PROOF OF INSURANCE (2015) CLOSED03/12/2025 15:43 3106760041 BILLIARDS BARST❑ PAGE 01
WOULD AMY or YHE ABOVF DUCOWD IMMIC ES BE CAWCELLM BEFORE
CITY OF EL SEGUND0 TIM 11004RATIOW p^TV THMEOF. NCTIOE WILL BE DRI.NMED M
RS OFFICIALS AND EMPLOYEES ACCOCAOICE WFM TNT POLICYFROVINON&
401 Sheklm St lkurN¢p� YA1TU1 t
EL SEGUNDO CA Wm
RINA L SILVA
TM ACORD ". * and kmo am ttd MMcks Of AODRD
0310512025 11:57 3106760041 BILLIARDS BARSTO PAGE 07
POLICY NUME)ER- 605831433
RUSINESSOWNERS
BP 04 50 Ch 97
THIS IENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
I!' S,
,,; tllr -Ast K #1 Ink,
This endorsement modifies Insurance provided under ttv Mowing:
BUSINESSOWN15R6 POLICY
SCHEDULIIff-
Name Of Person Or Orgarlizatlon: CITY OF EL SEGUNDO, ITS OFFICIALS AND EWLOYEES
Information required to oomplah this Schedule, if not shown on this endorsement, will be shown in the Declas-
raitlQns.
The folloWing Is ridded to Paragraph C. Who W "An
insured in the Sa Wrieslowners Liability Coverage
Form:
4. Any person or organixetlort shown In the Schedule
Is also an insured, but only with ramped to liabillty
arising out of your ongoing operations performed
for that insured,
RP 04 80 01 97 Qopyright, Insumnoe Sarvires Offitse. 11M. 1907 Page 1 of 1 0
03/05/2025 11:57 3106760041 BILLIARDS BARSTO PAGE 06
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RFPECTIV19 10/07/2014
The enclosed Auto Insurance Renewal Bill axed the U251 IMPORTANT NOTIC$ are part of this policy. These
specify the amount of your premium, your payment Option*, any applicable fees, and the duftlldii l,�
Your automobile insurmzce expires and coverage ceases at 12:01A1.t on 10/07/3014. CoVeragp! undery
this policy will become effective provided you pay the premium, and any applicable feem' nd,lcated.
an the Auto I.neuranee Renewal Rill. If you have any queetions, please contact your Ag1 t bro er at
the phone number provided above. „.
PAY PLAN PA,YMIM AMT PER DUE DATE NEXT PAYKENT FEE DUE DATE
Full Pay $955.61 NONE 10/06/7014
2 Pay $494.11 $10.00 10/06/2014 $491.50 $10.00 12/19/2014
3 Pay $133.61 $10.00 10/06/2014 $331.00 510.00 11/19/2014
Same Pay $164.61 $1.00 10/06/2014 $161.40 $1.00 11/07/3014
VM. VIOL. 00D$ VIOL. DATE VIOL. CODE VIOL. DATE VIOL. CODE VIOL. DATE
2 ACC 11/27/2007 ACC 01/11/2013
I UND. R. Nghlrm AMOUNT DUE: S 164.61 OUR DATE: 1 2014 MAkAMOAM 0910F !t$'14
4un GAMIS OPY
Prowas Date, 09105/2014
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CAR GM
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U -1 0 0412013 UA.SC U -179
�1t
RFPECTIV19 10/07/2014
The enclosed Auto Insurance Renewal Bill axed the U251 IMPORTANT NOTIC$ are part of this policy. These
specify the amount of your premium, your payment Option*, any applicable fees, and the duftlldii l,�
Your automobile insurmzce expires and coverage ceases at 12:01A1.t on 10/07/3014. CoVeragp! undery
this policy will become effective provided you pay the premium, and any applicable feem' nd,lcated.
an the Auto I.neuranee Renewal Rill. If you have any queetions, please contact your Ag1 t bro er at
the phone number provided above. „.
PAY PLAN PA,YMIM AMT PER DUE DATE NEXT PAYKENT FEE DUE DATE
Full Pay $955.61 NONE 10/06/7014
2 Pay $494.11 $10.00 10/06/2014 $491.50 $10.00 12/19/2014
3 Pay $133.61 $10.00 10/06/2014 $331.00 510.00 11/19/2014
Same Pay $164.61 $1.00 10/06/2014 $161.40 $1.00 11/07/3014
VM. VIOL. 00D$ VIOL. DATE VIOL. CODE VIOL. DATE VIOL. CODE VIOL. DATE
2 ACC 11/27/2007 ACC 01/11/2013
I UND. R. Nghlrm AMOUNT DUE: S 164.61 OUR DATE: 1 2014 MAkAMOAM 0910F !t$'14
4un GAMIS OPY
Prowas Date, 09105/2014
bashed . SMANO, ROWRT & (INN)
Ijwttr ! . (OM)—MLLAME A RAPSTOOLS OF BAY
+ 157W HAWMRNE BLVD
+ LAWNBALE CA W250
Agent
79- 55 -3SL Ail9r�'s 0 �
EfferdVe
Date Policy Number POUCY
of die Company Ycar
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS I NNDOR NT. BLANKET
We have the right to r=ver our payments from anyone Iiabk for an injury mimed by dais polity. We will
not eQlurm our right against dw pawn or orgail=tion for which you perform work under a writtai cunu2ct
due requires you to obtain this agreement from us.
The vA&tionil premium, for this endocsentent shall he --!.O-%ofdwWodm'Cocipmatiostpremiuiii
otherwise due for the swc(s) listed below on such remuneration, subject to a mini nutu urge of $2S O
All written contracts in the states) of
CA
'Phis cndorsctncnt is part of yeaur policy_ It :gpMedea and cot M6 anything to the contrary. It i,s odherwile
subiwt to all the terms of the policy.
Counter hated Audwriacd ReptraentatLLvt
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