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PROOF OF INSURANCE (2016) CLOSEDClient #: 5688 50T(FFAHOMEC T"" CERTIFICATE F LIABILITY I DATE (M00lYYYY) #!7108/2015 - EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 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(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 MET Morris Hub Intl Ins Sery Lic #0757776 PHONE gOg 912 -6435 ' 909 543 -0825 o Ext : C No: Formerly Livermore & Assoc Ins E-MAIL 9570 Center Ave ADDRESS: — ___��_ INSURERS AFFORDING COVERAGE NAI d Rancho Cucamonga, GA 91730 INSURER A: Philadelphia Indemnity Ins INSURED Tiffany Home Care inc INSURER 8 : ? dba Always Right Home Care iq_SM99 t c- j 9700 Reseda Blvd Ste 105 INSURER D u _ fMEDXP(Anyoneperson) [$5,Q00 _.. Northridge, CA 91324 INSURER E: t 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 CONTRACTOR 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. t?tt TYPE OF INSURANCE IADDLtSUaRI ItVSR t«hjU . POLICY NUMBER f.SPMOILICY/YYYY} {MM /DD/YYYY! 3 LIMITS A 1 GENERAL LIABILITY � PHPK1344149 6/15 /2015 06/1512016 _ EACH OCCURRENCE 1 S1 000 000 A %ES tEs NTE enca).. ' s100,000 COMMERCIAL GENERAL LIABILITY € 91, XE- CiftIMS•MADE 0OCCUR j fMEDXP(Anyoneperson) [$5,Q00 _.. PERSONAL &ADV INJURY 1 $1,000,000 J Retro Date: 06/15/03 � _ GENERAL AGGREGATE I3,000f}00 G�EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG 0,000,000 _ + POLICY ? PFD ?_i l.00 .�. �. �'# - A AUTOMOBILE LIABILITY PHPK1344149 6115/2015 06/15/201 ae�lN�eDtSINGLE LIMIT X1,000,000 BODILYINJURY (Par person) $ ANY AUTO 4 — 1 ALL w SCHEDULED jjj BODILY INJURY (Par acc deni)1 $ AUTOS AUTOS -�[� PROPERTY DAMAGE (Per accidenit { i NON -OWNED X ! LXX HIREDAUTOS AUTOS a } P f UMBRELLA LIAB OCCUR s f EACH OCCURRENCE #� AGGREGATE S t t EXCESS LIAB CLAIMS•MADEY WORftETENTiON$ KERS COMPENSATION AND EMPLOYERS' LIABILITY YIN W STA7U j� T�. . TQ12YJ„ 1 ! R_ l i ANY PROPRIETOR/PARTNER/EXECUTiVE E L. EACH ACCIDENT OFFiCERIMEMBER EXCLUDED? ; N t A "!E, - - (Mandatary In NH) i ( E.L. DISEASE - EA EMPLOYEE! S yes, describe under {' U z 3 DESCRIPTION OF OPERATIONS below ! I E.L. DISEASE - POLICY LIMIT I s A Prof Liability PHPK1344149 6/15/2015 061151201E $1,000,000 Ea Incident _ ...._,._ Retro: 06/15/03 I I $3,000,000 Aggregate DESCRIPTION OF OPERATIONS / LOCATIONS t VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) Coverage includes $1,000,000/$3,000,000 Sexual /Physical Abuse or Molestation Claims Made Retro Date: 06/15/03 Certificate Holder is Included as Additional insured per policy terms and conditions as respects Senior In Home Care Project for the City City of El Segundo THE SHOULD XPIRATIONH DATE VTHEREOF, E NOTICEIEWILLL BE CDELIVERED O NE 350 Main Street ° ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 ' 4 AUTHORIZED REPRESENTATIVE ?3� 0 O 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (20101051 1 of 9 The ACORD name and loco are registered marks of ACORD POLICY NUMBER: eHeK134414g COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART _ A. Section D —Who Is An Insured is amended to include as an additional insured th organization(s) 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, |n the performance of your ongoing operations; or 2. |n connection with your premises owned byor rented boyou. tThm insurance afforded to such additional insured only applies to the extent permitted by law; and 2. if coverage provided Lo 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 Ula contract or agreement to provide for such additional insured. ElVVith 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 ofthe additional insured is the amount ofinsurance: 1. Required bv the contract or agreement; mr 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever ialess. This endorsement ehoU not increase the applicable Limits of Insurance shown in the DeokaoaUons. CG 20 26 8413 @|mourence Services Office, Inc., 2012 Page 3 of 9 CERTIFICATE LIABILITY t � DA (MMIDDIYYYY ) PRODUCER Douglas J Carlson 1820 S. Elena Avenue, Suite H Redondo Beach, CA 90277 INSURED Tiffany Homecare Inc. dba Always Right Home Care 9700 Reseda Blvd. Ste 105 Northridge, CA 91324 COVERAGES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURER A: Wesco Insurance Company 25011 INSURER B: INSURER C: INSURER D: INSURER E: 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADD' INSR TYPEOFINSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMIDD POLICY EXPIRATION DATE MMIDDIYY LIMITS 1 GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE D OCCUR EACH OCCURRENCE 5 DAMAGE T �RE�1TE PREMISES Ea occurence _ $______ MEO EXP (Any one person) $ PERSONAL & ADV INJURY S GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: 17 POLICY PRO- J LOC EC PRODUCTS - COMPIOP AGG S $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Pef person) $ BODILY INJURY (Per accident) S PROPERTY DAMAGE (Per aocident) S GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC AUTO ONLY: AGG $ $ EXCESSIUMBRELLA LIABILITY 7 OCCUR EI CLAIMS MADE DEDUCTIBLE RETENTION $ EACH OCCURRENCE $ AGGREGATE $ S $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below WWC3131680 03/01/2015 03/0112016 VJC STATU- 0TH TORY LIMITS ER E.L. EACH ACCIDENT _ $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT S 1,000,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS GEKI II-IGA I t HULUtK L:ANt;tLL.A I IUIV SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of El Seguno DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN 350 Main Street El Segundo, CA 90245 � NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE RATIO 988 ACORD 25 (2001108) �� 'ORATION 1 If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statment on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). INNIO -1111TIM The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001108) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B POLICY INFORMATION PAGE ENDORSEMENT Insured: Tiffany Homnenare'inc.(ACorp.) Policy No: VVVVC3131680 DBA: Always Right Home Care Policy Period: 3/1/2015 to 3/1/2816 Endorsement No: 3 Carrier Name: Wesoo Insurance Company EndmtEfectiva: 718/2015 Authorized Rep: e. The following item(s) Fl|nsured'a Name (WC 8AOGU1) n Policy Number (WC 8AOG02) Fl Effective Date (WC 8SO8O3) �1Expiration Date (WC 89OSO4) �l |noured'n Mailing Address (WC 8AO805) F1 Experience Modification (WC 8Q04O8) n Producer's Name (WC 80UGO7) Fl Change in Workplace nf Insured (WC 8S0G08) n|naunod'o Legal Status (WC 89OS10) Fl �� Item 3.A. States (WC 8Q0S11) ks changed toread: Fl Item 3.8. Limits (WC 8Q0G12) [] Item 3.C. States (WC 890S13) 0 Item 3.O. Endorsement Numbers (WC 880G14) Item 4,* Class, Rute, Other (WC 89 04 15) �linterim Adjustment of Premium (WC 88U41G) FlCarrier Servicing Office (WC 8A8617) �l Interstate/intrastate Risk !D Number (WC 8OO6 18) Fl Carrier Number (WC 80 08 19) n Issuing Agency/Producer Office Address (WC 8AOG25) Adding waiver of subrogation to the policy ' form VYCO4O30G. City ofBSeguno 35D Main Street B Segundo, CAQU245 Location: City of El Segundo Adding form VVCU4O3OG. VVwaco Insurance Company WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY VVC890001C 1of2 INFORMATION PAGE Insured: Tiffany Honoacaue,lnc.(A Corp') Policy Number: VVVVC3131GOO Total Premium Subject bo Experience Modification EXTENSION OF INFORMATION PAGE FOR ITEM #4 452.360 Experience Modification G2% ITEM 4: SCHEDULE OFPREMIUMS 280.463 California Territorial Factor 1.1 Premium Basis Rate Per $100 Estimated Premium Discount 4.G96 of Code Total Est. Annual of Annual Classifications Em s No. Remuneration Remuneration Premium California Salespersons --Outside 1 8742 27.000 1.24 335 Clerical Office Employees 12 8810 500'000 O'AQ 4.960 Homemaker Services 70 8827 3.050,000 14.65 446.825 Manual Premium 9741 452.110 Total Manual Premium 452.118 Total Premium Subject bo Experience Modification 452.360 Experience Modification G2% 280.463 California Territorial Factor 1.1 28.046 Premium Discount 4.G96 0063 '13.883 Waiver ofSubrogaUon: City ofBSaguno.350 Main Street, BSegundo, CAQO245' Location: City ofBSegundo 8930 250 Expense Constant 0900 200 Terrorism 9740 1.073 Catastrophe (other than Terrorism) 9741 358 Total CAPremium 298.257 C|G/\1.O34128% QQQQ 5.434 VVCARFO.7i96 QQAA 2.103 UEBTFO.117796 8089 349 SIBTFO.05389& 9998 159 OSHAF8234896 9999 896 LECFO.15O696 9099 446 FRAUD 0.1814Y6 0999 637 Total CA Cost 305.981 TOTAL ESTIMATED ANNUAL PREMIUM STATE ASSESSMENT 296,257 TOTAL COST ` 305,981 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 0% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization City of El Seguno El Segundo, CA 90245 Job Description Specific contract per written form This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement Effective 3/1/2015 Policy No. WWC3131680 Endorsement No. WC040306 Insured Tiffany Homecare, Inc.(A Corp.) Premium $ 296257 Insurance Company Wesco Insurance Company Countersigned by