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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