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PROOF OF INSURANCE (2017) CLOSEDTHIS CERTIFIC CERTIFICATE I BELOW. THIS REPRESENTAY IMP " SUSPOGATIC PRODUCER 51wWrVill Im INSURED CERTIFICATE OF LIABILITY INSURANCE Dais 1 0812312016 ED A8 A MATTER OF INFORMATION ONLY AND CONFiWS ­NO RIGHTS UPON C FICATE HOLDER. THIS DES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE uriohm) BY THE POLICIES ,oERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED W OR PRODUCER, AND THE CERTIFICATE HOLDER. Re- co ELal�e ljor Is �wAOD�MONAL 7INSURto, ��- pO­ficytjefta)�m��7st­hays ADDITION I SURED Provisions —end&rsed. 4 IS WAfVED, sublOct bD the terms and conditions of the polky, ceftin policies may numira an er4oraemenL A sUtornent on not oontoT j!gt" the cowiftato holder In lieu of such; andornamnnital L HASSAN HIGHLAND AVE HATTAN BEACH, cA 90266 CLIFtORD, SUSAN SAXE OR APR FESS*NAI, CORPORATION 16530 VENTURA BLVD STE X03 ENCIN,OCA 91436 .3 1 0 545-6579 C 310 546-6821 I Wq N* DILL qIAI Form Gonoral Inm Company ;7"ftoe Cony 251'51 as: StSle Faffli Fire and Casualty Company 25143 INSURER D: MRS IS TO UCRTtfY TKAT THF POLICIES 61� _INSU D BELOW "AVE KKN ISS4*0 TO THE INSURED NAMED ARMii FOR 14 —POLICT- ,T OR OCHER DOCUMENT V01111 RESPECT TO V*ItCjj THIS INDICATED, NOT�JTHSTANCANq ANY RFOUIREMENT. TERrA OR CONDITION OF ANY CONTI�AC i-�R­frj 5 GERTIFICAT BE ISSUED OR MAY PERTAIN, THE INSUriANCE AFFORDED BY THE POLICIES DIESCRISED HEREAN IS SUBJECT 10 ALL THE HET EXCLUSIONS ANI) �CONDJTION$ OF SUCH POLICIES, LimrTs sw)wN MAY I 1AVE BEEN REDucr--D BY PAIL) cLAws, 19,41, 1— AWKIWO6141 __' — — ,Et F $NSUAANCV, C C' JUMCRCZ owcAci4� OMRAL LIASjUrY CA 1.000.000 CLAIMS*Aw- OCCLN 300,660 Mrf��_ 7 5,066 A Awg.'�QhT I V"I AmPLIES PLR Y 11 92-02-2 -2 Ly t - — GFNERALACIZAECAIC 2.000,0w RO- 0�n Ntl V[ LOC __ PkODUCTS PAM A 2.OW,000 -NY AUTO Ohl) OWNED 90131ILY INJURY (Pbr p*mN SCHEOUL17D AUTOS ON Y Aliros 13MLY #4JURY (Par mwiowk T HIRM NQN4A'jWE0 ALnCSCNLV I 4A u �11 IWOCLOWLY UMOMLLA U�D CC UR CCCUR EACH OCCURRENCE EXCESSLIAO I I 1, r" , AGC� E_GAIF lift N, 104 S N I A � N � 92-EK_K5ra2-2 ty 11 0710W016 07101=117 E-LEACMACCIWNT 1,000,000 1:.L DISSFARF - � 1.000,000 WFA.5i 1-1ma-600 ;&�W-WVTION OF OPERA'A"S) LOCATIONS I VENICLAS VWDRD m, Ad*ajw Ma01N4_MSCh_fflk_ft,_My be —&jlaCftW If Mj 'S'—pft'— Psychological $ejyjcc$ 991quffor SHOULD ANY Of,THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE FXPIFtA"O,kl DATE THEREOF, NOTICE WILL BE DELIVERED IN FI S"U,ndo FNIce Dept ACCORDANCE W1 I TH THE i"jCY PROVISIONS, W Main Street El Segundo. CA 90245 A! tHM601no RfOREWAWNP 0 1S O -:2415 ACORD CORPORATION. All daft reserved. ACORD 25 (201W03): The ACORD narno and k90 are registered n-tafki of ACORD 10014M 137449.12 03-16-016 G Policy No. 92 922579 2 RASSAN, EROL E THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CMP- 4786.1 ADDITIONAL INSURED — OWNERS, LESSEES, OR CONTRACTORS (Scheduled) This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 92 922579 2 Named Insured: CLIFFORD, SUSAN SAXE DR A PROFESSIONAL CORPORATION 16530 VENTURA BLVD STE 203 ENCINO CA 91436 -4535 CMP -4788.1 Page 1 of 2 //'ll' Name And Address Of Additional Insured Person Or Organization: THE CITY OF EL SEQUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES AGENTS AND VOLUNTEERS 348 MAIN ST EL SEGUNDO CA 90245 -3813 I. SECTION 11 WHO IS AN INSURED of SECTION If - LIABILITY is amended to In- clude, as an additional Insured, an,y person or or anization shown in the Schedule, but only with respect to liability for "bodily injuryy", "property damage ", or "personal and advertis- Ing Injury" caused" in whole or in part, by:. a. Ongoing Operations (1) Your acts or omissions; or (2) The acts or omissions of those acting on your behalf; Mw w w w ww f ••: - • • •w w .w w b. Products – Completed Operations "Your work "" performed for that additional insured and included in the "pro+ducts- completed operations hazard ". However, Paragraph 1. above is subject to the following: a. The insurance afforded to the additional insured only applies to the extent permit- ted by law; b. If coverage provided to the additional in- sured Is required by ,w agree. ment, the Insurance provided • the additional insu:w will not be broader that which you :w w by w or agreement wprovide fw addition- al aw and c. If the contract or agreement • w w w, a additional :uu rw : :,w C011fornia Civil Code Section 2782 or 2782.05, the Insurance provided w the additional insured is the lesser of lu w (1) Is allowed for the satisfaction of a de- fense or Indemnity obligation by Cali- fornia Civil Code Section 2782 or 2782.05 for your sole liability; or (2) You are required by contract or agreement to provide for such addi- tional insured. We have no duty to defend or indemnify the additional insured under this endorsement un- til a claim or "suit" is tendered to us.. O. Copyright, Stela r`e,rrrw Mutual Automobile Insurance Company, 2013 Includes wpyrighted material of Inauranos Senrloas Offlce, Inc., with Its permission. COhfTIN 0 CMP -4786.1 2. Any Insurance provided to the additional In- Page 2 of 2 (3) The nature and location of any injury sured shall only apply with respect to a claim made or a 0suit "' brought for {damages for or damage arising out of the "occur- which you are provided coverage. rence" or offense; 3. With respect to the Insurance afforded to the b. Tender the defense and Indemnity of any claim or "suit" to us and to all other insur - additional insured, the followin Is added to SECTION 11 LIMITS OF INORANCE: ers who may have Insurance potentially available to the additional insured; and If coverage provided to the additional insured is required by contract or agreement, the most c. Agree to make available any other Insur- we will pay on behalf of the additional insured ance the additional Insured has for de- fense or damages for which we would will be the lesser of the amount of Insurance: rovide coverage under SECTION 11 — a. Required by the contract or agreement; or IABILITY. b. Available under the ap licable Limits Of Insurance declarations. 5. With respect to the insurance afforded the ad- ditional' insured, shown in the the following replaces SEC- SEC- This endorsement shall not increase the a - Limits Of Insurance TION 11 - LIABILITY of Paragraph 7". Other insurance of SECTION 1 AND SECTION 1I plicable shown in the COMMON POLICY CONDITIONS: 4. With respect to the insurance afforded to the a• This insurance is primary to and will not seek contribution from any other Insurance additional insured, the following is added to available to the additional insured provided Paragraph 3. Duties In The Event Of Occur - „. that the additional insured is a named In- rence, Offense, Claim Or Suit of SECTION sured under such other insurance. II — GENERAL CONDITIONS: b, Regardless of any agreement between The additional insured must: you and the additional Insured, this insur- a. sae to it that we are notified as soon as re notified ° o ance is excess over any other insurance whether primary, excess, contingent or on practicable of an or of- fence which may result r a claim To the any other basis for which the additional in- extent possible, notice should include e: sured has been added as an additional in- sured on other policies. (1) How, when and where the "occur- rence” or offense took place; There will be no refund of premium In the event (2) The names and addresses of any in- this endorsement is cancelled. jured persons and witnesses; and All other policy provisions apply. CMP- 4786.1 1007033 148011 OB-21 -2014 ®. Copyri�tlit, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrigtrtsd material of Insurance Services C Ice, Inc.. with Its permission. Account Number: CA SUSA 1650 Date: 2/09/16 Initials: JA CERTIFICATE OF INSURANCE DARWIN NATIONAL ASSURANCE COMPANY C /O: American Professional Agency, Inc. 95 Broadway, Amityville, NY 11701 800 - 421 -6694 This is to certify that the insurance policies specified below have been Issued by the company indicated above to the lneured named herein and that, subject to their provisions and conditions, such policies afford the coverages Indicated insofar as such coverages apply to the occupation or business of the Named insured(s) as stated. THIS CERTIFICATE OF INSLRANCE NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR ALTERS THE COVERAGE(S) AFFORDED BY THE POLICY(IES) LISTED ON THIS CERTIFICATE. Name and Address of Insured: SUSAN SAXE- CLIFFORD, P'R.D. A PROFESSIONAL CORP. 16530 VENTURA BLVD STE 203 ENCINO CA 91436 Type of Work Covered: PROFESSIONAL PSYCHOLOGIST Location of Operations: N/A (If different than address listed above) Claim History: Retroactive date is 03/01/ 2004 Policy Effective' Coverages Number Date PROFESSIONAL/ LIABILITY 5011 -0137 3/01/16 Additional Named Insureds: SUSAN' SAXE-CL-IFFORD, P'H:D CATHY GOODMAN, PHD xpiratlon Date 3/01/,1..7 ms.µ Limits of Liability ass sss aee e�w NOTICE OF CANCELLATION WILL ONLY BE GIVEN TO THE FIRST NAMED INSURED, WHO SHALL ACT ON BEHALF OF ALL INSUREDS WITH RESPECT TO GIVING OR RECEIVING NOTICE OF CANCELLATION. Comments: THE DEFENSE REIMBURSEMENT LIMIT FOR PROCEEDING ON THIS POLICY IS $75,000. ADDITIONAL INSURED: SEE ATTACHED s iertJfi at_e Issued t PrIo B&B P"A"E"AICR INS 5008 CHESEBRO RD STE 200 AGOURA HILLS CA 81301 0401 06 140095420 FRANCIS CLIFFORD FRANCIS CLIFFORD SUSAN SAXE-CLIFFORD ��MERC URY 043988 06 TELEPHONE:(818) 223-8383 INSURANCE COMPANY 1004102/2017 12I01A "A A)' 14102/2016 11-­ - ............ MAILING 4908 044 LANE DR.. ENCINO, CA 91316.4001 3 MERCEDES E3504M WAGON AWD­ "AG "4'6'R 2 2015 FORD MUSTANG GT CPE 3 2016 FORD EXPLORER PLATINU UTL 4DR WDDHHBJB6DA758036 1FAOP8CF4F5322694 IFM5KBHT3GGD80021 AUTOMOBILE POLICY DECLARATIONS ORTANT COVERAC11F M(rtl I lQu N � 06/2013 N 11/2014 N 04/2018 overage applies only If Premium charge is listed below. CoVerage/Limits qf !"04 are subject to all Policy terms, 7 ­ ­­ ­­­_­­­ 20 BODILY INJURY UABRm $250,000 FAcH pEum 6„600 rAck A=DGNT CAR2 EMS INSURED AND AMOUNTS OF PROPERTY DAMAGE LIABILITY $250,0,00 µO00 FAcHAwDeff 330 174 in SURANCE FORD EACH IT ARE STATED 0 EM oft"91JAW 30 . . ..... .. .. . .... 282 HEAW ITEMS INSURED ARE SUBJECT TO BODiIY,NIJURYLIA�ILTIY $250,000 EACHF%UM $ 500,000 , THE DEDUCTUILE, WHACCIDOOT 108 110 68 UNMSUR91D MOTORISTS PROPERTY DAMAGE LIARtITV $ MAXIMUM ­ �_ "�11` , 7� '1 11 1 MEDICAL EXPENSE _­ _­­_ ___ LEABEWAN GAP ­ ­­ ­­­_­­­ 20 COVERAGE CAR CAR 2 Y CAR REPAIR OR . ........ R AR CAR CAR 3 Y 30 . . ..... .. .. . .... .. COST COVERAGE 50 OMPREN ENSNE 090,WPIUCARI $500 CAR2 $500 CAR3 $500 72 74 COLLISION kb4oiltr- FASSISTANCE DEDUCTIBUCAR1 $500 CAR2 $500 - , , . CAR 3 111500 a 1­1 ­ 38 - . . ....... 824 48 3 ....... CA FRAUD r -EE WoRumimcg CARI $75 CAR2 $75 CARS $75 6 RENTAL CAR BENEFIT $100 PER DAY 30 DAYS 100 6 CIGA FEE mm 100 1001 . ... ..... U -10 07/2015 U-236 884 1 1834 .TOTAL PR'EdW61Cl� . ..... 4,854�00 . . ..... . .. . . . .. ... EFFECTIVE 04/28/2016 This amended Policy declarations page replaces all declarations with the e same or prior effective date. Reason(s) Amended ADD VEHICLE(S) If there is a, lapse, coverage will not be provided during the lapse period. This Policy change has resulted in an additional premium of $956.00 The enclosed Auto Insurance Bill is part of this Policy- It specifies the amount of your premium, your payment options, any applicable fees, and the due date. If you have any questions, please contact your agent or broker at the phone number provided above. MAILED TO: FRANCIS CLIFFORD 4908 OAK LANE DR ENCINO, CA 91316-4001 INSURED COPY 0401 06 140095420 06/05/201 6