend or alter the cpverage afforded
by the policy listed herein, Notwithstanding any requirement, terra or condition of any contract or other document
with respect to Which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the policy described) !hrereirn is subialct to all the terms, exclustons, and condillores, of such policy.
Authorised Representative President and CEO
UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER TNI5 POLICY EXCLUDES THE FOLLOWING:
THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER;
EMPLOYEES COVERED ON A COMPREHGNSIvg PERSONAL LIABILITY ;NSURANCE POLICY ALSO AFFORDING
CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERSi
COMPENSATION LAW.
EMPLOYER'S LIABILITY LIMIT INCLUDING OCFIENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT 92069 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01 -01 -2005 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
EMPLOYER
HOFMANN, HAROLD SC
4443 W IG1ST ST
LAWNDALE CA 80250
[B10,SGj
(FIEV.9-20 1o) PRINTED : 05 -03 -2012