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PROOF OF INSURANCE (2017) CLOSEDPRODUCER Alliance Mgt. & Insurance Sery 366 Via Vora Cruz #7 CA AggppentlBroker Lick# 0737966 Sari Marcos, CA 92078 Michelle A. Nowell MESSI -1 INSURED Messina & Associates Inc INSURER A :Acceptance.,.CasuaIt,y. I is Come ...._.r, m...._._...: -10349 814 Forbes Drive Brea, CA 92821 INSURERS INSURER C: INSURER E : 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1NSR TYPE OF INSURANCE ..,..._ . ............. .-,. .�............................_ 1NS& g _ POLICY NUMBER ASR YYY LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000,00 A X COMMERCIAL GENERi L LIABILITY X CP00961046 0610112016 06/01/2017 PREMISE ocoa,rroncP S 100,00 7 5,00 -1 CLAIMS-MADE OCCUR MED EXP (Any one person) $ X Errors & Omission PERSONAL & nDV INJURY $ 1,000,00( GENERAL AGGREGATE $ 51000100 GEN L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AG G $ 1,000,00 A I POLICY PtO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Es accident) ANYAUTO BODILY INJURY (Per person) $ » -- _LL OWNED AUTOS BODILY INJURY (Per acddent) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS PER ACCIDENT) E Y NON -OWNED AUTOS $ S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS- MAD E AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC SrATU- 0TH. AND EMPLOYERS' LIABILITY YIN ... TORY "MMIwTS,'. "ER ". ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? NIA (Mandatory ' ) El DISEASE EMPLOYE $ If describe under _ - --, — QE& RIPTION OF OPERATIONS beL4tM EL 0 $I ASE -PIT I OLICY LIMIT $ OPERATIONS f more apace Is required) vlunteers,emAlpRees Additional l CA of EI Se resl:ntativ re �r p es do INS office 9 na ed as a One nsure W respec t0 woac I r b the name ,insured Ith,Prlma Nora -onto 30 Da�rs Utice of Cancellation. tautory "Hording and Invest ation CA -- CERTIFICATE HOLDER CANCELLATION SHOULD ANY' OF THE OVE DESCRIBED POLL B ANCELLED BEFORE THE EXPIRATION D TE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of El Segundo Attn Christopher Donovan 314 Main Street AUTHORED REPRESENTATIVE EI Segundo, CA 040tkpw ©1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: CP00961045 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. SCHEDULE Name Of Additional Insured Persons Or Or anization s Automatic Status Included Where Required by Written Contract. All Where Required by Written Contract. "It is agreed, as respects the Policy, thirty (30) days notice of cancellation, except as respects non- payment of premium, for which ten (10) days notice will apply, or other regulatory requirements that may apply, will be given as respects the indicated certificate holder." Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s) or organ- izations) shown in the Schedule, but only with re- spect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ •. Interinsurance Exchange of the Automobile Club Automobile Insurance Policy Coverages and Limits Policy Change Declarations s; Insurance is in effect only for the vehicles, coverages, and limits of liability shown on this declarations page and as set forth in the insurance policy and endorsements. These declarations, together with the contract and the endorsements in effect, complete your policy. NAMED INSURED (Item 1.,) AUTO POLICY NUMBER: CAA 066044011 MESSINA, MICHAEL AND CAROLYNA 814 FORBES DR BREA CA 92821 -7306 POLICY PERIOD (PACIFIC STANDARD TIME) POLICY EFFECTIVE DATE: 03 -25 -16 12:01 A.M. POLICY EXPIRATION DATE: 03 -25 -17 12:01 A.M. POLICY CHANGE EFFECTIVE DATE: 05 -30 -16 12:01 A.M. SUBJECT OF POLICY CHANGE THIS IS NOT A BILL REPLACE VEHICLE This policy change will increase your premium by $267, AUTO - CORRECTION VEHICLES VEH. YEAR MAKE MODEL IDENTIFICATION VEHICLE GARAGE ANNUAL VERIFIED SALVAGE NO. NUMBER USE ZIP CODE MILES MILEAGE 2 2005 AMGL HUMMER H2 5GRGN23L155H108695 COMMUTE 92821 7,501 -10,000 VERIFIED NO 5 2012 KIA SOUL SW /! /SPORT KNDJT2A65C7474113 PLEASURE 92821 3,501 - 4,500 VERIFIED NO 7 2009 JEEP WRANGLER UNLIMITED 1J4GA39159L745955 PLEASURE 92821 10,001 - 12,500 VERIFIED NO 8 2016 MBNZ E CLASS 550 WDDKJ7DBOGF314383 PLEASURE 92821 4,501 - 5,500 VERIFIED NO 9 2016 CHEV SLVRDO 1500 CR 4X4 3GCUKSEC3GG285230 PLEASURE 92821 12,501 - 15,000 VERIFIED NO COVERAGES AND LIMITS ANNUAL PREMIUMS Coverage Is not In efrect unless a premium or the word "Included" Is shown. COVERAGES LIMITS OF LIABILITY Vehicle 2 Vehicle 5 Vehicle 7 Vehicle 8 Vehicle 9 Uability s Bodily Injury $100,000 each person/ $300,000 each occurrence $ 245 $ 314 1 $ 442 $170 $ 294 Property Damage $50,000 each occurrence $ 102 $ 218 Medical No Coverage No Coverage'!' No Coverage "No Coverage i No Coverage a. Physical Damage (Actual Cash Value unless otherWse stated, less deductible) ?' Vehicle 2 Vehicle 5 Vehicle 7 Vehicle 8 Vehicle 9 a' Comprehensive ACV ACV ACV ACV ACV 4176 ' $ 62 $ 60 $ 128 $ 58 (Less Deductible) $250 $250 $250 $250 $250 3' Collision ACV ACV ACV ACV ACV i $ 339 ' $ 731 $ 402 $815 i $686 (Less Deductible) $250 $250 $250 $250 $250 I Car Rental Expense Per Da $'35 $35 $'35 $35 $35 R $ 30 $ 50 £ S 68 i $ 27 $ 28 Uninsured Motorist a ; Bodily Injury - $30,000 each person/ $60,000 each accident ; 42 S 38 S 51 $ 36 $ 28 Uninsured & Underinsured Vehicles ? Uninsured Deductible Waiver Included ; Induded Included Included Included Uninsured Collision No Coverage No Coverage i No Coverage g No Covera a i' No Coverage Total Premium 1 $ 889 $ 1404 € $ 1286 s $ 1277 $ 1312 PREMIUM DISCOUNTS "No Coverage" indicates coverage not purchased. Please refer to the enclosed document entitled "Premium Discounts Applied to Your Automobile Policy." Adjusted Total Annual Premium " If at any time you choose to pay less than the full balance outstanding„ finance charges of up, to 1.5% per month of the balance Outstanding will apply as explained in your billing statements, which are part of these declarations, (Includes all applicable discounts.) .100101 Less Policyholder Savings Dividend $ 709 (Previously applied to your premium balance) Adjusted Net Annual Premium $ 5458 Glance after ovious dividend).. It PROCESS DATE 06 -0146 PLEASE ATTACH TO YOUR POLICY (SEE REVERSE) 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 Policy Number Expiration Date Name of Agent Phone # (_� I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those provisions or the agreement will automatically become void. Signature of Applicant Date 7/12/2016 Agreement for: Dated: 08 • o, Reviewed b y.