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PROOF OF INSURANCE (2016) CLOSED^. BUFKIA OP ID: KC ACRO� /DD/rrYY) ATE (MM CERTIFICATE OF LIABILITY INSURANCE DA TE(MM/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 Joe F Parker Parker General Ins. Services PHO NE CA Insurance License 0545437 Pr10 559 224 -8222 N)= 5.59- 224 -8277 5094 N. Fruit, #101 E -MAIL Fresno, CA 93711 A010"REp ° L,.... , INSURER(S) AFFORDING COVERAGE NAIC # INSURER A:ColonV Insurance Companv INSURED Gary V. Bufkin Computer ....... ....................... �,...�.,,,,,. ............. .- .- .- ..-.. - .. -.... ..- .. -..- - -- A. .... COr1SUI INSURER B 1374 N. Linden Avenue -- - - - - -- -- - - - - -- - - - -- Fresno, CA 93728 -INSURER C:_ INSURER D 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, Sk mm pA615L »SUBA... ... ... _ . _. ....., .._ POLICY Y �,� - .- .....- ......... ----- ----- INS TYPE OF INSURANCE W Y MMI ICM EXF LIMITS R INCr1 VIIVf> POLICY NUMBER DD„rY'y'YY A X COMMERCIAL GENERAL LIABILITY j EACH OCCURRENCE $ 1,000,00 _ PREMISES (Ea occurrence) _$ CLAIMS -MADE X I occuR X GL000943401 03/01/2015 03/01/2016 100,00 MED EXP (Anv one person) $ 5,00 PERSONAL & ADV INJURY .$ 1,000,,0,0., GEN'L AGGREGATE LIMIT A PPLIESPER GENERAL AGGREGATE $ 2,000,00 ., JECT TS COMP/ PRO � LOC PRODUCTS OP AGG $ 1,000,00 POLICY OT) IE R $ AUTOMOBILE LIABILITY COMBINED SINGLE UMP $ (Fa 89;0er' ) ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS $ BODILY INJURY (Per accident) NON -OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Peraneadnk)s ......w..,....,. UMBRELLA LIAR CLAIMS MADE "AGGREGATE E " $ EXCESS LIAB g .., .1­­­­ ,1 ... .......... OCCUR EACH OCCURRENC DI RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY cTQTI ITF FR YIN... . ... ..... .�...µ,. ............. ANY PROPRIETOR /PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? N/A EA ACCID ENT $ EL; CH (Mandatory In NH) E L DISEASE - EA EMPLOYEE $ If yes, describe under .......... .............. --- ---------.. DESCRIPTION OF OPERATIONS below E L DISEASE POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is named as an additional insured. CERTIFICATE HOLDER CANCELLATION CITYE -1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. Rebecca Stack 350 Main St. 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 POLICY NUMBER: GL000943401 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s) or or- ganization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property dam- age" 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: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. All terms and conditions of this policy apply unless modified by this endorsement. CG 20 26 07 04 Includes copyrighted material of Insurance Services Office, Inc. with permission. Page 1 of 1 0 ISO Properties, Inc., 2004 .pct zu eu i o .i 4mb hr rax page e Evidence of Insurance /Lienholder Interest PatkyNurt b r: 18300.50 -40 P 2nd Effective: 8/17/2008 12:01 AM Expiration: lability Continuous until cancel) Expiration Ti e: 12 :01 AM Insured: Liability Gary Bufkin Medical Cov rage 1374 N Linden Ave Uninsured M torist. Bodily Injury Fresno, CA 93728 -2320 Vehicle lire of mation Year Make Model 2003 Isuzu Rodeo 4D 4X4 Coverage Type Limftioeductible Bodily Injury I lability $250,000 each person $500,000 each accident Property Damage Liability $100,000 each accident Medical Cov rage Not Covered Uninsured M torist. Bodily Injury $250,000 each person Additional Equipment $1,000 $500,000 each accident Comprehensve Damage With Collision - ........... .I ...... ,, $1,000Dedu' .. Deductible lienhaldr rs, andAdditionalInterests Additional In 'erect City of El Seg indo 350 Main St El Sgndo, CA, 0245.3813 Th i s evldenci furnished as certificates. fa rme Loan Number N of Appl ica ble 0;k FARMERS INSURANCE Underwritten By: Mid - Century Insurance Company 6301 Owensmouth Ave. Woodland Hills, CA 91367 YourAgent: Nicole M Lerno 7636 N Ingram Ave Ste 102 Fresno, CA 93711 -6200 (559) 999 -9005 FAX: (559) 921-5200 nlerno@farmersagent.com VIN 4S2DM58W234304721 ;, iffi'r Coverage Type Limit/Deductible Collision $1,000 Deductible Additional Equipment $1,000 Uninsured Motorist Property Damage With Collision - ........... .I ...... ,, Covered Towing and Road Service $150 each accident Other Covered is subject to all of the terms, conditions and limitations set forth in the policy a nd endorsements attached to it, It is matter of information only and does not change, modify or extend the policy in anyway. It supersedes all previously issued 25 -8976 9113 Page 1 of Jct GU GU -It) 14:025 FIF Fax page 3 Personal al Um rella Application and Subscription FARMERS � '. Agreerrient INSURANCE This is an App, ication and a Subscription Agreement. Your signature at the end of this document Is required. If our records do not show that you have provided us with a signed copy of this document, we reserve the right to terminate your coverage. Please keep a copy for your records. Poli`cyNumb r; 60559 -16 -27 Policy Limits: $1,000,000 Effective0at: 1/5/2015 12:01 A.M. Retained Limit: (SIR) $250 Expiration: 1/5/2016 12:01 AM' Billing Account A546715947 xp � 9 Your Farmer` Agent: Nicole MLerno Number: (559) 999 -9005 Reference Number: nlerno@farmersagent.com Household Number: 0515924496 Underwritten By: Truck Insurance Exchange 6301 Owensmouth Ave - Woodland Hills, CA 91367 Applications ust bear the exact date of applicant's signature- Dating th e application to be effective prior to the date, hour and minute of the signat re is prohibited. Policy Information Risk lnfoomation 1. Are there PropertyAddress or ❑ Yes Email Address/ No Name/Trust Legal Description ._ ._._ MailingAddress _... Personal Phone# /Business Phone# _........ Territory Gary ry Bufk in - - - - - -- 1374 N Linden Ave 1374 N Linden Ave garybs?a psnw.com 93728 -2320 3. Is t here Fresno, CA93728 -2320 Fresno, CA 93728 -2320 (559) 917 -0350 No Driver injormation (list all licensed drivers in the household) ❑ Yes ❑ Name 5.. Is child State and DL /Permit Number DOS �**/: Age .. •52 Gary Bufkin". -_ .w._...._. ...._.m�....,... CA*** * * *21 ..M..._.__........ ......,..... *°1963,...._,_...,r...�...a._.w. ❑ ......... Risk lnfoomation 1. Are there any excluded drivers on any underlying policies scheduled on the Umbrella policy? ............. ❑ Yes ❑ ..... No 2. Is anyo n In the household a prominent public figure " "" ❑ Yes ❑ No (e.g., ac r, actress, professional athlete, politician, public lecturer, etc.)? ......... 3. Is t here n unfenced swimming trampoline the prernises? g pool or tram Yes ❑ No 4 Ism t on y in the household in the business of providing child day c p g are in the home? ............ . ❑ Yes ❑ No 5.. Is child re covered by the scheduled underlying Insurance? C] Yes E] No u 6 Excl „dIn es y household operate a home based business? child care doesa�l ogle m the ho ❑ Yes ............... ......., ❑ ......... No 7. Is the 'h'r",,,,,, a , ,,, a based business covered by the scheduled . und_ underlying insurance? ❑ Yes ❑ No 8 Does an household member have use of a company car? ❑ Yes C] No Policy No. 60559 -16 -27 31.7131 i -14 Page1of4 ict eu zw o '14:025 hr rax page 4 Applicatil ni and Subscription Agreement (continued) List all minor lolations for all members of the household during the last 3 years. List all major Molations for all members of the household during the last 5 years. Household[M mber Tyke Violation ate ..� 014 List all accidents and losses for all members of the household during the last 3 years. Household Member Type Date of Loss Description of Loss Amount Paid List ALL hou: hold member's exposures. Include applicant, spouse and all household members. Auto Lfob iiity (all licensed, owned or leased) Type of Vehi le Underlying Liability Limits Carrier Policy Number No. of Units Auto _ ' -e .. m . i�A �� iCl�:� ._� ._.�.w.. mia- entury�.._ -.cw._ o"m "... ........_ "16-3-0-0-,5-0-4-0--,-,-,-*,-,-",-,-,, ...... �.._ .. .._... .._ Insuranceomparly 1 Personal Liability oasonal/5e ondaryextension of liability must be reflected on the primary underlying homeowners policy. Type of Pal(c ynlderlyin,g� Liability' Limits Carrier Policy Number 301 0, mm... _ Fire Insurance Exchange 936520422 Uninsured Motorist /Underinsured Motorist Coverages UninsuredAt hderinsured Motorist coverage will pay for damages that you, the insured, are legally entitled to recover as a result of injuries caused by a driver who has no Bodily Injury Liability, or by a driver who has Bodily Injury Liability limits which are lower than the Uninsured Motorist limits provided byyour policy. For an add iti naIcharge ,doyouwantUM /UIMcoverage? ❑ Yes El No Ifyes: Dc all nderlying Auto policies carry UM /UIM coverage? E] Yes p No Are tloseLl M /U IM limits equa I to the Auto Liability Lim its? ❑ Yes x❑ No Remarks: I hereby clecli are that the statements on al I pages of this application, Including those relating to the use of the vehicle(s), are true and request the I xchange or Company to issue the Insurance applied for in reliance thereon and at rates based on these facts. I understand that any material misrepresentation or omission may void or cancel coverage subject to the statutory requiremerts of my state. I authorize the driving record of all drivers to be checked through the state Motor Vehicle Department.. Pollcytimit. $1,000,000 The quoted premium is subj ect to verification and change Premium quoted: $214.00 (increase or decrease), when necessary, by the company. "(also see Information on Additional Fees below) Policy No. 60559 -16 -27 31 -7111 1 .14 Page 2of4 `i.i' & y V. Bufkin Computer Consulting 1374 N. Linden Ave. Fresno, CA 93728 (559) 499 -8349 Office (559) 917 -0350 Cell To: City of El Segundo From: Gary V. Bufkin Computer Consulting Regarding: Workers Comp Insurance Coverage Not Needed Gary V. Bufkin Computer Consulting ( GVBCC) is a sole proprietorship located in Fresno, California dedicated to the development of custom computer software and database for the government sector. GVBCC is a one man operation and does not employ a staff, which, negates the need for Workers Compensation Insurance. GVBCC shall not employ any person in any manner so as to become subject to the Workers Compensation Laws of California. Regards Gary V. Bufkin Gary V. Bufkin Computer Consulting Fresno, California Providing Integrated SoWtfons to fit your needs ggab(c- ,psnw.co www.gvbcc.com Page 1 of 4 Shilling, Mona From: Cullen, Deborah Sent: Thursday, February 05, 2009 4:14 PM To: Shilling, Mona Subject: RE: Pending Agreements with Gary Bufkin Om WIMIZZIMS Of- City, Sep From: Shilling, Mona Sent: Thursday, February 05, 2009 12:07 PM To: Cullen, Deborah Subject: FW: Pending Agreements with Gary Bufkin Deborah, Based on our previous conversation I'm going to assume you are OK w /Greg waiving the Professional Liability„ Thanks, Mona 1:7 q..I R��:"":""K•��u.l p4. �_.jt!) �� " G..-_J 1' "�i�q�XV I'II' d -)co oundo a, 902+5 From: Carpenter, Greg Sent: Thursday, February 05, 2009 12:02 PM To: Garcia, Daniel; Greenwood, Dana; Shilling, Mona; Lee, Sam; Cullen, Deborah Subject: RE: Pending Agreements with Gary Bufkin Mona /Dan — I would recommend waiver of the insurance PL insurance requirement based on the fact that we oversee and approve all of the work done by Gary before it is implemented. He does not represent the City nor deal directly with any of our customers. Let me know if you need additional information. From: Garcia, Daniel Sent: Thursday, February 05, 2009 11:07 AM To: Greenwood, Dana; Carpenter, Greg Subject: FW: Pending Agreements with Gary Bufkin Dana & Greg, I understand either or both of you can waive the Professional Liability insurance requirement per Mona's email below for Gary Bufkin, If either or both of you are okay with this, let me know so we can finalize Gary Bufkin's contract. My recommendation is to waive it. Thanks. 2/19/2009 Dan 'l a F��una!o ( ",4 002115 From: Shilling, Mona Sent: Thursday, February 05, 2009 11:03 AM To: Lee, Sam; Garcia, Daniel Cc: Lewis, Mary; Domann, Cathy Subject: Pending Agreements with Gary Bufkin Page 2 of 4 Sam /Dan, I just got off the phone w /Gary Bufkin's insurance agent. It looks like he will be able to provide the required proof of insurance for the contract with the exception of the Professional Liability. Greg & Dana as directors can waive this requirement. I would just need an email from them stating this and then I would run it by Deborah for final approval. Dan, I'm addressing this to you also because of the pending work Gary will be doing for Public Works, so... if you can address this now with Dana nothing will hold up the contract once Karl advises what type of agreement to provide. Let me know. If you have any questions come by and see me. Thanks, Cqb 0`tl r i y:', ^S.m1 (-'t,I Of I....� '. �a`,0 AIFn Ca, 902A 5 From: Gary V. Bufkin [mailto:garyb @psnw.com] Sent: Thursday, February 05, 2009 8:50 AM To: Shilling, Mona Cc: Lewis, Mary Subject: RE: 1 Million Personal Liability Umbrella for Insured Gary V. Bufkin I will forward this to my Insurance Agent and work with him on getting you the required information. I do not have any of that paperwork office. um From: Shilling, Mona [mailto:MShilling @elsegundo.org] Sent: Thursday, February 05, 2009 8:21 AM To: garyb @psnw.com Cc: Lewis, Mary Subject: FW: 1 Million Personal Liability Umbrella for Insured Gary V. Bufkin 2/19/2009 Page 3 of 4 Mr. Bufkin, My name is Mona Shilling. I work with Mary Lewis at The City of El Segundo but in the City Clerk's Office. Our department processes the contracts for the City. We have almost completed the signature process for the amendment to the existing Professional Services Agreement between yourself and the City of El Segundo. The delay right now is the required proof of insurance. If you could please review the email below and either fax or email the required proof of insurance. Thank you, C .J tjl of I I m.J 15e%^ Ma Clo, C .au. 9'0 RAJ 710) � 2.Mi - - -Z ", C7 pp: From: Shilling, Mona Sent: Wednesday, February 04, 2009 9:53 AM To: 'ddedmore @farmersagent.com' Cc: Lewis, Mary Subject: FW: 1 Million Personal Liability Umbrella for Insured Gary V. Bufkin Daivd, Thank you for the attached proof of insurance for Gary V. Bufkin; however, this is not what we are requesting. I have attached previous proof of insurance that met our requirements. I have also attached pages 3 &4 of the contract which address the proof of insurance requirements. I am looking for an updated Certificate of Liability Insurance Acord and endorsement for the general commercial liability, refer to page 1&2 of previous proof of insurance attached. Also, usually we request the cancellation clause on the Acord be amended to exclude the following wording "endeavor to" and "but failure to do so shall impose no obligation or liability of any kind upon the insurer, its agents or representatives." I don't believe the carrier would agree to this previously, if you refer to page 3 of the attached previous proof of insurance, Integrity agreed to provide 30 day written notice if the insurance was cancelled. Please confirm if Integrity still agrees to do this. Also, we will use Gary's previous letter stating he is sole proprietor and does not employee staff in relation to the Workers Compensation requirement, refer to page 4 of the attached previous proof of insurance. If you could please email the updated required proof of insurance that would be great. If you have any questions let me know. Thank you, p �(11r1i � � d:� "m)I7PII IIpI¢s G ".D?,au nrlcD "Y C.) Main 5"C )bract, I ..II Ca. �02A From: David Dedmore [mailto :ddedmore @farmersagent.com] Sent: Tuesday, February 03, 2009 11:42 AM To: Lewis, Mary; Shilling, Mona Subject: 1 Million Personal Liability Umbrella for Insured Gary V. Bufkin 2/19/2009 Page 4 of 4 Please find umbrella policy information for our insured Gary V. Bufkin below: (Document also attached) (Please feel free to call me with any questions @ (559) 790 -6207) CA Lic. #: OE52979 PH: 559 - 790 -6207 Fax: 559 - 227 -1012 email: ddedmore @farmersagent.com 2/19/2009