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PROOF OF INSURANCE (2013) CLOSED�1 OP ID: GB CERTIFICATE OF LIABILITY INSURANCE °ATE'MM' 061055 /12 /12 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 endorsement(s). PRODUCER &Conn, Inc. 814- 237 -0492 Robert ert M 492 r F p No 814-234-0389 9 , er 1:. PRtkDGYA R CSYnOF:CO P. O. Box 469 814 - 234 -0389 814 237 State College, PA 16804 -0469 Robert F Meds er CPCU VR'66y�Pa Mty, 91NTU� stand rtmecie - 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. ............ —.. ..,...�.m:.: .......,,.� IV;�_ .m, :TYPE OF _T Lid ` .. P7LIL "Y EXP INSURANCE POLICY NUMBER M D1YYY'Y MMIDD/YYY Wyn ,._,.,,_. ,� _..... ,,,e,,,. ........ LIMITS .w ...... GENERAL LIABILITY CH OCCURRENCE $ 1,000,000 A X CCI� C'BP8143163 05/01/12 05/01/13�I CLAIMS- 41 epe_em $ ......�n105,000 MADE OCCUR MEDEXP(Anyo PERSONAL &ADV INJURY $ 1,000,000 - :- ....�:2.- ,.. _,_- „,�,:.:..._ .:......... GENERALAGGREGATE _...$ _ 000,00 PLIESPER: GEN'L AGGREGATE LIMIT AP .:..:.:. PRODUCTS - COMP /OPAGG $ 2,000,000 X POLICY L1 PRO- we 'UJ $ AUTOMOBILE LIABILITY IeOMBINED SINGLE LIMIT $ 1,000,000! A X ANY AUTO BA8179156 05/01/12 05/0111 (Ea accident) -� BODILY INJURY (Per person) $ ALL OWNED AUTOS ... ....._ -. BODILYINJURY (Per accident) $ SCHEDULED AUTOS .-.:......_: ................ w_._. ......................... .... .. PROPERTY DAMAGE $ HIRED AUTOS (Per accident) ......,......... .:.:.:.:.: ..................... ...........................:.: NON -OWNED AUTOS ....._. .:.:.._�,.................,...e $ ..... -..,,, .:.:.:.:.: . ..............:.:..,........... ._ ........ ....,............:..- UMBRELLA LIAB ...., OCCUR EACH OCCURRENCE .:.:.......... $ EXCESSLIAB IMS -MAD -- ... - -- - -_ E.' .,.,.............. AGGREGATE ... ...,.,.,.,.,.. $ ,. ... .................:.....:...:. DEDUCTIBLE . .... .,...�� __... ..............._ - RETENTION $ $ WORKERS COMPENSATION WCSTATU I 'OTH- AND EMPLOYERS' LIA BILITY YIN •° ^TD�BY -1'- --������F.R• ° . - - -- ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? NIA ACCIDENT DSEAS: -: - - -- .......... $ _,m.m .....: -:�: i Mandato in NH (Mandatory � ) E.L. E - FA EMPLOYEE $ I yes, describe under _.,....�.� ............. DESCRIPTION OF OPERATIONS below DIS..... E EASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) TION CITYEL1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cit y of Ell Main Street ACCORDANCE WITH THE POLICY PROVISIONS. 348 El Segundo„ CA 90245 -3713 .,.,: ” '': AUTHORIZED REPRESENTATIVE ©1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization (s): Locations Of Covered O erations City of_. B1,.,_$egundo 348 Main Street Itrs Officers, Officials . E1 Segundo, CA 90245 =3713 Employees, Agents and.m Volunteers Information required to complete this Schedule„ if not shown above„ will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional exclu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for "bodily injury ", "property "personal This insurance does not apply to "bodily injury" or damage or and advertising injury' "property damage" occurring after: caused, in whole or in part, by: 1. Your acts or omissions; or 1. All work, including materials, parts or equip - ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project (other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) desig- covered operations has been completed; or nated above. 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑