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PROOF OF INSURANCE (2016) CLOSEDDATE (MMIDD/YYYY) AC '')R" CERTIFICATE OF LIABILITY INSURANCE 01/06/2016 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 I CONTACT 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. ........ ...... ... INSR - ,ADDL '013k - - - -_ .__. -. -- POLICY EFF POLICYEXP. LTR TYPE OF INSURANCE imnn wun POLICY NUMBER rnnnnronrwvvl IMnmm�mvvl LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 �AMAOE TO �CNTO CLAIMS-MADE OCC ❑ OCCUR PRFMICFS rF rr 1 $ 100.000 �. ,........... �p��- / N ry MED EXP (Any one person) $ 5,000 A Y UDC- 1506408- CGL -15 10/24/2015 10/24/2016 PERSON . 2,000.000 GEN'LAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 PRO- POLICY ECT LOC PRODUCTS COMP /OP AGG ,. $ S/T Gen Alga OTHER; $ AUTOMOBILE COMBINED SINGLE LIMP $ ANY AUTO BODILY INJURY (Per person) $ _ ALL OWNED SCHEDULED AUTOS AUTOS -- BODILY INJURY (Per accident) $ NON -OWNED PROPER'rYDAMAGE $ HIRED AUTOS AUTOS rPe rIC adonq UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ '..... $ WORKERS COMPENSATION PER I TH- AND EMPLOYERS' LIABILITY Y / N CTATI ITF FR $ F /REMBE EXCLUDED? OFFICER /MEMBER EXCLUDED? (Mandatory )........ N/A ... ., "" EL DISEASECEDAEMPLOYEE $ IF yes, describe under DESCRIPTION OF 1_1 ,.... 11 ., . ... - .- . -...- E,L DISEASE $ OPERATIONS below - POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of El Segundo is an addtional insured CERTIFICATE HOLDER City Of El Segundo 350 Main St El Segundo, CA 90245 ACORD 25 (2014/01) 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 ©1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Aew HISCOX Policy Number: Named Insured: Endorsement Number: Endorsement Effective UDC - 1506408- CGL -15 Gabriel Barrientos 17 January 13, 2016 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OIL ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART y SCHEDULE.,, Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s) or organi- zation(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 omis- sions 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 © ISO Properties, Inc., 2004 Page 1 of 1 7E(MM/DDfYYYY) � ��1 CERTIFICATE OF LIABILITY INSURANCE /06/2016 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' NAME, Hiscox Inc. d /b /a /Hiscox Insurance Agency in CA P N IA /C- ExU (888) 202 3007 �,p FAX No); 520 Madison Avenue cony st tax cqm E-MAIL ADDRESS act hi - _� ................. ...... .e ..... , ®. 32nd Floor INSURER(S) AFFORDING COVERAGE NAIC# ............. New York, NY 10022 INSURER A: Hiscox Insurance Company Inc 10200 ........ INSURED INSURER B: Gabriel Barrientos INSURER C : 9506 Karmont Ave INSURER D : INSURER E South Gate CA 90280 INSURER 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, _- ...... - - - -. ...... .. ....... INSR ADDL Aitfk POLICY EFF POLICY EXP I TR TYPE OF INSURANCE ucn un,n P(]LICY NUMBER IMMIDDlYYYYI MMIDDIYYYY' LIMITS LTR , COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS MADE OCCUR AA A "iTO REXTr5b PREh 6119k pace)— . $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ POLICY JP� r SLOG PRODUCTSGCOMPCOPAGG $ GENT AGGREGATE LIMIT APPLIES $ .. OTHER: $ AUTOMOBILE LIABILITY COMBIWID SINGE E LIMIT $ !Fa a Oent ANY AUTO BODILY INJURY (Per person) $ ........... . ............... AUTOS AUTOS _ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ . HIRED AUTOS NON -OWNED PROPk R1 Y DAf)L AUTOS UMBRELLALIAB OCCUR EACH OCCURRENCE $ ........ ..... . .. .... . ....... EXCESS LIAB CLAIMS -MADE AGGREGATE $ I DED RETENTION $ l $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY YIN STATYTE FR ANYPROPRIETOR /PARTNER/EXECUTIVE F_ E.L. EACH ACCIDENT $ OFFICER /MEMBER EXCLUDED? NIA (Mandatory in NH) E DISEASE - EA EMPLOYEE, $ If yes, describe under ---- -... __. , , , , . -e ... .... . ..........wr DESCRIPTION OF OPERATIONS below E L, -- DISEASE POLICY LIMIT $ Professional Liability "� "' ach Claim: $ 1,000,000 A Y UDC- 1506408 -EO -15 10/24/2015 10/24/2015 i ggr @gat@: $1,000,000 Id DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) City Of El Segundo is an addtional insured CERTIFICATE HOLDER CANCELLATION FSe Segundo St SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE do, CA 90245 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD S`'t3ft'EJ'tr State Farm Mutual Automobile Insurance Company 900 Old River Road Bakersfield CA 93311 -9501 NAMEDINSURED AT3 75- 0807 -1 Z 001400 0058 BARRIENTOS, GABRIEL 9506 KARMONT AVE SOUTH GATE CA 90280 -5407 t -•.. DO NOT PAY PREMIUMS SHOWN ON THIS PAGE. IF AN AMOUNT IS DUE, THEN A SEPARATE STATEMENT IS ENCLOSED. . ................. ....._ ...... uu..... -- YOUR CAR 03798.1 -Z MUTL VOL DECLARATIONS PAGE POLICY NUMBER 508 7318- F25 -75 POLICY PERIOD JUN 25 2015 to DEC 25 2015 12:01 A.M. Standard Time STATE FARM PAYMENT PLAN NUMBER 1207132623 AGENT CASARES INS AGENCY INC 9901 PARAMOUNT BLVD STE 140 DOWNEY, CA 90240 -3857 PHONE: (562)927 -2297 2013 INFINITI FX37 SPORT WG JN8CS1 MW8DM175076 003HAX1 H New Policy Form State Farm works hard to Offer YOU the best combination of price, service, and protection. The amount you pay for automobile insurance is deteniiined by many factors such as the coverages you have, where you live, the kind of car you drive, how your car is used, who drives the oar„ and information from consumer reports. Consumer report reference number: 15177141115571 Please refer to the enclosed insert for additional information. FORM 9805BY ANDSANYSENDORSEMENTSLTHATIAPPLY, MCLUDINGLTHOSEOOISSUED TO YOU WITH ANY SOBSEQUENT RENEWAL NOTICE. 6126MD EXCttSS COVERAGE FOR PERSONAL VEHICLE SHARING. Agent: CASARES INS AGENCY INC Telephone: (562)927 -2297 02661/01290 See Reverse Side Prepared JUN 29 2015 0807 -B85 1553866 CA.2 05 -2002 (00251o) (00254c) 14SXON (o1 a025te) This policy is issued by State Farm Mutual Automobile Insurance Company. MUTUAL CONDITIONS 1. Membership. While this policy is in force, the first insured shown on the Declarations Page is entitled to vote at all meetings of members and to receive dividends the Board of Directors in its discretion may declare in accordance with reasonable classifications and groupings of policyholders established by such Board. 2. No Contingent Liability. This policy is non - assessable. 3. Annual Meeting. The annual meeting of the members of the company shall be held at its home office at Bloomington, Illinois, on the second Monday of June at the hour of 10:00 A.M., unless the Board of Directors shall elect to change the time and place of such meeting, in which case, but not otherwise, due notice shall be mailed each member at the address disclosed in this policy at least 10 days prior thereto. In Witness Whereof, the State Farm Mutual Automobile Insurance Company has caused this policy to be signed by its President and Secretary at Bloomington, Illinois. 0 Secretary President Important ... California law reqwires us to provide you with information for filing complaints with the State Insurance Department regalUing the coverage and service provided underthis policy. Complaints should be filed only after you and State FarmiO or your agent or other company representative have failed to reach a satisfactory agreement on a probl'orm, Please forward such complaints to: California Department of Insurance Consumer Services Division 300 South Spring Street Los Angeles, CA 99013 Or call toll free 1- 800 - 927- HELP(4357) NOTICE We are required to furnish you with the following information: 1 An automobile liability insurance company rna cancel a policy before the end of the current policy period for reasons described in the prnav�s#ran tetTod Cancella't'ion which is located in the General arms section of your policy (refer to the Contents in the beginning of your policy for the page numbed. 2. An automobile liability insurance company may increase the premium or refuse to renew the policy for any at the following reasons: a. Accident involvement by an insured, and whether an insured is atfault in the accident. b. A change in, or an addition of, an insured vehicle. c. A change in, or addition of, an insured underthe policy. d. A change in the location of garaging of an insured vehicle. e. A change in the use of the insured vehicle. f. Convictions for violatingg any provision of the Vehicle Code or the Penal Code relating to the operation of a motorvehiclo. g. The payment made by an insurer due to a claim filed by an insured or a third party. An automobile liability insurance company may increase the premium or refuse to renew the policy for reasons that are not listed above butwhich are lawful and not unfairly discriminatory. uA2 B10 I JO I ioq,c, SL-§ZA-SIEL 909 :-ToqmnM Ililloa 12tTMOOff AD110d HfIOA 01 HDVIIV HSV UIJ I m I w W3 062 1029920 P SL-SZJ-9TCL80S UNUMNA0110d laINO09 A31'10J HfIOA Ol HDVJJV 5fSV AVId I o 0 -T3 0 P SL-SZJ-9TCL80S UNUMNA0110d laINO09 A31'10J HfIOA Ol HDVJJV 5fSV AVId I o CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: (_) I have and will maintain a certificate of consent of self- insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement with the City of El Segundo. Policy No, (_) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Name of Agent Policy Number Expiration Date Phone # ( X) I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with ose provislons or the agreement will automatically become void. Signature of Applicant / .� �•c, Date 01/12/16 Agreement for: 604 �� ° � % � cei — N r 4*U2- Dated: DI ICI - IL/ Reviewed � -...�