Loading...
PROOF OF INSURANCE (2017) CLOSEDDate Entered: /22/2016 Policy Number: 0400701436 / 1/22/2016 W_. A CERTIFICATE OF LIABILITY INSURANCE ""' 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 pollcy(ie) 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 endorsenlent(s). PRODUCER"r rDi(408) 286-1334 IArC Nep. .. Mary Barnard Insurance PHONE rAX (408) 286-6425 11 INS1JRPR F r. __ .e.........e,,,. -- 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, REDUCED BY PAID CLAIMS — —.. , D w- _ — .... LTR BEEN RE LIMITS 1 0 EXCLUSIONS AND CONDITIONS URANCE OF SUCH POLICIES LIMITS SHOWN HAVE BE _ MM DDY LFr POLICY EXP NsR AiS611. sISER R �vYY MMIDDIYYY 100 000 �W� COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ r 000 OO CLAIMS -MADE ®OCCUR 0400701632 1/20/2016 7/20/2017 Erk.MltlF"q& qac rcxr utt� $ r 5 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO- POLICY 1:1 JECT LOC AUTOMOBILE LIABILITY $ ANY AUTO 00,00 1 0 0 $ , ALLOWNED �..._� SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS-MADE WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN OFFICERIM roT' ER EA,RTNI F/I XE CkJ' pVf 4NYF" ERdM'LMBFREAriT,NJIIE EggN /A (Mandatory In NH) If es de*.�00e undo N (,)F I br r9'�ATIONS below P gAaaoneperL91"d .., $ PERS NAL & AB;PV INJURY O 00,00 1 0 0 $ , GENERAL AGGREGATE $r PRODUCTS -COMP/OP AGO S INCLUDED OMINL1: 7INi r LIMY $ — a�a �Ip &w9tln _ - -.. .......- BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ �� eWt D'ARAa I ... E L E 1_14 9 R ACCIDENT $ E L DISEASE EA r MPI OY'E $, E.L. DISEASE - N'2�OI ICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS & VEHICLES pACORD 101, Additional Remarks Schedule, may be attached if more space Is require TEN DAYS NOTICE OF CANCELLATION APPLIES FOR NON — PAYMENT OF PREMIUM e30 DAYS FOR ALL OTHER, RE: ALL CALIFORNIA OPERATIONS. CERTIFICATE HOLDEN IS NAMED AS ADDITIONAL INSURED„ CERTIFICATCI OLDER OF EL SEGUNDO, CITY CLERK 11) ATTENTION; BRIAN EFTANSKI & 350 MAIN STREET EL SECUND0, CA 90215 q ,yd " CANCELL.A 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 REPRESENTATPVE ©1988- ACORD 25 (2014/01) The ACORD name and logo are registered marks of &IM6ul )RD CORPORATION. All rights reserved. POLICY NUMBER: 0400701 632 r COMMERCIAL GENERA CG LIA0 0 �1 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE A. Section II — W'ho Is An Insured is emended to include as an additional insured the person(s) or organization(s) shown in the Schedule, ��o buy With respect to liability for "bodily injury p p art y damage° or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance ie ot additional insured nly applies the extent permitted by law; and 2. if coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader that arr are required by onr ct geementte provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work„ including materials, parts or equipment fut-nished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of ,youi- work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor' or subcontractor engaged in performing operations for a principal as a part of the same project. °> I; 0 .,. " o--- I of 7 C. respect ect b^ the insurance afforded to these insmm*do, the following is added to --- ��M�--���i�sOf Insurance: - '��� b� dhm additional \mau��d is if coverage �Fow - t ne�u1redb����noaul�r roeNnent the nuos xwa -�\t�mm�\ lm�unmd is the ` ����c��m�� uuN pay on ,.~..~ .._ amount ofinsurance: 1' Required by the contract oragreement; or , ` 2. Available under- the mppflcable Limits of |memnamme shown inthe 1:3ecoanaourvu. m/h\ohaver Is |suo. ` This emduroannant shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 10 04 13 Policy Number: BAP0165200 Date Entered: 10/22/2015 F CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 10/22/2015 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 cAMET TDiane.. .DeSilva ....................... ° M, c Mary Barnard Insurance NAME.,- , 2190 Stokes Street PHONE (408)286-1334 FAQ (408)286 -6425 E -MAIL Suite 201 ADDRESS: San Jose CA 95128 INSURER(S) AFFORDING COVERAGE NAIC # INSURED John and Donna P. O. Box 2270 Arnold, CA 95223 COVERAGES INSURERA;CENTURY NATIONAL INSURANCE COMPANY w ,..._ �.. ......... ......... ...... - -- -- ---- e Services, L.L.C. INSURER B: Foggiato INSURER C 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 SUER -------- . .... - POLICY EFF POLICY EXP _____ -.................. ..................... .. I TR. TYPE OF INSURANCE W.. ynrn POLICY NUMBER rMM /ooN YY Y1 (Mnmoorvwn LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ lul DAMAG OF2ENi�D CLAIMS -MADE _ .. OCCUR PRFMIGE w:�:G�,I ........, _� �m R .... $ ................ ..................... MED EXP (Anv one person) $ PERSONAL & ADV INJURY 3 GtEN1 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ .....�. POLICY � jE(° 1 LOC PRODUCTS AG.G . .... OTHER..: $ AU TOMOBILE LIABILITY AU COMBINED ShNGJ.0 LIMIT $1,000,000 LEa cr e,nl _ .... .... .. ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED I r accident) $ AUTOS AUTOS A NON-OWNED NON -OWNED BAP0165200 1 /24/2015 :.1/24/2016 GE PROPERTY DAMAGE ______ HIREDAUTOS AUTOS �lPararndenl) $ UMBRE,LLA.UAB JOCCUR EACH OCCURRENCE ......................................................$......................................... $ .............................. EXCESS LIAR CLAIMS -MADE AGGREGATE DED RETENTION.$ $ WORKERS COMPENSATION 4E.4TORH AND EMPLOYERS' LIABILITY •�.. ^- I ITF - - - - -ER NIA ......... -_ .. (Mandatory in NH) E.L.. DISEASE - EA EMPLOYEE: $ If yes, describe under ._.. ._ .....,..,, ....... ............ _...........---....., DESCRIPTION OF OPERATIONS helow E L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If strode e.pace is regaired) Thirty Days Notice of Cancellation;Ten Days Notice Due To Non- Pay"R'tent Of Premium CITY OF EL SEGUNDO, CITY CLERK ARE NAMED AS ADDITIONAL INSURED AS PER ADDITIONAL INSURED ENDORSEMENT ATTACHED, CERTIFICATE HOLDER b CITY OF EL SEGUNDO - CITY CLERK, " #,a) 350 MAIN STREET W pt EL SEGUNDO, CA 90245 w CANCELLATION 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 - ACORD 25 (2014/01) The ACORD name and logo are registered marks of Produced using Forms Boss Plus software, www,FormsBoss.com; Impressive Publishing 800 - 208 -1977 &.1 a ' lck, ORD CORPORATION. All rights reserved. Policy Number: 1760432-15 Date Entered: 10/2.2/2015 DATE (MWDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 10/22/2015 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. It the certificate holder Is an ADDITIONAL INSURED, the Policy(les) 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 B PRODUCER uaanc. .��� �.... ........ Mary Barnard Insurance P Silva A No 408) 286 6425 Diane DeSz 2190 Stokes Street 408)286 -1334 ! " E-MAIL E MAJ - Suite 201 ADDRIS_ STATE APPORDING COVERAGE San Jose CA 95128 _ RAGE NAIL # .,�., .. COMPENSATION INSURANCE FUND ....m,..,.e -. INSURED RanCle Maintenance Services, L.L.C. John and Donna Foggiato (INSURER C! P. O. Box 2270 Ilkr INSURE U: Arnold, CA 95223 INSURER E: 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. ....... .........- ...... I "' ADD 11, $.U..B_ R POLICYEFF POLICYEXP TR TYPE! INSURANCE uc un,n POLICY NDMBER rMMlDDlVVYVI fMMIDDIYWY I LIMITS COMMERCIAL GENERAL LIABILITY EACHOC LIRRENCE S E] .rc'r7,hMA F'r`t ftFNrLD � -... CLAIMS -MADE OCCUR f�I�4.i0aiz�fal.rgra���... -- ..... PERSONAL & ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER. GENERALAGOREGATE $ f�9t . POLICY ❑ JECr 0• FI LOC PRODUCTS COMPlOPAGG $ 01 HEW S AUTOMOBILE LIABILITY o nBc�t� I SINGLE LIMIT S ... ANY AUTO BODILY INJURY (Per person) S ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS '.... NON -OWNED PROPERTYOAMAGtM .....__ S .. -. .. .... HIRED AUTOS AUTOS -. ... ',. S ... .. ...._ -... ........................ _ UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LLAB CLAIMS MADE, AGGREGATE S OF0 RETENTION $ S WORKERS COMPENSATION PEfi G "I °H- CTATI ITF FR AND EMPLOYERS' LIABILITY YIN A ANY PROPRIETOR /PARTNER/EXECUTIVE ! NIA 1760432 --15 11�01�2015 1�01�2016 E L EACH ACCIDENT $1,000,000 OFFICERIMEMBEft EXCLUDED' OFFICERIMEMB LLL���,�MM' I'000'000 H} E L DISEASE EA EM.P LOYEE s If yes. describe under DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES (ACORD 101, Additional Remarks Schedule, may he attached if more apace is required) Waiver of Subrogation Attached. V )k rr,ccaT'f tr,.A,rr- Hnl nFR ' CANCELLATION NN CITY OF EL SEGUNDO) Wr CITY CLERK'q r 350 MAIN STREET l Ik ✓�� EL SEGUNDO, CA 90245 -3813 )f 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 / " I ©1988 -2014 2bRD CORPORATION. All rights reserved. ACORD 26 (2014101) The ACORD name and logo are registered marks of ACO Produced using Forms Boss Plus so(Nmre. www.FolmsBoss „eom; Impressive Publishing 800 -208 -1977 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS HOME OFFICE SAN FRANCISCO EFFECTIVE NOVEMBER 1, 2015 AT 12.01 A.M. ALL. EFFECTIVE DATES ARE AND EXPIRING NOVEMBER 1, 2016 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME RANGE MAINTENANCE SERVICES, LLC PO BOX 2270 ARNOLD, CA 95223 WE HAVE THE RIGHT TO RECOVER OUR PAYMENTS FROM ANYONE LIABLE FOR AN INJURY COVERED BY THIS POLICY. WE WILL NOT ENFORCE OUR RIGHT AGAINST THE PERSON OR ORGANIZATION NAMED IN THE SCHEDULE. THIS AGREEMENT APPLIES ONLY TO THE EXTENT THAT YOU PERFORM WORK UNDER A WRITTEN CONTRACT THAT REQUIRES YOU TO OBTAIN THIS AGREEMENT FROM US. THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 2.00% OF THE TOTAL POLICY PREMIUM. 1760432 -15 RENEWAL NA 6- 17 -16 -03 PAGE 1 OF 1 SCHEDULEI °� PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER BLANKET WAIVER OF � SURROGATION' NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: OCTOBER 7, 2015 AUTHORIZED REPRESENT °IVI PRESIDENT AND CEO SCIF FORM 10217 IREV.7 -20141 2572 OLD DP 217