PROOF OF INSURANCE (2017) CLOSEDQt DATE (MM /DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
12/10/2015
.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
_ NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 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.
_. .. ..... _ww. ................. .. .
JIPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the
.erms 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 ondor°sement(s).
CONTACT
PRODUCER NAME
WILLIS OF ILLINOIS, INC. PHONE 8 780-5381 �rA
!A/C. No. ..6atth � 8 _ 8 � _.0- ..,, _ I���_N�I• (8 /7) 737-8498
233 S WACKER DR,SUITE 2000 E-MAIL
ADDRESS: Ce rtlfl Cate a- hanover.com
CHICAGO, IL 60606
INSURERS) AFFORDING COVERAGE NAIC #
INSURER A, : Citizens Ins Co of America 31534
_ . Allme. __ „. _.__
INSURED INSURER 8: rica Financial Benefit 41840
BUCKNAM & ASSOCIATES INC
INSURER C Hanover Insurance Co 22292
25004 LA PLATA DRIVE _
INSURER D:
LAGUNA NIGUEL CA 92677
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,
..... ............ .......... .TYPE OF INSURANCE............_ .... VADDC SUBfE . POLICY--- --- .,, ..,,.. .
R POLICY EFF POLICY EXP
INSR6 NUMBER MM /DD/YYYY MMIDDIYYYY„1, LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL ), p 1 O
D EXP (An one person) $ 1 OOO OOO
CO CLAIMS -MADE LIABILITY MRF�MISFSOEaOCCiarren .,.
ce
A X OBC A405022 02 01/02/2016 01/02/2017 E.. n) $ 000
m....._. .,,... _......._.__.._ ........... ..
PERSONAL &ADV INJURY $1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN1 AGGREGATE LIMIT APPLIES __
PER: PRODUCTS $ 2,000,000
.. POLICY.m Q LOC
AUTOMOBILE LIABILITY �
ANY AUTO
BODILY INJURY (Per person) §�OOO,OOO
ALL OWNED SCHEDULED OBC A405022 02 01/02/2016 ' 01/02/2017 � "I U a �`
AUTOS DAMAGE AUTOS PROPERTDAMAGE dent) $
X HIRED AUTOS X ANOTN,OVVNED jeer acddenti er acre„ $
OCCUR j�''''''— q ^� EACH OCCURRENCE $4,000,000
X UMBRELLA LIAB X.., p 1
A EXCESS LIAB CLAIMS- MADE.P 1 OBC A405022 02 01/02/2016 01/02/2017 AGGREGATE $ 4,000,000
AND EMPLO
YERS LIABILITY .._.... �Ri ImC rU OI"F8
ANY ROPRIETOR/PARTNER/EXECUTIVE E T ACCIDENT WORKERS COMPENSATION X
DED
B OFFICE/MEMBEREXCLUDED? 17 N/A F X W2C A401794 02 01/02/2016 01/02/2017 Si, CIDENT $ 1,000,000
L EACH A
(Mandatory in NH) E.L DISEASE EA EMPLOYEE $ 1,'000,0`0'0
If yes, describe under _ EL DISEASE POLICY LIMIT $ 1,
CRlPDQMQEFQHBA11QN5hWaw ................. ___. 000,000
C Profess onal hers
Liability f F LHC A505932 01 01102/2016 01/02/2017 $1,000,000 Per Cla
Claims -Made Coverage $1,000,000 Aggreg,,
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` P
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES Attach ACORD 101, Additional Remarks Schedule, if mores .,�.,... ,,,,..... .._._..,,,,�,,...,�.
....... _ �,.,,.._.� ..........�-- . —.___ space is required)
RE: All Operations of the Named Insured
Waiver of subrogation as provided by: WC040306 (California Form)
CERTIFICATE HOLDER CANCELLATION
LLAT
n...... ION
City of El Segundo
Attn: Maryam Jonas
350 Main St.
El Segundo, CA 90245
ACORD 25 (2010/05)
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
O 1988 -2010 ACORD CORPORATION. PORATION. All rights reserved.
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