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PROOF OF INSURANCE (2016) CLOSEDDATE (MM /DDIYYYY) -
ACC►,w " CERTIFICATE OF LIABILITY INSURANCE i 07/14/2016
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 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). 99
PRODUCER PHONE JOHN EKNO la � NOI.... 14 11 JOHN L EKNO rta Xt), 714 257 2517 I 714 257 2522
I ,.Ii _ Vjekn9 farmera�l.. e .
BR EA CA 9 82105 INSURE I i E EXCHANGE __ rtAlc a
INSURI R S AF'' I.. —
Ik
TRUCK INSURANCE EXCHANGE 21709
INSURED ...... _ FARMERS IN � ..
INSURED INSUReRB.. XCHANGE 21652
CROSSROADS SOFTWARE, INC INSURPRC MID CENTURY INSURANCE EXCHANGE 21687
.....r I.
210 W. BIRCH ST. #207 t SCURER D ., .. .................. _
BREA, CA 92821 INStFr^BEl'dE ..., .,.,.
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 BY PAID CLAIMS
.. LIMITS SHOWN MAY HAVE BEEN REDUCED -
IT
—
CE
TYPE OF INSURANCE
�
POWµtC'Y NUMBER �.
MMFDD� PYYYY
MlDrBAY'YYY
LIMITS
COMMERCIAL GENERAL,
60439 -58-4 5
08/271201608/2712016
EACH OCCURRENCE 4
$ 2,000,000
� CLAIMS MADE �.x � occuR
f a
� acTa�rr-rWCrt1) ...
PREMISES IEa
..
E .
B
..�YPvf"'lC,,NRPNTf`ia
m _
MED EXP (AnT one porsan)
$ S,000
. . _ ...... .... .....__ - --
Y
& A URY
PERSONAL DV INJURY
$ 2,000,000..
- -- PER:
•Nl AGGW�kGATE LIMIT APPLIES
otr
_....
GENERALACsORi'G?'iE,
4 000,000
$"
q ffI�
PIo'" Loc
POLICY �. JCOT
PROOUCrs d WJMPfOP Acc
2,000,000
$
OTHER
IL
AUTOMOBILE LIABILITY
60439 -58-45
0812712015
8127'12016
Cat riI) Ira L iufiJUT
0, ,,....,
s._2,000.,m 00
B
INJURY (Per person)
L....,,„
$
ANY AUTO
ALL OWNED SCHEDULED
...BODILY
... ...........__
BODILY INJURY (Per accident)
..............
$
AUTOS AUTOS
_- - -- NON -OWNED
F'ROPFit1 DAMAG4
$
X,,,,,
HIRED AUTOS AUTOS
(#�dWx ¢Tud�inl)
UMBRELLA LIAB OCCUR
EACH OCCOURRFNCCEE.. mm.....
E„ ,...,
_....._...... ..__.] .
EXCESS LIAR CI.AW!S, MADE.
.
AGO EGATL ...........IT .,....___
$
C
�...----..
DED RETENTIONS,
N
WORKERS COMPENSATION
A09465956
81"9 312015
8113/2016
I°rR
_ � �H
$
LIABILITY YIN
AND EMPLOYERS LIABILITY mm
In W. EACH4.ITF
AC ID
1,000 0 00
,XE
.
ANY PROP RIE'fORYPARTNL CUTIVE ��
OPFIC EWddMEMBER EXCLUD�E.Dd
NIA
E L. DISEASE EA E.,
MP
, .. ,
$ 1,000,000
(Mandatory In NH)
If yetis describe under..:..._. _:.M.. w... ,.
...,
L L.. DISEASE - POUC'Y LIMIT
S 1,000,000..
. . . . . . . . . . . . . . . . . . . . . . . . . . .
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
CERTIFICATE HOLDER LISTED BELOW ALSO ADDED AS ADDITIONAL INSURED
CERTIFICATE HOLDER
CANCELLA
CITY OF EL SEGUNDO POLICE DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
348 MAIN ST ACCORDANCE WITH THE POLICY PROVISIONS.
EL SEGUNDO CA 90245
AUTHORIZED REPRESENTATIVE
John Ekno
© 1988 -2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: 60439 -58 -45 BUSINESSOWNERS
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED . DESIGNATED: PERSON
ONE ORGANIZATION
This endorsement modifles Insurance provided under the following:
BUSINESSOWNERS POLICY
SCHEDULE*
Name Of Person Or Organization:
CITY OF EL SEGUNDO
POLICE DEPARTMENT
:lid ""?-.
* Information required to complete this Schedule, if not shown on this endorsement, will be shown In the
Declarations.
The following Is added to Paragraph C. Who Is An
Insured In the Buslnessowners Liability Coverage
Form:
4. Any person or organization shown In the Sched-
ule Is also an Insured, but only with respect to
liability arising out of your ongoing operations
or premises owned by or rented to you.
BP 04 48 01 97 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 11
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ R CAREFULLY.
Policy Number: 60439 -58 -45
POLICY CHANGES
Effective Date of Change: 08/27/16
Change Endorsement No.: 003
Named Insured: CROSSROADS SOFTWARE INC
210 W BIRCH ST STE 207
BRE CA 92821 -4504
The following item (s):
Expiration Date: 08/27/17
Agent: 97 -55 -316
Insured's Name Insured's Mailing Address
Policy Number Company
Effective / Expiration Date Insured's Leval Status / Business of Insured
Payment Plan Premium Determination
X Additional Interested Parties Coverage Forms and Endorsements
Limits / Exposures D(iltic tibles
Covered Property / Location Description Classification / Class Cod(, -,,
Ra::c";, Underlying Insurance
is (are) changed to read {See Additional Page(s)}:
The above amendments result in a change in the premium as follows:
X No Changes To Be Adjusted At Audit j Additional Premium Return Premium
E4277
1 it Edidon
Authorizt,1 Representative Signature:
0;PhA FARMERS
INSURANCE.
914211 1ST EDMON 742 Induda EaWghled Hakb Inwrano Ww Oft Ina, w1h Ih pamhdaa E4277101 PAGE 1 OF 2
E42774DI
Policy Changes Endorsement Description
Removal If Covered Property is removed to a new location that is described on this Policy Change,
Permit you may extend this insurance to include that Covered Property at each location during
the removal. Coycrage at e -aeh loe aadon will apply in the proportion that the value at cuch
location beats to the value of all Covered Property being removed. This permit applies up
to 10 drays after the ef'fec'tive date of this Policy Chang after that, this insurance d(,)( s not
apply at the previous location,
914277 1ST EDITION 7 -02 I t IOhI®d MMAI, Imutanto Suft Oft Int, A h podalm, E4277102 PAGE 2 OF 2
E42774DI
Shillin , Mona
From: Shilling, Mona
Sent: Monday, August 01, 2016 2:00 PM
To: Evanski, Brian (Captain)
Cc: Sandoval, Lili
Subject: FW: Crossroads Software, Inc. - Serv. Agr. No. 5163 - Confirm Waiver not Required
Brian,
This email is to confirm the Waiver of Subrogation for the Workers Compensation is not required because the vender
will not be on site or any other site on the City's behalf.
If this is not the case, please advise.
Thanks,
Mona S
From: Shilling, Mona
Sent: Monday, August 01, 2016 1:55 PM
To: Evanski, Brian (Captain)
Cc: Lillio, Joseph; Cerritos, Maria; Sandoval, Lili; 'jcullen @corssroadssoftware.com'
Subject: Crossroads Software, Inc. - Serv. Agr. No. 5163
Brian,
The signature process for Service Agreement No. 5163 with Crossroads Software, Inc. is complete. The proof of
insurance provided has been accepted. Attached is a PDF copy of the agreement for the department and the vender.
PLEAE NOTE: The vender has been copied on this email.
r Ltvuolo,
Work-, " r , o
s r 0
Work-, emclU Mfr