PROOF OF INSURANCE (2013) CLOSEDOP ID: KC
CERTIR:�..ATE OF LIABILITY INSI►,�ANCE f(MWDWYYYY) E
10/03/12
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(les) 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 endomementls).
PRODUCER Yj1 mss«
559 - 224 -8222 NA M
Parker Isurance License 054554437 559 - 224 - 827711 ffi
5094 N. Fruit #1016,
Fresno, CA 93711 PRODU
cD9mM'gn its a, BUFKl -1
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.
INS R TYPE Of INSURANCE POLICY NUMBER IMMIDDrffrn IMMIDDWYYYI LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
S 1,000,00
Py . p een
$ 100,00
A
X COMMERCIAL GENERAL LIABILITY
X
GL3829700
03101/12
03/01113
CLAIMS -MADE X I OCCUR
MED EXP (Any one parson)
$ 5,00
PERSONAL & ADV INJURY
$ 1,000,00
GENERAL, AGGREGATE
$ 1,000,00
PRODUCTS - COMPIOP AGG
$ 11000100
GEN'L AGGREGATE LIMIT APPLIES PER'
POLICY LOC
$
AUTOMOBILE
..
LIABILITY
COMBINED SINGLE LIMB
(Ea accident(
$
ANY AUTO
BODILY INJURY (Per person)
S
ALL OWNED AUTOS
BODILY INJURY (Per accident)
$
SCHEDULED AUTOS
HIRED AUTOS
PROPERTY DAMAGE
(Per accident)
..............
$
— --
NON -OWNED AUTOS
$
UMBRELLA LU4B OCCUR
KJ CH OCCURRENCE
$
EXCESS I CLAIMS -MADE
AGGREGATE
$
$
DEDUCTIBLE
$
RETENTION I
WORKERS COMPENSATION
WC STATU- OTH-
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORIPARTNERIEXECUTIVE
OFFICERIMEMBER EXCLUDED? f
N f A
)vIMITS_......__. �.EEi_
E L. EACH ACCIDENT
°-• ••••• ^
S
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS
E. tl . DI'$EASE - EA EMPLOYE
$
E.L. DISEASE - POLICY LIMIITT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 10t, Addltlonel Remarks Schedule, If more space Is required)
Certificate Holder is named as Additional Insured. O
V
"v,
CITYE -1 N 'V I
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS.
Becky Sum!
EP
El Segundo, CA 90245REPRESE A
350 Main St, AUTHORIZED
/ - 1988 -2009 ACORD CORPORATION, All rights reserved.
ACORD 25 (2009/09) T ACORD name and logo are i marks of ACORD
44w� N%�.
COMMERCIAL GENERAL LIABILITY
CG 2010 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)
Location(s) Of Covered Operations
Or Organization(s):
CITY OF EL SE71460
BECKY SUMI
350 MAIN STREET
EL SEGUNDO, CA 90245
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 in-
clude as an additional insured the person(s) or or-
ganizations) shown in the Schedule, but only with
respect to liability for "bodily injury', "property dam-
age" or "personal and advertising injury" caused, in
whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your
behalf;
in the performance of your ongoing operations for
the additional insured(s) at the location(s) desig-
nated above.
CG 20 10 07 04
B. With respect to the insurance afforded to these ad-
ditional insureds, the following additional exclusions
apply:
This insurance does not apply to "bodily injury" or
"property damage" occurring after:
1. All work, including materials, parts or equipment
furnished in connection with such work, on the
project (other than service, maintenance or re-
pairs) to be performed by or on behalf of the ad-
ditional insured(s) at the location of the covered
operations has been completed; or
2. That portion of "your work" out of which the in-
jury 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.
Copyright ISO Properties, Inc., 2004
Retail Agent
Page 1 of 1
Oct 03 2012 6:42PM HP Fax
page 2
FAR.MBRV
F'oli I status
Active
last Transaction Processed On
11 -21 -2011
COMM.
Truck Insurance Excha a
Last Transaction Ef elke Date
01-05-2012
Uwe Due
$0.0
Lost Transadon T
rrwal
Rone
Polio Effective, From
01- 05.2012
Pofic Efl ctive To
01-05-2013
Err urre
Quattr
r led w0mve
1
Household Polhts
0
Address
1374 N LINDEN AVE
MoWdud Vehicle
UNVUIM
-
0
Cfty
FRESNO
Youthful Driver
0
Slate
CA
Unlicensed recreational vehicle
0
zip
93728 -2320
wateretaft
0
Prematic Account No.
BQ44826
Rental Dvvdinq
0
ent
9515578
On or Off Promises,
0
Attachment Point
No
Insured as an Employee
0
Credit
TettoA
Teacher Uabllq
0
Polly Number
604628727
Vacant Land total acres
0
Prior Policy Number
Farm Liab,r
IVO
Limits
General Liabilit I.00Q000
Retained Limit 250
UMNIM 0
0
SldiJet Sled