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PROOF OF INSURANCE (2016) CLOSEDOP ID: DR YY ........DATE (MM/DD/YY) I CE TF CATE OF LIABILITY INSURANCE 0212312016 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 endorsementisi. PRODUCER 'I.W4 IA % ;r ACCORDANCE WITH THE POLICY PROVISIONS. oval Attn: Lill Sandoval Alliance Mgt. & Insurance Sery wive _ 350 Main Street .... -. 355 Via Vera Cruz #7 (A/C No Exe) !NCO NO: ,,. ..... -. CA Agent/Broker Lic# 0737966 MAJIJL ADDRESS ,.... m... �. San Marcos, CA 92078 10CTi ANNA -1 Michelle A. Nowell u$gOmME - ,y•� INSURERISI AFFORDING COVERAGE NAIC # �._._.. ... ........ ..r.. .. INSURED Barry Aninag Investigations A: Acceptance Casualty Ins Comp INSURER .........�. 10349 .__ W._ :..................-----------------.........- Lt-C INSURER 0: --------------------._....�.._. _.®_. .......,,:, 11 Barry n)nag _ _... 27756 Santa Margarita Pkwy 594 IN8URERC: Mission Viejo, CA 92691 INSURER D: m....._,.... -, ._...,..... 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. ... ............................... ....W.._,.... .... ---- „,(„M POLICY YYYY MoUdY -tv ..,. IN SIR _. ............. A)SOG ii'�IS�'N ._ .. r TYPE OF INSURANCE i aac wvn POLICY NUMBER ,may �.....,I . .................. _. -- ......... LIMITS - .. -... ...:....:.., GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A ..X . COMMERCIAL GENERAL LIABILITY X CP00961685 11/11/2015 11!11!2016 PRE(M SESE R aana1 . ...,,.... E >.,.,.,, • 100,Q0 CLAIMS -MADE X L OCCUR ____ MED EXP (Anv one persons $ 5,00 X Errors & Ortli$$IOn PERSONAL & ADV INJURY $ 1 000,00 y 2ENERALAGGREGATE _ mm„ $ 5,000,00..' GENL ACF Lit 9T APPLIES PRODUCTS - COMPfOPGG ODO,OO R0 X .mm......1 � } Cb J4�ILCC ...- ...- .- .___..._ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S j (Ea accident) ANY AUTO BODILY INJURY (Par person) $ ALL OWNED AUTOS - - - - - -- --- .._.. ------ .. ,,,,.,.,.�,.,.- BODILY INJURY (Per accident) ._.- ....... ........... ..._ $ UTOS PROPERTY DAMAGE H RED AUTOS (PER ACCIDENT) E DENT) _ $ NON -OWNED AUTOS $ UMBRELLA LIIAB OCCUR EACH OCCURRENCE $ ....,...... E XCESS LIAB CLAIMS -MADE AGGREGATE $ _ .. W- .....m DEDUCTIBLE '..., RETENTION WORKERS COMPENSATION _ WC STATU- OTH- AND EMPLOYERS' LIABILITY Y/N TgRV uMITS FR ,.. ww tiNY PROPRIETORIPARTNEWEXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? r NIA (Mandatory In NH) - -• E L. DISE',SE - EA EMPLOYEE! $ Il'yes, describe under •- •••• -• _..... — DESCRIPTION OF OPERATIONS below E L. DISEASE - POLICY LIMIT S -: .._...._.. ____.....k........_._ -... DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) City of El Segundorits Officers ,Officials,Employees,Agents,and Volunteers are named as additional insured with respect to the work performed by the named insured with Primary Insurance and 30 Day NOC. lsandoval @elsegundo.org Investigations, CA -- CERTIFICATE HOLDER � CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN d Cit of EL Se undo d Y ACCORDANCE WITH THE POLICY PROVISIONS. oval Attn: Lill Sandoval 350 Main Street AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 ” 0 4m_ _ C /I // ©1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: CP00961685 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -- DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Oraanization(s) Automatic Status Included Where Required by Written Contract. All Where Required by Written Contract. "It is agreed, as respects the Policy, thirty (30) days notice of cancellation, except as respects non- payment of premium, for which ten (10) days notice will apply, or other regulatory requirements that may apply, will be given as respects the indicated certificate holder." Information required to complete this Schedule, if not shown Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s) or organ- izations) shown in the Schedule, but only with re- spect 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. A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. will be shown in CG 20 26 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ iT CAREFULLY, PRIMARY AND NON - CONTRIBUTING INSURANCE ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART To the extent that this insurance is afforded to any additional insured under this policy, SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance, is deleted in its entirety and replaced with the following condition: 4. Other Insurance If all of the other insurance permits contribution by equal shares, we will follow this method unless the insured Is required by written contract signed by both parties, to provide insurance that is primary and non - contributory, and the "insured contract" is executed prior to any loss. Where required by a written contract signed by both parties, this insurance will be primary and non - contributing only when and to the specific extent required by that contract. However, under the contributory approach each Insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first. If any of the other insurance does not permit contribution by equal shares, we will contribute by limits, Under this method, each insurer's share Is based on the proportional ratio of its applicable limit of insurance to the total applicable limits of insurance of all insurers. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. This endorsement forms a part of the Policy to which attached, effective on the inception date of the Policy unless otherwise stated herein. (The following information is required only when this endorsement is issued subsequent to preparation of the Policy.) Endorsement effective Policy No, CP00961685 Endorsement No. Named Insured Barry Aninag Investigations LLC Countersigned by C IGL 30 0114 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: fJ I have and will maintain a ce"cale 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- .w..._ U 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 Policy Number Expiration Date Name of Agent Phone # w ny certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not nifAoy any person in any manner so as to become subject to the workers' compensation laws of California, and rree that, if I should become subject to ,tlo-workers' compensation provisions of Labor Code § 3700 I must immediately Pb wrth��ovasr r r t b agreement will automatically become void. Da Applicant - j Agreement for:...� Dated: I G . Reviewed by q $� - uj ww iu 31 4 Cn(M CK, cr. 115. uf