PROOF OF INSURANCE (2016) CLOSEDvRe �R
AM1»11�E.I�NEIVT S EVENT PLANNERS INSURANCE SPECIALISTS
25422 TRABUCO ROAD 0106 -406
LAKE FOREST, CA 92634
(11911) 360.3372
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Ron Ialcoplad.el dlkma jump For Joy
530 S Francisco Ave
Redondo B0110111, CA 90 1'7
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SRPGP- 101 -0715 oerta12ai5 OQI1412016A0H0
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EOOILY IN.URY (Par 11411"13M
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The Of I die UpNdO, It^ta efltGera, O�Idt aOente and volunteers 8M added as an additional insured but only with respect to liability arising
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CERTIFICATE HOLDER t+ltrdUMLLAIla.rn
ACORD 23 (2010105) V141120.001 ID 1ee5.2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are rnglatoned marks c1 ACORD
COMMERCIAL GENERAL LIABILITY
CG 20 26 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
1, 114rtliml
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Policy Number: SRPGP- 101- 0715/USP192456
Insured: Ron lacopucci dbo Jump For Joy
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Of Additional Insured Person(s) Or
City of El Segundo
350 Main Street
El Segundo, CA 90245
Section II - WHO IS AN INSURED is amended to
include as an insured the person(s) or 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 of 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.
CG 20 26 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 0
TRAVELERS
AUTOMOBILE POLICY CONTINUATION DECLARATIONS
1. Named Insured
RON &VALERIE IACOPUCCI
530 S FRANCISCA AVE UNIT B
REDONDO BEACH CA 902774241
Your Service Center Address
KNOXVILLE BUSINESS CENTER
P O BOX 59059
KNOXVILLE TN 379509059
Subtotals for your vehicles: $ 408 $224 $299 $280
Continued on next page Page 1 of 5
PL-7782 5.94 870/GM1e05 000073/00007 F3115MO $414 07/01/15
Your Policy Number : 941113867 101 1
For Policy Service Call 1- 800 - 842 -5075
Your Account Number: 941113867
For Claim Service Call 1- 800- CLAIM33
2.
Your Total Premium for the Policy Period is $1,211.00.
The
policy period is from August 1, 2015,12
:01 a.m. to February 1, 2016.
3.
Your Vehicles
Identification Numbers
1 2006 TOYOT TUNDRA LIM
5TBDT48126S519837
2 1990 FORD F350
2FDKF37M1LCA88678
3 2001 TOYOT AVALON XL/
4T1BF28B11U131498
4 2010 TOYOT PRIUS
JTDKN3DUXA0148831
4.
Coverages, Limits of Liability and Premiums
Insurance is provided only where a premium is shown for the coverage.
1 2 3
4
06 TOYOT 90 FORD 01 TOYOT
10 TOYOT
TUNDRA LIM F350 AVALON XL/
PRIUS
A
- Bodily Injury
$100,000 each person
$ 254 $ 188 $ 195
$ 173
$300,000 each accident
B
- Property Damage
$50,000 each accident
Incl* Incl* Incl*
Incl*
D1
- Uninsured /Underinsured Motorists
Bodily Injury
$100,000 each person
48 36 60
30
$300,000 each accident
See Endorsement A04044
E
- Collision
Actual Cash Value less
78 - 34
59
$2,500 deductible
F
- Comprehensive
(Other than Collision)
Actual Cash Value less
21 - 10
14
$2,500 deductible
T
- Waiver of Collision Deductible
7 - -
4
Subtotals for your vehicles: $ 408 $224 $299 $280
Continued on next page Page 1 of 5
PL-7782 5.94 870/GM1e05 000073/00007 F3115MO $414 07/01/15
Jump for Joy
To whom it may concern,
I am a sole proprietor and not required to carry workers comp in the state of
California: therefore, I take responsibility for any injuries that I may incur while
providing a service to the City of El Segundo.
fl-
Date