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PROOF OF INSURANCE (2017) CLOSEDClient#: 5688 50TIFFAHOMEC ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM1DDIYYYY) 06/14/2016 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: It the cartificete hol,dor is an ADDITIONAL INSURED, ll . It SUBROGATION S �m..._ the lao(Ir�!�tas) I�tu�t tea a�ttl'orsesd, It fiITROC�%TIt�N I a WAIVED, scab)tbct 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 andoreornerd(s), PRODUCER rIA E: Hub InYI Ins Sery Uc#0757776' 909 912 6438 ' HMI 909 543 -0807 A , a, Exlia... �m... .. Formerly Livermore &Assoc Ins ��~1 ,. 3390 University Ave, Ste 300 _.,. ...... ,m.m .,.,..,.,. .. i • � ERA Phlladel I NShUlRa E R OVERAGE Riverside, CA 92501 _ Indemnity Insuranc su D NAIL R Tiffany Home Care - . ....... .._ dba Always Right Home Care . . ..... _,.�_... 9700 Reseda Blvd Ste 105 a1HSURERD�.... ....�_.._ .. v_w .. .,..... _ ..... ........ Northridge, CA 91324 INSURER E INSURER r; 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. If R ,R .,.m ,,,,,,,,..� .,.,.. ..,. _ TYPEOFINSURANCE N1 i!VM .,..... ... .1........ POLICY NUMBER ........Ihik�MNy18fY�.II1�IfP.. 0 dWl ,trYU WY .1.,.ro.�... .,,. ......_�.. - - - - ,. LIMITS A GENERAL LIABILITY PHPK1510026 611512016 061151201 EACH OCCURRENeE C(VAMF.RC dfiM;.. IIE NLRA1 IA1MI1 4iY I. Ir r� x100,000 _ JV 4 p AIpIi1 l MAI d air CtRli .. �.. rdFUJFEXP �An) an ®Eaarr) S SQtIO e e Retro Date 06115/03 PERSONAL B MV INJURY 1�ODODOD _..__....... _.._.m .. C3ENERAL AtORECiATF .. � x3,000 OEN�L, AGGREGATEp LI ITAP P S PER PRODUCTS P10P AGO $3000000 L.M I g IuIC LJLCT LLD(" w... . . � A . ...na.. AUTOMOBILE unealrY PHPK1510026 ..A.�.._. 0611512016 ._.,._�.._m ,,.. ,. 06115/201 ... .....�... t t5k slNr I I LItAI...._..... ,a Na:Ill1 000 000 m ,�. .. ANY AUTO BODILY INJURY (Per person) '$ ALL ED AUTOS �„� SCHEDULED AUTOS BODILY INJURY (Per dent) $ ....:, HIRED AUTOS NON -OVMED AUTOS P'RO PR`7"Y U uMA4 L (i ^F➢ 4 U vIL_... ..n..... ..._ s UMBRELLA a OCCUR EACH OCCURRENCE s Ex CE LIA® _ CLAIMS-MADE Ac GREGATE � a 1 ! .. ............. w U COMPENSATION H AN D EMPLOYERS' LIABILITY YIN _ m S LUV EXmi UiIVF Ar lh8R�Ci M,tNq N d A 55 ._..........A afulai ary In NHI E DISEASE -EA EMPLOYEE ....,...3 ........,,. Par 11 tov dr0aa ea i2RTT ON N 1. R@� R,,wISRhulyd. , E.L. DISEASE POLICY LIMIT ....a.,..�.. ,_._, ... .... A Prof Liablilty PHPK1510026 0611512016 061151201 ._ . $1,000,000 Ea Incident Retro: 06/15103 $3,000,000 Aggregate DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101, Addltlonal Ramarks Schedule, If more space Is required) Coverage includes $1,000,0001$3,000,000 Sexual /Physical Abuse or Molestation Claims Made Retro Date: 06115103 Certificate Holder is Included as Additional Insured per policy terms and conditions as respects Senior In Home Care Project for the City C IFICATF HOLDER .. CANCL'11ATION City Of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 _ w_ AUTHORIiF REPRESENTATIVE • 01988 -2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S379111NI37904 KAREG TIFFHOM -01 RMCATEER �- CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) - 6/30/2016 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(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 certificate holder in lieu of such endorsement(s).. PRODUCER CONTACT" All Insurance Underwriters Inc. NAME, PHONE 013 343 -3100 2600 Sumerian Drive P 343 -3090 Suite 107 AD�rSS. a1IIGyrIUITC.Cm Land O Lakes, FL 34638 _ INSURER S) AF'FOROING COVERAGE NAIC A ...... . ........ INSUMIL a� : Wesco Insurance Conr an _ INSURED INSURER B Tiffany Homecare Inc dba Always Right Homecare INSURER C: 9700 Rol >eda Blvd Ste 105 INSURER D Northridge, CA 91324 __. °° . - -• INSURER E z 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. LTi_ TYPE OF INSURANCE tNSD POLICY NUMBER MhI dYYY1 /pDlyyyY', LIMITS VWVO COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE D OCCUR DAsFAAGMRSNTED-" _PREMISES Eaor urrence $ ...�. MED EXP (Any one porson) $ PERSONAL & ADV INJURY "a GEN'� _�. LAGGREGATELIMITAPPLIESPER: GENERAL AGGREGATE POLICY P . � JLCT RO• El LOC PRODUCTS • COMPYOP AGG $ OTHER: _...... �....._ $ AUTOMOBILE LIABILITY C IAB NGLE LI t $ Eaaeddent .. ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per person) $ ........... .._ AUTOS AUTOS BODILY INJURY (Per accidenQ $ NON -OWNED -- ...... HIREDAUTOS AUTOS PROPERTY OAMAte. $ gLAcddanl $ UMBRELLA LIAB OCCUR EACH OCCURRENCE _ EXCESS LIAB CLAIMS -MADE .... -• AGGREGATE $ DEO RETENTION$ $ WORKERS COMPENSATION ER EXCLUDED? X STA UTE ER AND EMPLOYERS' LIABILITY A ANY PROPRtETORIPARTNER/EXECUTtVE YIN X SWC1102934 03/0112016 03/01/2017 E L. EACH ACCIDENT $ 1,000,000 OFFICERIMEMB ED? N� NIA �.. lrryibln Uas„ dDunder E.L. DISEASE- CAEMPL.�O. YC $ �1,000,0_0..0 SCR .. OF OPERATIONS E.L. DISEASE - POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS /LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space Is required) Waiver of Subrogation in favor of: City of El Segundo 350 Main Street El Segundo, CA 90245 r'*'a�t•rr�e°*n^wc^ n.arwn ern.. _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PHPKI510026 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -- DESIGNATED ED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect 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: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you, However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section 111 — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additlonal insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 0413 © Insurance Services Office, Inc., 2012 Page 3 of 9 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 01 -84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 0% of the California workers' compensation premium otherwise due on such remuneration. Person or Organization City of El Segundo El Segundo, CA 90245 Schedule Job Description All CA Operations This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below Is required only when this endorsement is Issued subsequent to preparation of the policy.) Endorsement Effective 3/1/2016 Policy No. SWC1102934 Endorsement No. WC 04 03 06 Insured Tiffany Homecare, Inc. (A Corp.) Premium $ 212815 Insurance Company Security National Insurance Company Countersigned by WC 04 03 06 (Ed. 01 -84) IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statment on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. AUVKU AD tLUU11Ut5J