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PROOF OF INSURANCE (2011) CLOSED°' CERTIFICATE OF DATE (MMIDDNYYY) LIABILITY INSURANCE 9 1 12 010 PRODUCER Phone: 530 -661 -1300 Fax: 530 -661 -1303 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION InterWest Insurance Services ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE License #OB01094 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 222 Court Street Woodland CA 95695 ... ................ ...... ..... „ INSURERS AFFORDING COVERAGE NAIC # ---........ INSURE D ,,,., INSURERA SC,O,t,tS( al,e Insurance Co. 1297 ... U.S. Healthworks, Inc. - ......... _ 25124 Springfield Ct., Ste 200 INSURER STravel r„ (USHEA -1) INSURERC St Paul Travelers Valencia CA 91355 INSURER D:,G„afety Na-ttionl....Casa]y. Mgr5,105 INSURER E: COVERAGES 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. INS' Y,.DD.' . .. „ .... .POLICY NUMBER �... ... .. ... OLICY EFFECTIVE POLICY EXPIRATION' _.....,_. _ ,... LIMITS...... .. A GENERAL LIABILITY BCS0022924 9/1/2010 9/1/2011 EACH OCCURRENCE S 11 000,_QQQ LO E LIABIOT"Y C,., DAMAGE TL "REN7W' G 0 0, 0 Q 9 '�� CLAIMS MADE .. OCCUR MED EIXP (Any one person) � $ 1 Q r Q Q Q.., ... ERSONAL A ADV INJ URY $ J,, , Q Q . Q Q Q GENERAL GGREGATE $ 3 Q Q Q Q Q Q - GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG J. $ ( Q Q 1'000_ POLICY LLOC Q B AUTOMOBILE LIABILITY BA7470R699 9/1/2010 9/1/2011 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) .... .. ­......M „ ... $1, 000, 0 0 0 ...... ......... , ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) m, X HIREDAUTOS BODILY INJURY NON -OWNED AUTOS (Per accident) --- - - - - -- PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ _ ANY AUTO - -- ,EA OTHER THAN ACC $ AUTO ONLY: AGGI$ C EXCESS / UMBRELLA LIABILITY QK0 91017 5 2 9/l/2010 9 / 1 / 2 011 EACH OCCURRENCE $. Q < Q Q Q Q Q Q . ,. ( OCCUR CLAIMS MADE AGGREGATE $ 2Q, r 0 0 0 Q Q Q $ DEDUCTIBLE RETENTION 5 $ WORKERS COMPENSATION D AND EMPLOYERS'LIABILITY LDC4042721 VIK: STATU- VOTH 9/1/2010 9/1/2011 „X �TURY,IIITSIR,..... YIN ANY PROPRIETOR /PARTNER/EXECUTIVE ----------------------- - E.L EACH ACCIDE OFFICER /MEMBER EXCLUDED? ❑ (Mandatory in NH) E,L DISEASE EA $ 1 Q Q Q�,Q Q Q If yes describe under ..,.. ..... -... �....... SPECIAL PROVISIONS below EL DISEASE POLIMIT $ 1 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS *10 days notice applies if cancelled for non - payment of premium. DITIONAL INSURED IN FAVOR OF CITY OF EL SEGUNDO, ITS OFFICIALS, AND EMPLOYEES (ON ALL POLICIES EXCEPT WORKERS' ""OMPENSATION /EL AND MEDICAL PROFESSIONAL LIABILITY) WHERE AND TO THE EXTENT REQUIRED BY WRITTEN CONTRACT. CERTIFICATE HOLDER CANCELLATION* SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL *30 DAYS WRITTEN NOTICE TO THE CITY OF EL SEGUNDO CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO 350 MAIN STREET SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON EL SEGUNDO CA 90245 -3813 THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2009/01) } ©1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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 This Certificate of Insurance 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 (2009/01) POLICY NUMBER:BCS0022924 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LI SSIS OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following; COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Descri !ion Of Completed Operations CITY OF EL SEGUNDO *10 days notice applies if cancelled for 350 MAIN STREET N non- payment of premium. EL SEGUNDO CA 90245 -3 ADDITIONAL INSURED IN FAVOR OF CITY OF EL SEGUNDO, ITS OFFICIALS, AND EMPLOYEES (ON ALL POLICIES EXCEPT WORKERS' COMPENSATION /EL AND MEDICAL PROFESSIONAL LIABILITY) WHERE AND TO THE EXTENT REQUIRED BY WRITTEN CONTRACT. Information required to complete this Schedule, if not shown above, will be shown in the Declarations, Section 11 — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sched- ule of this endorsement performed for that additional insured and included in the "products- completed operations hazard ". > 110 CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1