No preview available
PROOF OF INSURANCE (2015) CLOSEDDATE (MM/DDIYYYY) CERTIFICATE OF LIABILITY ' TY I SU A C 06/18/2015 HCC Specialty NONE FAX ,. kM) 401 Edgewater Place, Suite 400 ADDrR�a Wakefield, MA 01880 ........... ... ..... __._m �_........... „m,,,, iNSURERCS AFFOADINRCOWCRAGE NAIC# INSURED INSURERA. New Hampshire Insurance COmpanV 23841 Main Street INSURERe United States i_ s Fire Insurance Com Spy 21113 406 Maryland St _ _ INSURERC: .�...... El Segundo, CA 90245 INSURERD ..... ._ . .._.. - INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER - THIS IS TO CERTIFY THAT T14E POLICIES OF INSURANCE LIS'TEO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR PIE POLICY PFAIOD INDICATED, NOTWITHSTANDING ANY REOUIREMoMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, �'HF INSURANCE AFFORDED BY THE POLJCIE DESCRIBED HEREIN Is SR)BJECT TO ALL THE TERMS, S, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS, X T .... _ _ ADD/ SODA b �C �TYPEOFINSURANCE dYYY Y............ •• W —_POCYNU#BER #MD1YYYY .. . m LIMITS m OENERALLIABI'LITY A X SEL010334480 x 06/19/2015 07/07/2015 r � � OAMEIC6AL GENERAL LIABILITY Wmm I_ s - op 0 OCCUR CLAIMS -MADE iuFnFxa(anvnnwLw . pJ �_ 5tI DO _ i liost Liquor PERSONAL 9 ADV INJURY $ 1,000,000 g Mtadlcal Exn US435549 06/19/2015 07/07/2015 GENERAL AGGREGATE $ 2000,000 GEN'L AGGREGATE LIMIT APPLW,9 PER: PRODUCTS. COMP/OP AGG S 1,000,000 X POLICY j1CT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ '........ (Ea accidenl) ANY AUTO BODILY INJURY (Per Person) $ W -- ALL OWNED AUTOS — ° °�— BODILYINJURY(Peracddent) $ SCHEDULED AUTOS �.W ,w_ ......- .» � ...�S�.w.e-------- PROPERTY DAMAGE ------- -- - --. HIRED AUTOS (Per accident) NON -OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAS CLAIMS -MADE ...... .. .. -..... AGGFREOATE, $ ..r DEDUCTIBLE _m_ ... S RETENTION ! S ES COMPENSATION -rnov , uarc F AND EMPLOYERS' LI ABILTY Y ANY RIPARTNEPJEXECUrNE � OFFICERIMEMBER EXCLUDED? E L. EACH ACCIDENT S (Mandatory In NH) E.L. DISEASE - EA EMPLOYE S If OPERATI9PIS _ ...... ............_. �_,.......�.U........._---- D ESLtRIPON OFU M?alAw ESL. DISEASE POLICY LJMIT S DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks SchedWe, It more apace Is required) The Certificate Holder is added as Additional Insured with respects to our Insured's operations only.., This Insurance la primary and nwconftulory as required by vwillen conwacl.. This coverage Is with respect 10 41h of Aly CeleMation event to be held 7/4/2015 - 7/4/2015 at Stevenson Field El Segundo CA City of El Segundo, its officers, officials, employees, agents, and Volunteers SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AuTNDI:tzED REPRESENrATr!( ACORD 25 (2010105) ©1988 -2010 ACORD CORPORATION. All rights reserved. f POLICY NUMBER: 10334480_ XV\-/, 00hWRCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL I SURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE A. Section II — Who Is An Insured is amended to Include as an additional insured the person(s) or organization() shown In the Schedule, but only with respect to liability for "bodily injury ", "property damage" or "personal and advertising injury " caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf., 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: I. The insurance afforded to such additional Insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the Insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CCU 20 26 0413 B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. © Insurance Services Office, Inc., 2012 Page 1 of 1 Main Street (Vintage Band) Date: 6 -23 -15 To: City of El Segundo Re: Business Automobile Liability Insurance and Worker's Comp I, Jean -Louis Boudreau, band member of Main Street Band, certify that all band members are independent contractors. The band is not incorporated and does not carry Business Automobile Liability Insurance. 1hon1 you., .,ie6 Louis Boudreau 406 Maryland Street • El Segundo - CA 90245 . tel: 310.720.9360 • fax: 310.726.0138 6!2312015 AAA- Print Auto Policy Details Current Term 05/13/2015 - 05/13/2016 DRIVERS Name Date of Birth Driver Status Josette Murphy 11/26/1967 Regular Operator Driver Details Gender Female Marital Status Married Year First Licensed 1984 Accidents & Traffic Convictions Accidents 0 Total Traffic Convictions 0 Minor: 0 Major: 0 Serious: 0 Severe: 0 Jean -louis Boudreau 06/09/1960 Regular Operator Driver Details Gender Male Marital Status Married Year First Licensed 1982 Accidents & Traffic Convictions Accidents 0 Total Traffic Convictions 0 Minor: 0 Major: 0 Serious: 0 Severe: 0 VEHICLES Vehicle No. Year Make 1 1999 Hond Mips: // apps .calitaaa.com /aceappstinsurance[ policies /PolicylPrintAuioPolicvDetalls 1004 ?i)olicvPreffx= CAA& paiicvNumber- 06767979wprintPreview 1/5 612312015 2 4 AAA- Print Auto Policy Details Vehicle Details Identification Number Garage Zip Code Annual Miles Special Equipment Sound Equipment 2008 Vehicle Details Identification Number Garage Zip Code Annual Miles Special Equipment Sound Equipment 2015 Vehicle Details JHLRD2845XCO15345 90245 5,001 - 7,500 None None Ford IFTPWI25XSFA30126 90245 10,001 - 15,000 None None Ford Identification Number IFM5K7683FGA03448 Garage Zip Code 90245 Annual Miles 5,001 - 7,500 Special Equipment None Sound Equipment None Premium $513 Coverage Details Coverages Limits of Liability Premium Liability Bodily Injury $500,000 Each Person $170 $500,000 Each Occurrence Property Damage $1D0,000 Each Occurrence $110 Physical Damage Comprehensive Actual Cash Value $61 (Less Deductible) $500 Collision Actual Cash Value $139 hit O /apps. calif. aaa. com/ aceaDmfi nsurarre/ oalicies /P(Aiev/PrintAtAoPoficvDetails ? icvPrefix =CAA&notievNumber= 06767979Wrir#Previf.w 2/A 6/23/2015 2 4 (Less Deductible) Uninsured Motorist AAA- Print Auto Policy Details $500 Uninsured & underinsured Motorist(s) $30,000 Each Person $33 Bodily Injury $60,000 Each Occurrence Uninsured Deductible Waiver Yes Total Premium $513 ref; Ford Coverage Details Coverages Limits of Liability Liability Bodily Injury $500,000 Each Person $500,000 Each Occurrence $936 Premium $272 Property Damage $100,000 Each Occurrence $182 Physical Damage Physical Damage Comprehensive Actual Cash Value $79 (Less Deductible) $500 Actual Cash Value $388 Collision Actual Cash Value $328 (Less Deductible) $500 Car Rental Expense (Per Day) $35 $36 Uninsured Motorist Uninsured & Underinsured Motorist(s) $30,000 Each Person $39 Bodily Injury $60,000 Each Occurrence Uninsured Deductible Waiver . .... Yes Total Premiu m _, _.... _. .. $936 2015 Ford $882 Coverage Details Coverages Limits of Liability Premium Liability Bodily Injury $500,000 Each Person_ $243 315 $500,000 Each Occurrence Property Damage $100,000 Each Occurrence $165 Physical Damage Comprehensive p Actual Ca _. Cash Value $41 (Less Deductible) $500 Collision Actual Cash Value $388 (Less Deductible) $500 tttpsJla p s.califaa . n/lac a fins ance/policiesi Policy /PrintkA olicVDetaits/004?pdicyPrefix= CAA&rdicyNurnber= t 67 7 rirdPr view^v' 315 6128/2015 Uninsured Motorist Uninsured & Underinsured Motorist(s) Bodily Injury Uninsured Deductible Waiver Total Premium AAA - Print Auto Policy Details $30,000 Each Person 5 $60,000 Each Occurrence Yes $882 ................... ... ,..,... Total Premium $2,331 You received a Policy Holder Savings Dividend last year in the amount of: $198 DISCOUNTS Policy Discounts Multi- Policy: Home Other Discounts: Loyalty , Multi Car Driver Discounts 3osette Murphy Good Driver Factor Sean -louis Boudreau Good Driver Factor Vehicle Discounts Vehicle 1: 1999 HOND CR -V LX SUV Vehicle 2: 2008 FORD F150 CREW C SUPER PICKUP Vehicle 4: 2015 FORD EXPLORER SUV ENDORSEMENTS AND CERTIFICATES Passive Restraint , Verified Mileage Passive Restraint , Verified Mileage Anti -theft , Passive Restraint , Verified Mileage Number Title 2011 MEMBER'S AUTOMOBILE POLI . CY - POLICY NUMBER CHANGE 2286 REDUCED UNINSURED MOTORIST COVERAGE The information displayed on this website is for informational purposes only and is not intended to replace your policy (including any endorsements) and declarations that are mailed to you. Insurance is in effect only for the coverages and limits of liability shown on the declarations and as set forth in the insurance policy and endorsements. This information is a helpful summary only and is not a comprehensive definition of all coverages, qualifications, limitations, etc. Please consult the policy and one of our insurance agents for more information. Also, the information displayed on this website may not reflect recent policy changes or payments and /or transactions on your account. Please allow up to three business days for your new information to be reflected in these records. The information displayed on this website is for informational purposes only and Is not intended to replace your policy (including any endorsements) and declarations that are mailed to you. Insurance is In effect only for the coverages and limits of liability shown on the declarations and as set forth in the insurance policy and endorsements. This information is a helpful summary only and is not a comprehensive definition of all coverages, qualifications, limitations, etc. Please consult the policy and one of our insurance agents for more information. Also, the information displayed on this website may not reflect recent policy changes or payments and /or transactions on your account. Please allow up to htips:lapps. calif. aaa .com /amppstinsurance/policies/ Policyl PrintWoPolicvDetAs /004 ?policvPferttx = CAA& poll cvNurnber =067679799#PriraPreview 415 612312015, AAA- Print Auto Pollcy Details three business days for your new information to be reflected in these records. The required payment must be postmarked, paid over the phone, paid online or paid in- person at one of our AAA office locations during normal business hours prior to the cancellation date /time or the policy will be cancelled for nonpayment of premium and all coverage will cease as of that time. If payment is not made or is made for less than the required amount, the amount due must be paid before the cancellation date /time to ensure that the insurance coverage does not lapse, Whenever a premium payment is returned unpaid by your financial institution, we may, at our option, notify you in writing that the entire outstanding prernium balance is immediately due and payable in cash or by cashier's check or money order at one of our AAA office locations. All returned payments, whether by check, electronic transaction, or other form of payment may be presented again electronically for payment. Each returned payment and each late payment is subject to a fee that may also be debited electronically. Fees are subject to change without notice, Payments are accepted from U.S. financial institutions only. utq_tnLatic Pa ments: Automatic debits from your checking account for insurance policies will begin with the first automatic payment billed after the Authorization Agreement is received and processed. (Please allow 15 days for processing,) Until then, your insurance premium payment is still due on the date shown on Your- most recent billing statement. If you enroll in automatic payments for more than one insurance policy, the processing bank will determine the order of processing debits (Le., the order of payment) for each policy. Automatic payments are subject to aft applicable finance charges, installment and other fees. We gave you notice of the amount of all applicable finance charges and /or fees at the time you applied for the insurance policy(s) above and upon renewals of your policy(s), Installment payment plans and all fees are subject to change without notice. Policyholders who have payments returned unpaid from their financial institution may have automatic payments authorization revoked as to all insurance policies by the Exchange. In the event that this occurs, you will be notified by mail and a return payment fee and late fee may be added to your bill (or to a second attempted debit to your account). If automatic payments are revoked, installments remaining for the current insurance policy period rill be billed on your regular payment plan with statements mailed to you. If an error is made the Exchange can correct it by initiating debits or credits. You may revoke enrollment in automatic payments, as to any one or more insurance policies, at any time by signing and dating a written request and mailing it to: AAA /Interinsurance Exchange of the Automobile Club, P.O. Box 25006, Santa Ana, CA 92799 -5006, While not requiredr a revocation form is available for your use upon request by contacting us at (800) 924 -6141 or your local office. Insurance Is provided to qualified Auto Club members by the Interinsurance Exchange of the Automobile Club ( "Exchange "). CA Dept of Insurance Lic, 1/0003259 CTR# 1016202 -80 Copyright Oc 2013 Automobile Club of Southern California. All Rights Reserved The Automobile Club of Southern California is a member club affiliated with the American Automobile Association (AAA) national federation and serves members in the following California counties: Inyo, Imperial, Kern, Los Angeles, Mono, Orange, Riverside, San Bernardino, San Diego, San Luis Obispo, Santa Barbara, Tulare, and Ventura. Find a different AAA club. https;llal as ,ca)if,aae,cornlareappslirt,>Lr as elodioi Pdi tlPrintAtAoPoli h elaiisIOD4 WicyP efix= AA ,r. tlicvNumber=0616197 riroPrevif.w 5/5 Enter your TIN in the appropriate box. The TIN provided marl match three name given on Una 'I to avoid 9a, .Aty number backup withholding. For lndh4duats, this is your social ty r (SSN). However, for a resident � aflhn, sola,pwde -tor, or disregarded entity. see the Part I Instrucltoats on page 3. For other entitles„ It I " LuLLI your ampfoyar idontific ti'on number ( Itf). It you do not have a number, see Now to get a Ttlht an page 3- or Note it the account Is in more Dian one rmme, see the chart an page 4 for guidelines on whose FErripluy7w laEaitlrElaalteai nwnber number to enter. Under penalties of -WJwy, I certify ftt 1. The number shown on this form Js my correct taxpayer identification number (or l am waiting for a numbs► to be Issued to me), and 2. I am not subject to backW wlthtro Ling because' (a) I am exempt from backup Withholding, or (b). I have not been notified by the Internal FlatwranUa Ssrwce QR ),that I ant svbl%t fa baokup withholding as a result of a failure to report all interest or dividends, or (a) the IRS has - rlotlfted me treat lam no longer subject to backup withholding, and 3, l am a U.S. citizen Or other U.S. person (defined below). afrtlftretton �o you aaratst cross out Item 2 above If you have been notilled by the lfttt drat yawl are curreenity awabjact to bocftup withholding wear frsa you havo fxallaad to report all intoreast and divrlda nda on your tax return. For real gestate lmnsactlon% item ,2 does not apply. For mortgage interest paid, aaqu itlon or abandomnent of secured property, cancellation of debt, contributions to an iradIvNdual retirement arrangamerrt (i(�, and ganorally, pa ants' other khan Interest, and divtdands, you are not required to sign droe Certification, but ,you must provide your ootredt TIhI. Sae„ the In uotiote on page 4. Sign signeft"of - -. -- HerO %S,jierson 0, General Instruct Section references are to the internal Revenue Code unless otherwise mated, Purpose of Form A Everson who Is req�llrad to file an Information nature with the IRS must obtain your correct.taxpayer Idenfificafiou number ( IN) to report, for example, Income paid to you, real estate transactions, hrfortgage interest you pald, acquisition or abandonment of secured property, cancollallon of debt,, or contriblrllons you mane to an IRA. Use Fottr W only If your ore a U.S, arson (including a res�ttt alletaj, to provide your uor�t I IN �to persorl requesting it (thei requester)) and, when applicable, to; 1. Certlfy that the TIN you are )lving is oo[rect (or yore are waiting for a (lumber to bo Issu, 2. t artify tflat you aria not subject °to backup withholding, or 3. claim exemlption front backup withholdin,gg if you are a U.S. exempt payee. If ap Icable, you arc also cartitying that as a .5 person, your shy of any partnership Income from a UA trade or bu*, Me$ Is not subject to the wlffrttolding tax on foreign partners` share of effactiv' ely connected income. Note- If a r+equestor gives you a fort other than Form W -8 to request your "("IPA, ybu must use the, register's force 0 (t is substan't ily similar to this Form Vii, ,-S.. afirlitfon of a U.S, person, for federal tax purposes, you are considered a U.S. person if you are.,. e Art lndlvtdual who is a US. citizen or U.S. resident allen,. eo A partnetship, corporation, company, or association created or organized In the united States or gander thaw Wwca of the United States„ e An estate (other than a foreign estate), or 0. A domestic trust (as defined In Regulations section 301.7701-7). Special rules for pet^ ner^sittpa. Partnerships sips that condubt a trade or business In the United States are gerterally rewired to ply a witlafroldlrrg tax art any foreign partners' share of Income frotta such btlslness. Furinar, in certain cases where a Form W -g has not been reoaivari, a partnarsialp is required to presume that a partner Is a foralgm rl, anal (aay tuts withholding faux. Therefore, if goal are a f).,5, parson that is a partner kt a p rtnerahNp conductlrlg a tracfa or tatlsinaso In the l)Mad tat, s provldet Foram VVa" -ty taa,th parbtersialp tie establish your U.S. n icoomm e. c alai awoNd withRwoldI , an your he of ship The Person who gives form "-t) to the partnership for purposes of r tabiishing its U-8, Mira and avoiding withholding on Its. Aftopable share of net Income from the partmatship conducfing a trade or business In the United Slates Is in the following cam; The U:& owner of a disregarded entity and not the entity Cat. No. 10231fi OW 10-2t1D7)