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PROOF OF INSURANCE (2017) CLOSED� �" CERTIFICATE OF LIABILITY INSURANCE DATEIMMMONYYYI 617/2016 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 pollcy(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 City of EIS undo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 0 Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 35 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo CA 90245 AUTH09 6D REPRESENTATIVE 01988 -2014 ACORD CORPORATION. All rights ACORD 26 (2014101) The ACORD name and logo are registered marks of ACORD GU 207 (AIP) (Ed.6 -78) ENDORSEMENT This endorsement, effective on 06 15 16 at 12:01 A.M. standard time, forms a part of Policy No. GL157386 #7 of the LANCER INSURANCE COMPANY (Name of insurance company) Issued to Five Star Transportation by LANCER INSURANCE COMPANY Aut)ofized Representative It is hereby understood and agreed that the following is added as Additional Insured only with respects to operation of the named insured. Name: City of E1 Segundo Addr: 350 Main Street E1 Segundo, CA 90245 n� ISSUE DATE: 06/15/16 Page 1 of 1 (Ed.6 -78) FIVESI 13 OP ID: OA CERTIFICATE OF LIABILITY INSURANCE G 0611512IY6 0811612018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THI8 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(les) must be endorsed. If SUBROGATION 18 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 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. TYPE OF INSURANCE POLICY N MBER LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE ! CLAIMS-MADE OCCUR PR tlultl��pypup !_„ MEOEXP(Agonapnon j s PERSONAL 6 ADV INJURY 3 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE ! POLICY El JFI El LOC PRODUCTS - COMPIOP AGO 3 Oonm 3 AUTOMOBILE LIABIUTY 02"NADISINGLE ANY AUTO BODILY INJURY (Per person) S � AUTOS AUTOS AUTOS�� BODILY INJURY (Per soddenly 3 HIRED AUTOS ANO�NOSWNED Myow 0 S S UMBRELLA LIAB OCCUR EACH OCCURRENCE 3 EXCESS LIAB CLAIMS-MADE AGGREGATE 3 DEC) RETENTION! ! WORKERS COMPENSATION X AND EMPLOYERS' LIABILITY VIIN A ER A ANY PROPRIETOWPARTNERIEXECUTIVE [y N IA X 916361916 0212412016 02/24/2017 E.L. EACH ACCIDENT ! 1,000,00 OPPICERIMEMSER EXCLUDED? (MemleCOry In NIN) E.L. DISEASE -EA EMPLOYEE S 1,000,00 II e� dew w�dar RIPTION OP OPERATIONS below ._. E.L. DISEASE - POLICY LIMIT 3 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addlllonal Remarks Schedule, may be attached H mom space Is required) Officer Exclusion Applies - Jack B Anderson II CER IFICATE HOLDER CANCELLATION 0000000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 360 Main Street El Segundo, CA 80246 AUTHORIM REPRESENTATIVE ACORD 25 (2014/01) ®1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION 9153519 -16 NEW SC PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE JUNE 16, 2016 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING FEBRUARY 24, 2017 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME FIVE STAR TRANSPORTATION PO BOX 470323 LOS ANGELES, CA 90047 fit✓ ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF EL SEGUNDO WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, FIVE STAR TRANSPORTATION IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03 %. 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: JUNE 17, 2016 2570 A4JTN9CNR02ED REPRI SEIUT NVE PRESIDENT AND CEO. SCIF FORM 10217 (REV.7 -2014! OLD DP 217