PROOF OF INSURANCE (2017) CLOSEDOP ID: DR
a DATE (MM/DDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE, 04125120�15
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
1M.4 II1e r ,
Alliance Mgt. & Insurance 'e'rWr
PHONE
355 Via Vera Cruz 47
rAiC No-
t
CA A ent[Broker Llc# 0737966
-MAIL°
ADDRess
San !arcos, CA 92078
c WYENN
Michelle A. Nowell
�9nneR to a -1
INSURED w enn ifs Associates Acceptance Casualty Ins Como 10349
Y INSURER A : CC
815 S Central Ave #20
Glendale, CA 91204 INSURERS:
INSURER C
_
INSURER D :
......... ...... .. .........•�����
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.
INSR
yeTrt,
...._.
Aube
TYPE OF INSURANCE ueo
SINE(
unm
POLICY Nl1MkEk
POLICY
JDD)Y'
DI Y DIP
lMMIDDIYYYYI LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,0
A
X COMMERCIAL GENERAL
COMMERCIAL ABILITY X
CP00960505
03/06/2016
�
0310612017 PRF qF,�b y a i¢rran a)
100.00"
OCCUR
MED EXP Any one person)
$
X Errors & Omission
PERSONAL & AD_V INJURY
$ 1,000,0
.,
GENERAL AGGREGATE
___�
$ 5,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP /OP AG I;
$ 7,000,00:
X POLICY PRO" LOC
S
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
$
(Ea acddeni)
ANY AUTO
.mBODIL
......... Y INJURY (Per person)
. . ......... ,.
$
ALL OWNED AUTOS
_ .... ...... .._.._
li BODILY INJURY (Per accident)
.��.µ.,.� ..............
$
.,..., SCHEDULED AUTOS
PMAGE
......., HIRED AUTOS
'..
( PER ACCIDENT)
.... „.
$
.... ,
NON- OWNEDAUTOS
S
a
UMBRELLA LIAB OCCUR
EN H OCCURRENCE
$�
EXCESSLIAB CLAIMS -MADE I
AGGREG,TE
DEDUCTIBLE
S
RFTFNTtQN
$
WORKERS COMPENSATION
I WC STATU= 0TH -
AND EMPLOYERS' LIABILITY YIN
-I1T0 X IJi ._....----
._._..... ,......
..NY PROPRIETORIPARTNERIEXECUTIVE ❑ IN /A
OFFICERIMEMBER EXCLUDED?
E L EACH ACCIDENT
$
(Mandatory In NH)
E L DISEASE - EA EMPLOYEE
$
If yes describe Balder
—
n, FSCRIPTIPN OF OPERATIONS halnw
E.L. DISEASE- POLICY LIMIT
S
DESCRIPTION
OF OPERATIONS I LOCATIONS I VEHICLES (Attach
ACORD 101, Additional Remarks Schedule,
if more apace Is
required)
E1
named
Segundo Police Department,officials,
as additional insured with
respect
officers, agents ands
to the work performed
toyees
by
are
the named
insured.
aodonnell
@elsegundo.org
Investigation,
CA --
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL ,BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
El Segundo Police Department
Assistant to the Captains f
Amanda O'Donnell AUTHORIZED REPRESENTATIVE
345 Main Street Q�
iEl Spaun,dq_ CA 90245
mm
0 1988 -2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD
Vi-OLICY NUMBER: CP00960505 COMMERCIAL GENERAL LIABILITY
CG 20 26 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
A
lllg ljllg
pr4,29, 1 �—, 4
CG 20 26 07 04 0 ISO Properties. ? ». 2004 Page 1 of 1 0
Amended auto policy declarations
Policy number: 934 426 951
Policy effective date: March 20, 2016
Your Allstate agency is Mike Krupka Inc
(818) 407 -1671
Discounts per vehicle (continued)
Listed drivers on your policy
Joel Wyenn
Tina Wyenn
Excluded drivers from your policy
None
Coverage detail for 2010 Hyundai Eiantra
Page 2 of 7
Coverage
Limits
Deductible
Premium
Automobile Liability Insurance
Not applicable
$206.03
Bodily Injury
$500,000 each person
$500,000 each occurrence
',' Property Damage
$100,000 each occurrence
...., .
Auto Collision Insurance _.
Actual cash v... .. ��.�.__. aw.,,,� �
slue
—.... _
$500
.....,,,, �_.... _
$136.73
Waiver of deductible applies
Auto Comprehensive Insurance
Actual cash value
$0
$21.83
Rental Reimbursement
up to $30 per day for a maximum of 30
Not applicable
$24.56
days
Towing and Labor Costs
Not purchased*
o
_
Uninsured Motorists Insurance for Bodily
$500,000 each person m..
Not applicable
$57.70 °a
Injury
- ic
$500,000 each accident
.0
Auto Medical Med a�
I Payments
�...... .,,. � �..,
Not purchased*
a�._._. ®e �.�
..........
Coordinated Medical Protection
Not purchased*
CO
Lease/Loan
Not purchased*
R
Repair Replacement Cost Option
pair o ReGacement Co
Not purchased*
, _
Sound System
Not purchased*
R
(continued)
a
C
°o
!
"u 0� u o a t 0 g u nrr d Ih o,: a u(:N,
Page 1 of 7
Information as of March 4, 2016
Summary
Named Insured(s)
Joel and Tina Wyenn
Mailing address
225E Hood Dr
Thousand Oaks CA 91362 -2422
Your policy provided by
Allstate Northbrook Indemnity
Company
Policy period
Beginning March 20, 2016 through
September 20, 2016 at 12:01 a.m.
standard time
Your policy change is effective
March 20, 2016
Your Allstate agency is
Mike Krupka Inc
22024 Lassen St #102
Chatsworth CA 91311
(818) 407 -1671
MikeKrupka @allstate.com
Some or all of the information on your
Policy Declarations is used in the rating
of your policy or it could affect your
eligibility for certain coverages. Please
notify us immediately if you believe that
any information on your Policy
Declarations is incorrect. We will make
corrections once you have notified us,
and any resulting rate adjustments, will
be made only for the current policy
period or for future policy periods.
Please also notify us immediately if you
believe any coverages are not listed or
are inaccurately listed.
0
a
0
0
a
V
mended auto policy declarations
our policy effective date is March 20, 2016
dotal Amount due for the Policy Period
lease review your insured vehicles and verify their VINs are correct.
Pehicles c i cation Mllarrer_ I�fltil iu+
!010 Hyrundai Elantra
242.5
3.5;
Total* $1,304.75
'if you pay less than the Pay in Full amount, you will be charged an installment fee(s).
See the Important payment and coverage information section for details about
installment fees.
Discounts (included in your total premium)
Good Driver (20 %) $310.82
Distinguished $196.34
Driver
Anti -theft $0.96
Total discounts
Multiple Policy
Specialized
Professionals
$23.96
$49.04
$581.12
Discounts per vehicle
WOONNOM
2010 Hyundai Elantra
$194.8
Good Driver (20 %) $97.22
Multiple Policy
$7.32
Distinguished $75.25
Specialized
$15.03
Driver
Professionals
1992 BMW 3181
$149.2;
Good Driver (20%) $83.41
Multiple Policy
$6.21
Distinguished $46.93
Specialized
$12.68
Driver
Professionals
1999 Che Trk S70
$1,27.7
Anti -theft $0.96
Goad Driver (20 %) $69.54
Multiple Policy $5.58
Distinguished
$40.21
Driver
Specialized $11.42
Professionals
(continue
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 #
V mp-c r`ti c that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not
oy any person in any manner so as to become subject to the workers' compensation laws of California, and
agree that, if I should coi a subject to the workers' compensation provisions of Labor Code § 3700 1 must
immediately comply wi th a provisions or the agreement will automatically become void.
Signature of Applicant Date
Agreement for: 4-- z
Dated:
Reviewed by: I