PROOF OF INSURANCE (2015) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE(MMIODNYYYI
11/05/2014
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 pollcy(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 endorsement(s).
PRODUCER License# 0751768 CONTACT' BOB HADZOR
NAME,
Robert Hadzor Insurance Services PHONE (925) 372 -9000 -11 Nn " t92st 3T = -Saes
3755 Alhambra Ave. Suite 7 Ann*=�,bob @hadzorinsurance.com
Martinez, CA 94553 -
Segundo Nursery INSURED E1 Se do Nurse School
Po Box 73
300 E. PINE STREET
COVERAGE
AMERICAN ELITE
Insurance Com
d
'E1 Segundo CA 90245- 1 INSURER F:
COVERAGES CERTIFICATE NUMiBER: REVISION NUMBER:
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.
TN - _ ,. No' ' ; ''0
LT'R TYPE OF INSURANCE OLIQY NUMBER WP I,p Y�E I'10LMY'Y�'P5" LIMITS " - -�-
A GENERAL LIABILITY 014- 20766 -NPO 4/01/2014 04/01/2015 EACH OCCURRENCE 5 1,000,000
X CO)A MLRCOL GENERAL LIABILITY T91US -"( � "a
PRFMISFS W.i acrxfonvn S 100,000
GbMI,1S -MADE OX / / / / BRED EXP (Any one Dersom S 10,000
PERSONAL & ADV INJURY S 1,000,000
GENERAL AGGREGATE S 3,000,000
C,4N L AGG�RI.OATE LIMIT Af PLIiCS PER: / / / / PRODUCTS - COMPIOP AGG 5 3,000,000
"x POI.!( `t P,A LOC / / / / LIQUOR LIAR S _. 1,, 000, 000..
• AUTOMOBILE LIABILITY 014- 20766 -NPO 4/01/2014 4/51/2015 COWWCU WR LIEI.VAI � 000
ANY AUTO / / / / BODILY INJURY (Par parson) S 000,
ALL . AUJOS EO SCHEDULED L
AUTOS / / BODILY INJURY (Pur =idanl) 5
X HIRED AUTOS X NON.OV NE0
AUTOS Pn nre dnnl
UMBRELLA LIAO OCCUR / / / / EACH OCCURRENCE 5
- - .....0 _,�..,, -
EXCESS LIARCLJ�iMSddADE AGGREGATE 5
ED RCTENTION$
C AND EMPLOYERS LIABILITY YIN 00023769-03 2/O1/201A; 2/51/2015 X. VELA OTH-
WORKERS COMPENSATION LrCOIw.D� LfAf TIyrE` Y NIA E L G/tCH ACCIDENT S 1100010 0 0
A CMeoda o InB H) - 014 - ?0766 -DD 4/01/2014 4/01/2015 "E L DISEASE � EAEMPLOYEE S 1, OOp
Y I
/ / / /
DLGCRIP ION OT C1{ i 1TFrTV(5N x' bo:ow E L DISEASE - POLICY LIMIT S
B PERSONAL PROPERTY 0006763 -0A 4/01/2014 4/01/2015 SPECIAL FORM RC 5,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Alfoch ACORD 101, Additional Romoft Sehodulo, If more spsco is raqulrad)
CITY OF EL SEGUNDO ITS OFFICERS OFFICIALS EMPLOYEES AGENTS AND VOLUNTEERS ARE ADDED AS ADDITIONAL INSURED
Also attached is the waiver of subrogation for the work comp policy through Markel Insurance company.
RE: LANDLORD
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
CITY OF EL SEGUNDO ITS OFFICIAL AND
EMPLOYEE r S C/O CITY CLERK AUTMOR199D RUPR93ENTATIVE
350 MAIN ST RM 5
EL SEGUNDO CA 90245 -3613
w.
ACORD 25 (2010105) 019 021)10 ACORD CORPORATION, All rights reamed.
INS025(2,zimalol The ACORD navne and logo are regletared marks of ACORD
COMMERCIAL GENERAL LIABILITY CG 20 11 0196
INSURED: EL SEGUNDO NURSERY SCHOOL
POLICY NUMBER: 2014 - 20766 -NPO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - MANAGERS OR LESSORS OF
PREMISES
This endorsement modifies insurance provided under the following:
CITY OF EL SEGUNDO IT'S OFFICIALS
AND EMPLOYEES C/O CITY CLERK
350 MAIN ST RM 5
EL SEGUNDO CA 90245 -3813
ISSUED TO: CITY OF EL
SEGUNDO ITS OFFICERS
OFFICIALS EMPLOYEES AGENTS
AND VOLUNTEERS ARE ADDED
AS ADDITIONAL INSURED
SCHEDULE
(If no entry appears above, the information required to complete this endorsement will be shown in the
Declarations as applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in
the Schedule but only with respect to liability arising out of the ownership, maintenance or use of that part of
the premises leased to you and shown in the Schedule and subject to the following additional exclusions:
This insurance does not apply to:
1. Any - occurrence- which takes place after you cease to be a tenant in that premises.
2. Structural alterations, new construction or demolition operations performed by or on bebalf of the person
or organization shown in the Schedule.
CG 20 11 01 96 Copyrigbt, Insurance Services Office, Inc., 1994 Page 1 of I
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
POLICY INFORMATION PAGE ENDORSEMENT
The following item(s)
Insured's Name (WC 89 06 01)
Policy Number (WC 89 06 02)
Effective Date (WC 89 06 03)
L'xpiration Date (WC 89 06 04)
Insured's Mailing Address (WC 89 06 06)
Experience Modification (WC 89 04 06)
Producer's Name (WC 89 06 07)
Change in Workplace of II1SUred (WC 89 06 08)
Insured's Legal Status (WC 89 06 10)
Item 3.A. States (WC 89 06 11)
is changed as follows:
Item 3.13. Limits (WC 89 06 12)
Item 3.C. States (WC 89 06 13)
X Item 3.D. Endorsement Numbers (\\'C 89 06 14)
Item 4. Class, Rate, Other (WC 89 04 16)
Interim Adjustment of Premium (WC 89 04 16)
WC 89 06 00 B
Carrier Servicing Office (WC 89 06 17)
Interstate /Intrastate Risk ID Number (WC 89 06 18)
Carrier Number (WC 89 06 19)
Issuing Agency /Producer Office Address (WC 89 06 25)
(Ed 7 -U 1)
Action
I'ype
Previous value
New v:rluc
Add
\ \`aiwrol'
VA
Type:Indiiidual
so itogatioit
Sialet CA
Class Code: NOS Vnyroll: N
Subnlgno Name: City of El Segundo its oflicm, ollicials, cngnlloyces,
agents & Volulntcer5
Subrogaut :Address: 350 Main Slrco Itoon 45,
Subrogam C'iry: El Segundo
Slalc: CA
Postal Code: 90245-3ti 13
Effective Date I I Wr2014
Expiration D:de: 112M 1!2015
Total Estimated Annual Premium 5929,00
Premium Adjustment S89,00
Nlinilnuln Premium S 590.00 Deposit Prenliunl 50.00
This endorsement changes the policy to which it Is attached and is effective an the date issued unless otherwise stated.
(The Informatlon below Is raquirod only when this ondorsomont Is Issuod subsequent to preparation of the policy,)
Endorsement Effective 1 110 512 01 4 Policy No. MWC0023768.03 Endorsement No
insured: EL SEGUNDO CO.OP NURSERY
SCHOOL(NONPROFIT) Premium (see At aoltedl
Insurance Company: Market Insurance Company Counlersi ®nod by..._
WC800600B 1 "
Ed. 7-01 ell
J 2001 National Councl on CmeGwuauon Inwraneu, Inc.
iIB{ IIQI�II�CI� °Illrrll! �I ►lilr!IU11fl "IOiI Nti 101`10
II' lll1ll�' ll���ll! �IIII!lll�klllllll�lll�l�ll�III
All'other tcnns and conditions of this policy rcinain unchanged,
This endorsement changes the policy to which It is attached and Is effective an the date issued unless othenvise stated,
(The Information below Is required only when this endorsement Is Issued subsequent to preparation of the policy.)
Endorsement Effective 111012014 Policy No, MWOOD23768-03
Insured: EL SEGUNDO CO-OP NURSERY
SCHOOL[NONPROFIT)
Insurance Company: Markel insurance Company Caunlarsigned
e906 008
Ed� 7.01
.92001 NOMOnal Cauncl an Camronmimn Insuranto, Inc.
Premiurn (See Attached)
by
2 of 10
I E
Shilling, Mona
From: Ramos, Vina
Sent: Thursday, January 29, 2015 1:41 PM
To: Shilling, Mona
Cc: Garcia, Angelina; Bobbett, Jesse; Dobay, Alison
Subject: RE: ES Nursery School License Agreement
Attachments: doc02892920150129115213.pdf
Hi Mona,
Attached is ES Nursery School License Agreement. David King helped us with language and Angie already approved all
insurance. Please process for final signatures.
Thank you,
Vina _
- - - -- Original Message---- -
From: Garcia, Angelina
Sent: Wednesday, November 05, 2014 5:10 PM
To: Ramos, Vina
Cc: Bobbett, Jesse; Dobay, Alison
Subject: RE: ES Nursery School License Agreement
Approved
Angelina Garcia
- - - -- Original Message---- -
From: Ramos, Vina
Sent: Wednesday, November 05, 2014 4:14 PM
To: Garcia, Angelina
Cc: Bobbett, Jesse; Dobay, Alison
Subject: RE: ES Nursery School License Agreement
Hi Angie,
Please see attached waiver for your review.
Thank you,
Vina Ramos
Senior Administrative Analyst
City Of El Segundo
Recreation and Parks Department
310 - 524 -2882
- - - -- Original Message---- -
From: Garcia, Angelina
Sent: Tuesday, October 28, 2014 9:20 AM
To: Ramos, Vina
Subject: Re: ES Nursery School License Agreement
1
Ramos, Vina
From: Garcia, Angelina
Sent: Tuesday, October 28, 2014 9:20 AM
To: Ramos, Vina
Subject: Re: ES Nursery School License Agreement
Hi Vina, ,/0
'.._„ ..
Endorsement is acceptable. Please reques waiver)
Thanks, -w"
Angie
Sent from my iPhone
> On Oct 27, 2014, at 12:08 PM, "Ramos, Vina" <vramos @elsegundo.org> wrote:
• Hi Angie,
• Attached are ES Nursery School's License Agreement and insurance documents. ES Nursery will pay the City as agreed
in the License Agreement. Please advise if:
> 1) GL Endorsement is acceptable;
> 2) ES Nursery is required to provide Waiver of Subrogation.
> Thank you!
> Thank you,
• Vina Ramos
• Senior Administrative Analyst
• City Of El Segundo
• Recreation and Parks Department
• 310 - 524 -2882
• - - -- Original Message - - - --
• From: donotreply @elsegundo.org [mailto:donotreply @elsegundo.org]
• Sent: Monday, October 27, 201412:01 PM
• To: Ramos, Vina
• Subject:
• TASKalfa 4550ci
• [OO:cO:ee:a5:9e:10]
> <doc02567720141027120046.pdf>
> <doc02567820141027120101.pdf>
1