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PROOF OF INSURANCE (2014) CLOSEDDATE (MM /DDNYYY) A� CERTIFICATE OF LIABILITY INSURANCE 8/22/2013 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 CONTACT Kathy Macias- Ramirez Millennium Corporate Solutions PHONE . (626) 275 -3000 FAX IC No. (626) 275-0130 -IAIC NQ License # OC13480 E-MAIL ADDR Ym m kath @mcsins.co 550 N Brand Blvd # 1100 ....... R(S AFFORDINGCOVERAGE NAIC# INSURE•„ �....�.._. _.. Glendale CA 91203 ... _W .................._.. _w� � ..... -„ INSURER A Mt_ Hawley Insurance Co 37974 . INSURED INSURER B:GoldenmWEagle Ins. Corp 10836 Trueline 1651 Market Street, Corona COVERAGES Ste. B CA 92880 CERTIFICATE NUMBER INSURER C :RSUI....IndeIRI11t CO1&k any mm 2.3m1m4 INSURERD:State mCompensation Ins Fund 35076 INSURER E: 2013 - 2014 RFVISIAN Nl1MRFR- 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, INS0 , tlti 0 . . ...... ......... w POLICY EFF POLICY EXP ,.. .- - -.... ______..... LTR TYPE OF INSURANCE POLICY NUMBER MIDD/YYYY MAMDOIXYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY 1twII�)� PitLMISEa oco�trren�i $ 50,000 A I—� CLAIMS -MADE 1 ° I OCCUR X MGLO179901 /25/2013 7/25/2014 MED EXP (Any one person) m $_ 5,000 PERSONAL & ADV INJURY ........ ............................... $ 11000,000 . ........ GENERAL AGGRE_GATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -W COMP /OP AGG $ 2000000 PRA' X POLICY L.OtW $ AUTOMOBILE LIABILITY I COMWNED SINGLE LIMIT .a acc'dent} $ 11000,000 B X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BA8857081 /25/2013 /25/2014 BODILY INJURY (Per accident) $ AUTOS AUTOS X X ED HIRED AUTOS AUTOS u CAfA P_,q,1g0 $ X COMP - $1,000 COLL - $1,000 a men M edical u $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE v $ 1,000,000 C EXCESS LIAB CLAIMS -MADE [7/25/2014 AGGREGATE $ 11000,000 DED X RETENTION$ 10,00 NRA233509 7/25/2013 $ D WORKERS COMPENSATION Y WC STATU- 10TH- X AND EMPLOYERS' LIABILITY YIN °1Qi�Y11b T3" "' " " " " " " " "' " " "ER ANY PROPRIETOR /PARTNER/EXECUTIVE E L. EACH ACCIDENT $ 1,000,000 OFFICER /MEMBER EXCLUDED? (Mandatory in NH) N / A 9066350 -13 /25/2013 /25/2014 °• °-- ° ° °•_ °-----_ ° ° °° __ E L, DISEASE - EA EMPLOYE[, $ 1 000 000 If yes, describe under mDESCRIPTION OF OPERATIONS below mmmmmm -mmm mmmm ww E1, DISEASE- POLICY LIMIT $ - 1 000 000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) City of E1 Segundo, its officers, officials, employee, agents, and volunteers are included as an additional insured on the Gen Liability, primary wording, as respects to the insureds operations and only if required by written contract per the attached endorsement. Waiver of Subrogation applies to the Workers Comp. 30 days NOC except non - payment /10 days given. w, K 11 Ilr it :A l r MULUtK Z I I;ANC;tLLA I I1UN City of E1 Segundo Recreation and Parks 350 Main Street E1 Segundo, CA 90245 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Margaret Gilmore /NB- ACORD 25 (2010/05) ©1988 -2010 ACORD CORPORATION. All rights reserved. INSnw; tgni ns5 M Tha Aftf1Rr1 noma and Inn^ 9ra ranieforarl morlrc ^f AC(1Rr1 Pok .yNUmber MGL0179901 ML Hawley InsuramXca L THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADD17IONAL INSUIRED - OWNERS, LIESSIEES OR CONTRACTORS (FORM C) 1477,M, =77j,'# "3"" and adw lmwmnoo which may be avelable to Buch addMonal Wwxodo YAN be roo Socillon IV., CondMon 4., of thla policy Is amended accordIngly. SCHEDULE W ALL OTNER TERMS AND CONDMONG OF THO POUCY REMAIN UNCHANGED. CGL 210 (04198) Pap I of I InAMW T" CIYV VIlJC1Y1C1Y I P%UnCC1Y1C1Y 1 WAIVER OF SUBROGATION REP 02 9066350 -13 NEW SP 1- 24 -96 -63 PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE AUGUST 20, 2013 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING JULY 25, 2014 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME TRUELINE 1651 MARKET ST STE B CORONA, CA 92880 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF EL SEGUNDO WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, TRUELINE IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03 %. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUGUST 22, 2013 AUTHORIZED REPRESENT A IVE PRESIDENT AND CEO 2570