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PROOF OF INSURANCE (2016) CLOSEDCERTIFICAT OF LIABILITY INSU NCB 17/ 6"' 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 ce�rtificats holder, Is an ADDITIONAL INSURED, the polloy(les) must Ira endorsed. If SUBROGATION IS INA)V'ED, eUtl)',taCt 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 Marie Rivera Nickerson Insurance Services, Inc. 19 Ed,, (310)326 -6333 (31o)szs -s�>ls LIC X10491589 marieQnickersonins.cam 2106 West Lomita Blvd. INSUff&9I AFFORDING COVERAGE NAIC0 Lomita CA 90717 A :Sentinel Insurance Co an LTD..... INSURED IN RER B : TCD Kids Foundation Org IN 2390 Crenshaw Blvd )1315 maunown. Torrance CA 90501 1 ws RER F COVERAGES CERTIFICATE NUMBER:15 -16 GL 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. AM TYPE OF INSURANCE Po I U 11 CYRUMM LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIARMIT'Y PREMISES Me I S 1, 000, 000 A CLAIMS E,, OCCUR 7253MAR4986 0/8/2015 0/8/2016 MEDEXP orn S 10,000 PERSONAL a AM INJURY S 1,000,000', GENERAL AGGREGATE S 2,000,000 GENL AGGREGATE LIMIT APPLIES PER PRODUCTS - OOMPIOP AGO $ 2,000,000 POLICY P F1 LOC S AUTOMOBILE LIABILITY ANY AUTO BODILY INJURY (Pa pomm) S ALLOED AS SCHEDULED BODILY INJURY (Per udd@M) - NON -OWNED E S HIRED AUTOS AUTOS S UMBRELLA LULB HOCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS -MADE AGGREGATE S IMER—Tof S WORKERS COMPE%ISATION AND EMPLOYERS' LIABILITY YIN ER ANY �� E L EACH ACCIDENT S FFIC.. ---- IN NIA qi l ry 1 E.L, DISEASE EA EMPLOYEE S d�Q Iyys wundsr DISEASE POLICY LIMIT OESGRIPTtON OF OPERATIONS below E,L. - $ DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES (Alpeh ACORD 107. Addltbnd Ramrlw 8chrrdulrr, K more"* b esgWnd) 'holder Certificate is hereby ,included as Additional Insured with respects to loc:300 E Pine St El Segundo, CA *30 day notice of cancelation; 10 day non payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of El Segundo, its officers, officio ACCORDANCE WITH THE POLICY PROVISIONS. employees, agents and volunteers 350 Main St AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 Sarah Kelly /DMP� d-- ACORD 25 (2010108) ®1988 -2010 ACORD CORPORATION. All rights reserved. INS029 mnirxut ni This Arnpn name and innn arm ranisfaraA mar4s of Af.npn F1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGE This endorsement changes the policy effective on the Inception Date of the policy unless another date is indicated below: Policy Number: 72 SBM AR4886 SC Named Insured and Mailing Address; TCD KIDS FOUNDATION ORG 2390 CRENSHAW BLVD # 315 TORRANCE CA 90501 Policy Change Effective Date: 06/21/16 Policy Change Number: 002 Agent Name: NICKERSON INSURANCE SERVICES INC Code: 255512 Effective hour is the same as stated in the Declarations Page of the Policy. POLICY CHANGES: SENTINEL INSURANCE COMPANY, LIMITED ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING STATEMENT.IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BANK ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A BILL. NO PREMIUM DUE AS OF POLICY CHANGE EFFECTIVE DATE FORM NUMBERS OF ENDORSEMENTS REVISED AT ENDORSEMENT ISSUE: IH12001185 ADDITIONAL INSURED - PERSON - ORGANIZATION IH12001185 ADDITIONAL INSURED - OWNER, LESSEES OR CONTRACTOR PRO RATA FACTOR: 0.299 THIS ENDORSEMENT DOES NOT CHANGE THE POLICY EXCEPT AS SHOWN. Form SS 12 11 04 05 T Page 001 Process Date: 06/23/16 Policy Effective Date: 10/08/15 Policy Expiration Date: 10/08/16 POLICY NUMBER: 72 SsM AR4886 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PERSON - ORGANIZATION CITY OF EL SEGUNDO ITS OFFICERS, OFFICIALS, EMPLOYEES, AND AGENTS 350 MAIN STREET EL SEGUNDO CA 90245 Form IH 12 00 11 85 T SEQ. NO. 001 Printed In U.S.A. Page 001 Process Date: 06/23/16 Expiration Date: 10/08/16 POLICY NUMBER: 72 SBM AR4886 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED — OWNER, LESSEES OR CONTRACTOR CITY OF EL SEGUNDO ITS OFFICERS, OFFICIALS, EMPLOYEES, AND AGENTS 350 MAIN STREET EL SEGUNDO CA 90245 Form IH 12 00 11 85 T SEQ. NO. 002 Printed In U.S.A. Page 001 Process Date: 06/23/16 Expiration Date: 10/08/16 d California Casualty For questions on your policy onto report a loss, Home Office San aiaceo CA call 1.800-800-9410, This document can be viewed at calcas.com /My- Account. Coverage provided by: CALIFORNIA CASUALTY INDEMNITY EXCHANGE AUTOMOBILE POLICY DECLARATIONS Your policy Is billed by E-Z Pay, Billing AMENDMENT information will be mailed separately. This ce 1 i rincildipil s lin c NAMED INSURED(S)c POLICY NUMBER: POLICY PERIOD: BOURGEOIS, TANEEKA & DA SILVA, 101 5936119 Effective 08/01115 Expiration 08/01/16 CHRISTOPHER . � . 12:01 A.M. Standard Time at the Named Insured's address of record Amendment Effective: 08/25/15 Outl)ne of Coverage for the 2010 MERZ E 360 Vehicle ID Number. WDDHF5GB5AA213002 ..leRholder(s): CALIFORNIA CU � Other ymbol 22 Collision Symbol: 22 Limit Coverage is provided premium is shiown. See your Policy Contract where p ntract for coverage details. ra Coverage Limits Deductible Premium Bodily Injury Liability $100,000/$300,000 Each Person/Each Accident $ 167.00 Property Damage Liability $50,000 Each Accident $ 108.00 Unin$ured Motorists - Bodily Injury $100,000 1$300,000 Each Person /Each Accident $ 45.00 Other Than Collision Actual Cash Value Subject to Deductible $500 $ 123.00 C011ision Actual Cash Value Subject to Deductible $500 $ 434.00 Transportation Expense Optional Limits Apply $30 Per Day /$900 Maximum $ 8,00 Towin and Labor Costs Broad Covera e A apll s w $ 15.00 Tota(Vehicle Premium: $ 900.00 The following discounted factors have been applied to this vehicle: Plafirlum Level, Multi -Car Discount, Good Driver Discount, Auto -Home Discount, Persistency (Loyalty) Rating and AffiMy Group Member UP -1 � (11111) INSURED COPY 08/31/15 Page:1 of 4 California C Home 011ice asualiy For 1uestions on your policy or to report a loss, San hlaieo Ca call 1- 800 - 8009410„ This document can be Coverage provided by: viewed at calcas.cor� /M , y CALIFORNIA CASUALTY INDEMNITY EXCHANGE y Account s Named lns�ured -. a () BOURGEOIS,, TANEEKA a DA SILVA, ,m Amendment d �._ectwe:08/25 /15 Outline of Coverage for the 2011 MEitZ GL 450 4MATI Vehicle Eff ienholder(s) for AUTO_ FINANCE , ID Number. 4JGVOF7I32BAt373888 oven a Is r. Class. 2PDF00 C Other Than Collision Symbol: 58 9 I ovlded where a remlum Is shown. See our Policy Limit: llislon Symbol: 57 Coverage Y o p Your Limits ntract for covers a details, Bodily; Injury Liability $100,000/$300,000 Each P Deductible Premium Person/Each Accident Property Damage Liability $50,000 $ 187.00 Uninsured Motorists -Bodil In Each Accident y j u Accident rY $100,000/$300,000 Each Person/Each Accid $ 120.00 Other Than Collision $ 53.00 Actual Cash Value Subject to Deductible Collision $500 $ 250.00 Actual Cash Value Subject to Deductible $500 Transportation Expense $ 582.00 Optional Limits Apply $30 Per Day /$900 Maximum "'uu. tn�'an,._.fr. d.�borCast $ 8.00 Total Veh -- Broad Covers e A Iles icle Premium: "� �" ��a.�. �...7.m�..��..n..�..�.�.. $ w _ 15.00 The following discounted factors have been applied to this vehicle: $ 1 215.00 Platinum Level, Multi -Car Discount, Good Driver Discount, Auto -Home Discount, Persistency (Loyalty) Rating and Affinity Group Member UP- 1176;(11111) INSURED COPY 06131115 Page:2 of 4 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION RNING: FAILURE T affirm under penalty of perjury under the laws Of California one of the following declarations: L—) 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 the wo s f the agreement with the City of El Segundo. Of work at forth Policy No. have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance of e of e1work for which the agreement with the City of El Segundo is executed. My workers, compensation insurance carrier and policy number are: Carrier Phone # Policy Number Expiration Date Name' of Agent Signa(pre of Applicant 601