Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
PROOF OF INSURANCE (2017) CLOSED
A� DATE (MM / Y) CERTIFICATE OF LIABILITY INSURANCE 11/15/2016 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 pollcy(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 CONTACTTANIA RICHARDSON NArr9E. '' 17R715HCREDNSOHAW BLVD PHONE Tanla �cha d o INSURANCE AGENCY, INC ADr�Rr Es O310-323-8171 0 . com (AIC "Not•310- 323 -8171 .... IAI� N� Ext! E MAIL n t W5 @statefar TORRANCE CA 90504 ., INSURER(S) NAIC# m INSURER Farm General Insurance Company � 25151 INSURED VISION ADELANTE INSURER B: ....- .. ----- ..... DBA PARTY POSIES INSURER C, ._,_. ...m,....- 1311 SARTORI AVENUE INSURER D: INSl1RER E TORRANCE, CA 90505 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, IL4 TYPE OF INSURANCE.... � POLICY NUMBER INSD E MOLICIYYYY POLICY EXP- ...�,,, MMIDDIYYYY LIMITS A X [COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ,., . /aACF"f'rJGtNYt•.b` ---.... ..,,,,,,,,,.. CLAIMS -MADE OCCUR P'uaEtuFUI E (E al Oct unrr_a,I rce $ X BUSINESS -• •- .......... 92- 137- P154 -9 G 07101/2016 07/01/2017 MED EXP (Any one person) $ 5 000 PERSONAL & ADV INJURY $ GEN'REGAT LIMIT APPLIES : _ AC POLICY L PG COMP OP AGG $ 2,000,000 R ODUCTS OTHER: $ AUTOMOBILE LIABILITY Z60INF5SINM,r.L9 I $ 1,000,000 (Ea (J04 1il. ................ . ...m ANY AUTO 92- 67- P154 -9G 07/01/2016 07/01/2017 BODILY INJURY (Per person) $ ALL OWNED SCHEDULED ,,. AUTOS .AUTOS BODILY INJURY Per accident $ ( X NON -OWNED ..PRC.7PI. R"I'Y DAMAGE..... � � " ", ........ ....,,.,,, HIRED AUTOS AUTOS or ddiult ..(Per -. ,,.� $ ,,, ........ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE .,.,. ---------. ..,.,. --- ... 111-11111111 ,, „�� .... ...., AGGREGATE ` $ DED ( RETENTION $ WORKERS COMPENSATION p I AND EMPLOYERS' LIABILITY YIN BILIITY V._� STATUTE l .......,.I. ERN ._..,_...,. ANY PRR/PARTNER /EXECUTIVE E L EACH ACCIDENTI $„ OFFICERIMEMBER EXCLUDED? N/A � ...___ (Mandatory n NH rY ) E L DISEASE EA EMPLOYEE, $ If yes, describe under DESCRIPTION OF OPERATIONS below f E L. DISEASE PO ° I LICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTOMATIC RENEWAL - If the Policy Period is shown as 12 months, this policy will be renewed automatically subject to the premiums, rules and forms in effect for each succeeding policy period. If this policy is terminated, we will give you the Mortgagee written notice in compliance with the policy provisions or as required by law: 10 days before the effective date of cancellation if we cancel for nonpayment of premium; 30 days before the effective date of cancellation if we cancel for any other reason. 350 MAIN ST EL SEGUNDO CA 90245 -3895 CERTIFICATE HOLDER CANCELLATION THE CITY OF EL SEGUNDO ITS OFFICERS, OFFICIALS, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EMPLOYEES, AGENTS, & VOLUNTEERS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATTN CITY CLERK ACCORDANCE WITH THE POLICY PROVISIONS. 350 MAIN ST EL SEGUNDO CA 90245 -3895 AUTHORIZED REPRESENTATIVE © 1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 1001486 132849.9 02 -04 -2014 CH Policy No. 92 B7P154 9 0919 -FA75 N CMP- 4786.1 Page 1 of 2 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 B7P154 9 Named Insured: VISION ADELANTE DBA PARTY POSIES 1311 SARTORI AVE TORRANCE CA 90501 -2720 Name And Address Of Additional Insured Person Or Organization: THE CITY OF EL SEGUNDO ITS OFFICERS, OFFICIALS, EMPLOYEES AGENTS & VOLUNTEERS ATTN CITY CLERK 350 MAIN ST EL SEGUNDO CA 90245 3895 SECTION II — WHO IS AN INSURED of SECTION II — LIABILITY is amended to in- clude, as an additional insured, any person or organization shown in the Schedule, but only with respect to liability for "bodily injury", "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; in the performance of your ongoing opera- tions for that additional insured; or b. Products – Completed Operations "Your work" performed for that additional insured and included in the "products - 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 a contract or agree- ment, the insurance provided to the additional insured will not be broader than that which you are required by the contract or agreement to provide for such addition- al insured; and c. If the contract or agreement between you and the additional insured is governed by California Civil Code Section 2782 or 2782.05, the insurance provided to the additional insured is the lesser of that which: (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. ©, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc,, with its permission. CONTINUED 2. Any insurance provided to the additional in- sured shall only apply with respect to a claim made or a "suit' brought for damages for which you are provided coverage. 3. With respect to the insurance afforded to the additional insured, the following is added to SECTION II — LIMITS OF INSURANCE: If coverage provided to the additional insured is required by contract or agreement, the most we will pay on behalf of the additional insured will be the lesser of the amount of insurance: a. Required by the contract or agreement; or b. Available under the applicable Limits Of Insurance shown in the Declarations. This endorsement shall not increase the ap- plicable Limits Of Insurance shown in the Declarations. 4. With respect to the insurance afforded to the additional insured, the following is added to Paragraph 3. Duties In The Event Of Occur- rence, Offense, Claim Or Suit of SECTION II — GENERAL CONDITIONS: The additional insured must: a. See to it that we are notified as soon as practicable of an 'occurrence" or an of- fense which may result in a claim. To the extent possible, notice should include: (1) How, when and where the "occur- rence" or offense took place; (2) The names and addresses of any in- jured ,persons and witnesses; and C M P- 4786.1 Page 2 of 2 (3) The nature and location of any injury or damage arising out of the "occur- rence" or offense; b. Tender the defense and indemnity of any claim or "suit' to us and to all other insur- ers who may have insurance potentially available to the additional insured; and c. Agree to make available any other insur- ance the additional insured has for de- fense or damages for which we would provide coverage under SECTION II — LIABILITY. 5. With respect to the insurance afforded the ad- ditional insured, the following replaces SEC- TION II — LIABILITY of Paragraph 7. Other Insurance of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: a. This insurance is primary to and will not seek contribution from any other insurance available to the additional insured, provided that the additional insured is a named in- sured under such other insurance. b. Regardless of any agreement between you and the additional insured, this insur- ance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the additional in- sured has been added as an additional in- sured on other policies. There will be no refund of premium in the event this endorsement is cancelled. All other policy provisions apply. CM P- 4786,1 1007033 148011 08 -21 -2014 ©, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc,, with its permission. CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), tN ADDtTION TO THE COST OF CQUPEKSATtOH, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: (_) I have and will maintain a certificate of consent of self - insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement with the City of El Segundo. Policy No. (_) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Name of Agent Policy Number Expiration Date Phone # } I certify that, in the performance # the work set forth in the agreement with the City of El Segundo, I will not employ any person in any manner s to become subject to the workers' compensation laws of California, and agree that, if I should become ct to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply "Wh Yhose "I cons or the agreement Will automatically become void. Signature of Applicant g pp Date Agreement for: Dated: Reviewed by: