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PROOF OF INSURANCE (2016) CLOSEDDRMAIJ-1 OP ID: C6 DATE (MM /DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 06/09/2015 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(ies) 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 CONTACT Carole S Mitchell Brakke Schafnitz Ins. Brokers NAME License #0428915 ro r K1 F: *, 310 524 1357 in c, Nol 949-313-3323 100 Wilshire Blvd. # 940 EMAIL Santa Monica, CA 90401 ADDRESS Carole mltchell si us GE NAIC # ,..,. ... ,.., SURER(SIAFFORDIS Li ...... ........... ...__ .... -... .......-----._.. Darla ray IN .. . INSURERA:WesicheSterSurpIu Ins INSURED ur. maureen bassoon INSURER P O BOX 2028 INSURER C Palos Verdes Peninsula, CA 90274 INSURER D . . ... ..... .... ........., , .. INSURER E: INSURER F CnVFRAr;FB CERTIFICATE NUMBER: 1 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. INSRR . .................... TYP.... U 'INSO WvD ------ POLICY NUMBER M F POLN .... °......,,,, . OLICY EF Y EXP INSURANCE °... MIDDIYYYy MM)DI.TIh"'rY'Y LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR X X ''G24270427004 07/01/2015 07/01/2016 DAMAGE TO RI81V1 ED .. PREMISES (,Ea occurrence) ........... $ 50,000 _ X Add'l Insured MED EXP (Any one person) 11 $ 5,000 X Prof & Pollut -CLM PERS ONA L8ADV INJURY $ 1,000,00 .... - GEN'L AGGREGATE LIMIT APPLIES PER. .... -- — - -- .............. GENERAL AGGREGATE $ 2,000,000'' POLICY El PRO LOC PRODUCTS - COMP /OPAGG - -- --- - $ 2,000,000' OTHER, $ AUTOMOBILE LIABILITY COME] ME]NED SINCI F I IMIT F........ .,... a accident $ ANY AUTO BODILY INJURY (Per person) $ ...SCHEDULED ALLOWNED URY (Per accident) BODILYINJU ................... nI) $ _ AUTOS [ AUTOS NON -OWNED �. ,. ....,., ................. PROPERTY DAMAGE --- $ HIRED AUTOS AUTOS Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE ... ............................... $ .. ........ ...... EXCESS LIAB CLAIMS -MADE AGGREGATE $ ED ON$ D RETENT $ WORKERS COMPENSATION 4TATI ITF 1 FR AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR /PARTNER /EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? �.N I A . - - - -- (Mandatory in NH) DISEASE EA EMPLOYEE $ If yes, describe under __EL nFCCRIPTIC'l,N QF (1PFRATIl7NS helnw .gym,. E..L. DISEASE POLICY LIMIT $ A Professional Liab. G24270427004 07/01/2015 07/01/2016 Prof.Liab 1,000,00 A Contractors Poll. G24270427004 07/01/2015 07101/2016 Pollution 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Policy Provides 30 days notice of cancellation except 10 days for nonpayment Applicable Endorsements Attached where required by Written Contract CERTIFICATE HOLDER CANCE'LLAT'ION C -ELSEG SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CI of El Segundo 0 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City g ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Julie DeZiel, HR Analyst 350 Main Street AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 ©1988 -2014 ACORD CORPORATION. All rights reserved, ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Insert the policy number. The remainder of the information is to be completed only when this endorsement Is issued subsequent to the preparation of the policy,. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ENDORSEMENT OWNERS, LESSEES OR CONTRACTORS — SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE CONTRACTOR'S POLLUTION LIABILITY COVERAGE SCHEDULE: Name of Person or Or anizaticn: Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. SECTION Il - WHO IS AN INSURED is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions 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 repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) That portion of your work out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. ENV -3100 (08 -04) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 1 of 1 Named Insured Endorsement Number Dr. Maureen Sassoon Policy Symbol Tpilky Number Policy Period Effective Date of Endorsement ECP G24270427 004 07/01/2015 to 07/01/2016 07/01/2015 Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company Insert the policy number. The remainder of the Information is to be completed onlywhen this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ENDORSEMENT - OWNERS, LESSEES OR CONTRACTORS (PRIMARY AND NON - CONTRIBUTORY) . This endorsement modifies insurance provided under the following; COMMERCIAL GENERAL LIABILITY COVERAGE CONTRACTOR'S POLLUTION LIABILITY COVERAGE SCHEDULE: • at Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, Information required to comp applicable to this endorsement,) SECTION II - WHO IS AN INSURED is amended to include: In the Declarations as A. SECTION II - WHO IS AN INSURED is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operatio�6erfdrmed for that insured, B. With respect to the insurance afforded to these additional insureds, the following exclusion is added; 2. Exclusions 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 repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) That portion of your worVout of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. The coverage provided hereunder shall be primary and not contributing with any other insurance available to those designated above under any other third party liability policy. ENV -3101 (08 -04) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 1 of 1 Named Insured Endorsement Number Dr. Maureen Sassoon Policy Symbol Policy Number Pollcy Period Effective Date of Endorsement ECP G24270427 004 07/01/2015 to 07/01/2016 07/01/2015 Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company Insert the policy number. The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART SCHEDULE Marna of Peon or Orgariixation: Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or your work done under a contract with that person or organization and included in the products - completed operations hazard. This waiver applies only to the person or organization shown in the Schedule above, All other terms and conditions remain the same. ENV -3143 (03 -05) Includes copyrighted material of Insurance Services Office, Inc. with its permission Page 1 of 1 ADDITIONAL INSURED ENDORSEMENT — PRODUCTS - COMPLETED OPERATIONS HAZARD Named Insured Endorsement Number Dr. Maureen Sassoon Policy Symbol Policy Number Policy Period Effective Date of Endorsement ECP 624270427 004 07/01/2015 to 07/01/2016 07/01 /2015 Issued By {Name of Insurance Company) Westchester Surplus Lines Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTOR'S POLLUTION LIABILITY COVERAGE PART SCHEDULE Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section II —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 damage caused, in whole or in part, by your work performed for that additional insured and included in the products - completed operations hazard. All other terms and conditions remain the same. ENV -3225 (10 -08) Copyright ©200 8C Page 1 of 1 ADDITIONAL INSURED ENDORSEMENT — PRODUCTS - COMPLETED OPERATIONS HAZARD PRIMARY & NON - CONTRIBUTORY Named Insured Endorsement Number Dr. Maureen Sassoon Policy Symbol Policy Number Porcy Period FO&dive Da_te of Endorsement ECP 624270427 004 07/01/2015 to 07/01/2016 07/01/2015 Issued By (Name of Insurance Company) Westchester Surplus Lines Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTOR'S POLLUTION LIABILITY COVERAGE PART SCHEDULE Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section II — 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 damage caused, in whole or in part, by your work performed for that additional insured and included in the products - completed operations hazard. Furthermore, the coverage provided hereunder shall be primary and not contributing with any other insurance available to those designated above under any other third party liability policy. All other terms and conditions remain the same. ENV -3226 (10 -08) Copyright ©200 Page 1 of 1 CALIFORNIA INSURANCE IDENTIFICATION CARD saafec,aa COMPANY laaaaaaaarc SAFECO INSURANCE. COMPANY OF AMERICA 62"MAPLE`AVENUE KEENE NH 03431 POLICY NUMBER EFFECTIVE DATE `EXPIRATION DATE A2074142 SEPT 1 2015 SEPT: 1 2016 YEAR MAKEIMODEL VEHICLE IDENTIFICATION NUMBER 2008 ONN WBAVC535 79FZ84867 AGENCY/COMPANY ISSUING:CARD NAIC 2.4740 NHC INSURANCE SERVICES lNC SROS CA 407313602 INSURED MAUREEN SASSOON AEON S PEN CA 90'274- 8028 CN= 7042 /GAFF 6113 VEHICLE REGISTRATION COPY. CALIFORNIA INSURANCE IDENTIFICATION CARD SaalaCa COMPANY iar alrance SAFECO INSURANCE COMPANY OF AMERICA 62 MAPLE AVENUE KEENE NH 03431 POLICY NUMBER EFFECTIVE DA's ' EXPIRATION DATE A2074142- SEPT 1 2015 SEPT 1 2016 YEAR MAK'E/M aDEL. VEHICLE IDENTIFICATION 14UM BER 2014 HONDA 2HKRM13H59 EH548165 AGENCY/COMPANY ISSUING CARD NAIC 24740 NHCC INSURANCE SERVICES fNC SAN 6�E���26 CA, 4071 -3602 INSURED MIA'UREEN SASSOON ALO RAMS PEN CA 90274 -8028 CN- 7042 /CAEP 6/13 VEHICLE REWSTRATION COPT ARD(S) ON THE PERFORATIONS. BE KEPT IN THE INSURED VEHICLE ND., THE OTHER COPY SHOULD BE PRESENTED TOR VEHICLE DEPARTMENT III II III 1111111111 IIIIIIIIIIIIIIIIIII YOUR VEHICLE REGISTRATION. E4aa dr. maurean sassoon ms, mph, cih providing management, health & safety services Julie DeZiel Human Resources Department City of El Segundo 350 Main Street El Segundo, California 90245 RE: Workers' Compensation Insurance July 13, 2015 Dear Ms. DeZiel: Due to the fact that Dr. Maureen Sassoon is self - employed and does not have any employees, Workers' Compensation insurance is not warranted and has not been obtained. Dr. Sassoon does maintain personal medical insurance through Kaiser Permanente. Cordially, Maureen Sassoon, DPP,, C11-11/5203 p.o, box 2028 palos verdes peninsula ca, 90274 (31 O� 544 -2,1 2