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PROOF OF INSURANCE (2013) CLOSEDM &JKI -1 OP ID: NR AFRO "' CERTIFICATE OF LIABILITY INSURANCE 1 DATE 06 /21D/YYYY)� 06/21 /12 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). PRODUCER 419- 255 -1020 CONTACT NAME ........ .. ..... Hylant Group Inc - Toledo PHONE FAx 811 Madison Ave 419 - 255 -7557 1ac1 M9 ,1 E Toledo, OH 43604 .MArt Jeannie Y. H lant AtlDRb 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, R .,.., ............. ...,.... ..... dS P . POI Y EXP L TR TYPE OF INSURANCE INR W D POLICY NUMBER M /DDIyYY y pWgD DYyyy ..._� LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X C COMMERCIAL GENE L LIABILITY X PHPK882160 07/01/12 07/01/13 PREMI ESiY LL PREMISES {„Ea occurrence) $ 300,000 CLAIMS -MADE � X OCCUR . _ J CLAIMS-MADE MED EXP_(Any one person) -- $ 15,000 ........_ ......... ....... PERSONAL & ADV..I INJURY $ 1,00_0,_00_ 0 A X_ Abuse /Molestation PHPK882160 07/01/12 07/01/13 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 FRO. POLICY X LOC A & M ...... $ - ... 500,00 AUTOMOBILE LIABILITY COMBINED SINGLE. V IIMff 1,000,00 - �Ea acc)de�?!)... $ A ANY AUTO PHPK882160 07/01/12 07/01/13 BODILY INJURY (Per person) $ ALLOWNED'- SCHEDULED AUTOS AUTOS . BODILY INJURY Per accident ( ) $ X ___ HIRED AUTOS X NON -OWNED AUTOS _ - ---- ... PROPERTY DAR�;�CaE Per acciQenk) ..., .... ......... $ _ UMBRELLA LIAB CCUR ]�­ EACH OCCURRENCE _.........— -----.,. -- -....EXCESS $ LIAB AIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION WC STATU- AND EMPLOYERS' LIABILITY Y / N �OTH- ...T.QR.Y- IMJTS- FR,_, „.... ANY PROPRIETOR /PARTNER /EXECUTIVE E L EACH ACCIDENT $ OFFICER /MEMBER EXCLUDED? F N / A (Mandatory in NH) EL. DISEASE - EA EMPLOYEE $ If yes, describe under ........... -. .._ ....... -.,_ - ._._._._._,,........... .............. .... - DESCRIPTION Or OPERATION'S bera,: E.1­ DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The City, its officers, officials, employees, agents and volunteers are included as an Additional Insured ATIMA per form CG2010. City of El Segundo Parks & Rec Attn: Ms. Vina Ramos CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St AUTHORIZED REPRESENTATIVE El Segundo, CA 90245 y ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PHPK882160 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organ ization s : Locations Of Covered Operations The City of El Segundo, All Work Performed Its Officers, Officials, Employees, Agents, and Volunteers Information required to complete this Schedule, if not shown above, will be shown in the Declarations. 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: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf, in the performance of your ongoing operations for the additional insured(s) at the location(s) desig- nated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a princi- pal as a part of the same project. CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑