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PROOF OF INSURANCE (2012) CLOSEDOP ID: M8 CERTIFICATE OF LIABILITY INSURANCE °AT 0 """"' a/20112or11 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 Brtificate holder in lieu of such endorsementfsl.. OUCER 310- 524 -1340 erakke Schafnitz West - D License #0428915 840 Apollo Street, Suite 150 El Segundo, CA 90245 Marlene Richardson 11,310-524-1343 mrichardsT n bsw -i i lO a: DRMAU -1 310- 524 -1344 INSURERISI AFFORDING COVERAGE NAIC 0 INSURED Dr. Maureen Sassoon_ INSURER A:WeStChe8terSuiplus Lines Ins P 0 BOX 2028 INSURER B: Palos Verdes Peninsula, CA 90274 INSURER C: INSURER 0: INSURER E:- _.... INSURER F: COVERAGES CERTIFICATE NUMBER: 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. IN'SR I T7i .........� TYPE OF INSURANCE ADDL iuea 3U OR wvn — POLICY NUMBER POLICYEFF'- MIO �.. P,• MMPDONY"rYY„I _ ..._. LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000,00 C OMMERMALGENE IAeILITY X 624061814003 05101111 05101112 Ef� aFKalcF❑ r em a � 50,00 X _ CLAIMS- MADE OCCUR MED EXP ( nv one oersoni 5 6,00 PERSONAL aADVINJURY .,.....,E 3 1,000,00~ X $2,500 DedlOccur GENEITALAGGREGATE 5 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 2,000,00 X POLICY [:] PRO- LOC $ IEC T ........ __ _ AUTOMOBILE LIABILITY '.. COMBINED SINGLE LIMIT S (Es accidenl) ANY AUTO BODILY INJURY {Per person) 5 ALL OWNED AUTOS BODILY INJURY (Per accident) 5 SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) 5 NON -OWNED AUTOS $ 'S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS MAbE AGGREGATE - 5 DEDUCTIRLE S 5 RETENTION 5 WORKERS COMPENSATION WC STATU• arm- AND EMPLOYERS LIABILITY YIN y 1 lnnirc Fw ANY PROPRIETORMARTNEWEXECUTIVE F7 OFFICERIMEMBER EXCLUDED? NIA E.L. EACH ACCIDENT S (Mandalory In NH) E,L OISFJISE - EA EMPLOYEE'' S Iryes describe under DESLIRIPTIDN OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 5 A Professional Lisb, "'"11 05101112 P L'iab $1mtn$'2mmA09 I'ncls. Pollution & I ASBESTOS COVGICLAIMS MAD Deduct $6,00004 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Atlneh ACORD 101, Additional Remarks Schedule, if more space Is roqulred) "Except 10 days IF cancelled for nonpayment of premium. The Certificate Holder is recognized as Additional Insured per endorsement (ENV -3100) attached. C -ELSEG City of El Segundo Attn City Clerks Office 530 Main Street El Segundo, CA 90245 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE t ©19BB -2009 ACORD CORPORATION. All rights reserved„ .ORD 26 (2009109) The ACORD name and logo are registered marks of ACORD n EPW 1 624061814003 I To Westchester Surplus Lines Insurance Co 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 OrEiantzatlon: 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 r n 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 1S 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 addtional 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 "" HLHHIN I LU FHUM I HL AHUHIVL„ I HE UHIUINAL I HANZJAU I IUN MAY INULUUL AUUI I IUNAL I-UHMJ "" y POLICY NUMBER: A2074142 c 4Bmtw.r of Ysh€r3g;ti4uoml. ¢im'p SAFECO INSURANCE COMPANY OF AMERICA AUTOMOBILE POLICY DECLARATIONS NAMED INSURED: MAUREEN SASSOON PO BOX 2028 PALOS VERDES PEN CA 90274 -802 AGENT: NHC INSURANCE SERVICES INC 796 W 9TH ST SAN PEDRO CA 90731 -3602 RENEWAL POLICY PERIOD FROM: SEPT 1 2011 TO: SEPT 1 2012 at 12:01 A.M. standard time at the address of the insured as stated herein. AGENT TELEPHONE: (310) 221 -0917 RATED DRIVERS MS MAUREEN SASSOON 2008 BMW 328I SULEV 4 DOOR SEDAN ID# WBAVC53578FZ84867 LOSS PAYEE BMW BANK OF NORTH AMERICA 1986 HONDA CIVIC 1500 4 DOOR SEDAN ID# 3HMAK7430GS007927 Insurance is afforded only for the coverages for which limits of liability or premium charges are indicated. COVERAGES 2008 BMW LIMITS I PREMIUMS 1986 HOND LIMITS1 PREMIUMS LIABILITY: BODILY INJURY $500,000 $ 216.40 $500,000 $ 141.10 PROPERTY DAMAGE Each Person $500,000 Each Occurrence $100,000 Each Occurrence MEDICAL PAYMENTS $5,000 UNINSURED AND UNDERINSURED MOTORISTS: BODILY INJURY $500,000 Each Person $500,000 Each Accident UNINSURED MOTORISTS: PROPERTY DAMAGE COMPREHENSIVE Actual Cash Value Less $250 Deductible COLLISION Actual Cash Value Less $500 Deductible WAIVER OF COLLISION DEDUCTIBLE Each Person $500,000 Each Occurrence 128.40 $100,000 Each Occurrence 12.90 $5,000 156.80 $500,000 Each Person $500,000 Each Accident 99.40 8.90 ADDITIONAL COVERAGES: LOSS OF USE $50 Per Day /$1200 Max 36.80 AUTO LOAN /LEASE 11.00 ANTI FRAUD FEE 1.80 ROADSIDE ASSIST 6.50 TOTAL $ 961.70 $3,500 Each Accident -CONTINUED - P 0 BOX 515097, LOS ANGELES, CA 90051 93.80 9.00 111.10 6.40 1.80 »-- TOTAL $ 363.20 08/18/2009 15:Iar 3105440752 DP S(4SS00t,,l PP'%GE 01. }lair r( C,F" mlph� C I h proviOng, management, heaH�h & safety services Lorrai-ne Ward August 18, 2009 Human Resources Department, C'ity oFEI Segundo 350 Main Street El Segundo, CaJifornia 90245 RE: Workcrs' Complensation Instirance Dear 4s. Ward: Due to the fact that Dr. Maureen Sassoon is self-employed and does not have any employees, Workers' Compensation insurance is no�t wan,antcd and Ilas riot been obt,ained, Dr. Sassoon does maintain personal medical insurance throug)i Kaiser Perpia.riente. Cordially, Maureen Sassoon p,O, box ,2028 pallos vercles penja isufa ca 90274