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PROOF OF INSURANCE (2017 - 2017) CLOSEDVANLING -01 Lame ABC SRO` DATE IMMtDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 1112812016 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 have ADDITIONAL INSURED provisions or 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 ). "g PRODUCER c, j�ct Sharon Prlddle WorldClass Insurance Services PHONE C Ext (916 789 -1523 i, N (916) 789 -1506 5708 Lonetree Blvd. ( -_ I' ) % a )�.. Rocklin, CA 95765 ADO .less, gal rrieQurdrdc18s5sNns.com INSURED INSURER 8:1_i opa Van Lingen Body Shop, Inc. INSURER C: ICW - dba Van Lingen Towing 20621 Earl St INSURER 0: Torrance, CA 90503 INSURER E 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 ADDUSUBR POLICY NUMBER I POLICY EFF i POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE . $ 1,000,000 DAMAGE TO RENTED 100,000 CLAIMS -MADE X I OCCUR X ACP3006960695 01/19/2016 01/19/2017 PRI MISS ll aar rfulrwca�1 1 $ _.. - -- -- - 5,000 ,G�IWfif`L AGGREGATE LIMIT APPLIES PER: X POLICY JE& ( LOC X I OTHER: AUTOMOBILE LIABILITY i J ANY AUTO ACP3006960695 01/1912016 0111912017 OWNED SCHEDULED AUTOS ONLY x I AUTOS XIRE pN W� p AUTOS ONLY 6„X„ AUTO WS UMBRELLA LIAB X OCCUR X , EXCESS LIAB CLAIMS -MADE IXL6608245 09/23/2016 01/19/2017 DIED " X RETENTION $ O WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PRRO/ PMREIETgOERR /PARTNER/EXECUTIVE!" I X WSA 5021332 04 07/01/2016 07/01/2017 �e datory in NH) EXCLUDED? N ! A If ves. describe under A EA 1,000,000 2,000,000 2,000,000 Included DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES iACORD 101, Additional Remarks Schedule may be attached If more space Is required Garagekeepers Legal Liability: 20621 Earl St, Torranceµ CA 90503 = $600,000 & 2Y55 Lomita Blvd, Torrance, CA 90505 = $600,000 ($1,000/$2,500 Ded) City of El Segundo, Its Officers, Agents, Employees and Volunteers is listed as ADDITIONAL INSUED with regar to Liability arising from "your Work" performed by the named Insured. "Should any of the above described policies be canceled before the expiration date thereof, or for non - payment a 30 day noticed will be delivered in accordance with the policy provisions." SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CI of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City 9 ACCORDANCE WITH THE POLICY PROVISIONS. City Clerk - Director of Finance 350 Main Street Room 5 El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) ®1988 -2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: ACP3006960695 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): The City of El Segundo, Its Officers, Officials, Employees, Agents & Volunteers Information reauired 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 your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. All terms and conditions apply unless modified by this endorsement. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 37 (Ed. 5 -02) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the schedule. The additional premium for this endorsement shall be 5 % of the California Workers' Compensation premium otherwise due on such remuneration, subject to a minimum premium of $ 50. Schedule Person or Organization THE CITY OF EL SEGUNDO 350 MAIN ST, EL SEGUNDO, CA 90245 Job Description JOB: THE CITY OF EL SEGUNDO TOW CONTRACT EL SEGUNDO, CA JOB DESC: TOWING CARS FOR CITY CONTRACT FOR OR ON BEHALF OF THE CITY This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 07/01/2016 Policy No. WSA 5021332 04 Endorsement No. 001 Insured VAN LINGEN BODY SHOP INC Premium $ INCL . Insurance Company INSURANCE COMPANY OF THE WEST WC 99 06 37 (Ed. 5-02) Countersigned By INSURED COMMERCIAL AUTO AC 99 37 03 10 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM //1__­ Location No. Coverages Limit Of Insurance For Each Location 1 Comprehensive $ 600,000 minus $ 1,000 deductible for each "customer's auto" for all perils subject to $ 2,500 maximum deductible for all such "loss" in anyone event. Collision $ 600,000 minus $ 1,000 deductible for each "customer's auto ". LOCATION WHERE YOU CONDUCT "GARAGE OPERATIONS" Location No. Address 1 20621 EARL ST TORRANCE CA 905033008 Premium 1 $ 795 DIRECT PRIMARY COVERAGE OPTION Indicate below with an "X" if the Direct Primary Coverage Option is selected. ❑ DIRECT PRIMARY INSURANCE If this box is checked, Garagekeepers Coverage is changed to apply without regard to your or any other "in- sured's" legal liability for "loss" to a "customer's auto" and is primary insurance. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. This endorsement provides only those coverag- parking, storing, "transporting" or "towing" it es: in your "garage operations" under: 1. Where a Limit of Insurance is shown for a. Comprehensive Coverage that coverage in the Schedule; and From any cause except: 2. For the location shown in the Schedule. (1) The "customer's auto's" collision B. Coverage with another object; or 1. We will pay all sums the "insured" legally (2) The "customer's auto's" overturn. must pay as damages for "loss" to a "cus- tomer's auto" or "customer's auto" equip- ment left in the "insured's" care while the "insured" is attending, servicing, repairing, AC 99 37 03 10 Includes copyrighted material of Insurance Services Office, Inc, with its permission Page 1 of 3 LDOC 16020 INSURED COPY ACP BA 3016960695 916044673 00 28380 AC 99 37 03 10 b. Collision Coverage the judgment that is within our Limit of Caused by: Insurance. (1) The "customer's auto's" collision These payments will not reduce the Limit of with another object; or Insurance. (2) The "customer's auto's" overturn. C. Exclusions 2. We will have the right and duty to defend 1. This insurance does not apply to any of the any "insured" against a "suit" asking for following: these damages. However, we have no duty a. Contractual Obligations to defend any "insured" against a "suit" Liability resulting from any contract or seeking damages for "loss" to which this in- agreement by which the "insured" ac- surance does not apply. We may investigate cepts responsibility for "loss ". But this and settle any claim or "suit" as we consider exclusion does not apply to liability for appropriate. Our duty to defend or settle "loss" that the "insured" would have in ends for a coverage when the Limit of Insur- the absence of the contract or agree - ance for that coverage has been exhausted ment. by payment of judgments or settlements. b. Theft 3. Who Is An Insured "Loss" due to theft or conversion caused The following are "insureds" for "loss" to in any way by you, your "employees" or "customer's autos" and "customer's auto" by your shareholders. equipment: c. Defective Parts a. You. Defective parts or materials. b. Your partners (if you are a partnership), d. Faulty Work or members (if you are a limited liability "employees ", Faulty "work you performed ". company), directors or shareholders while acting within the 2. We will not pay for "loss" to any of the fol- scope of their duties as such. lowing: 4. Coverage Extensions a. Tape decks or other sound reproducing The following applies as Supplementary Pay- equipment unless permanently installed "customer's ". ments. We will pay for the insured in a auto a. All expenses we incur. b. Tapes, records or other sound repro- ducing devices designed for use with b. The costs of bonds to release attach- sound reproducing equipment. ments in any "suit" against an "insured" c. Sound receiving equipment designed for we defend, but only for bond amounts use as a citizens' band radio, two -way within our Limit of Insurance. mobile radio or telephone or scanning c. All reasonable expenses incurred by the monitor receiver, including its antennas "insured" at our request, including actual and other accessories, unless perma- loss of earnings up to $250 a day be- nently installed in the dash or console cause of time off from work. opening normally used by the "custom - d. All court costs taxed against the "in- er's auto" manufacturer for the installa- sured" in any "suit" against an "insured" tion of a radio. we defend. However, these payments d. Any device designed or used to detect do not include attorneys' fees or attor- speed measurement equipment such as neys' expenses taxed against the "in- radar or laser detectors and any jam - sured". ming apparatus intended to elude or dis- e. All interest on the full amount of any rupt speed measurement equipment. judgment that accrues after entry of the 3. We will not pay for "loss" caused by or re- judgment in any "suit" against an "in- sulting from the following. Such "loss" is ex- sured" we defend; but our duty to pay in- cluded regardless of any other cause or terest ends when we have paid, offered event that contributes concurrently or in any to pay, or deposited in court the part of sequence to the "loss ": Page 2 of 3 Includes copyrighted material of Insurance Services Office, Inc, with its permission AC 99 37 03 10 LDOC 16020 INSURED COPY ACP BA 3016960695 916044673 00 28381 a. War, including undeclared or civil war; b. Warlike action by a military force, in- cluding action in hindering or defending against an actual or expected attack, by any government, sovereign or other au- thority using military personnel or other agents; or c. Insurrection, rebellion, revolution, usurped power, or action taken by go- vernmental authority in hindering or de- fending against any of these. D. Limit Of Insurance And Deductible Regardless of the number of "customer's autos ", "insureds ", premiums paid, claims made or "suits" brought, the most we will pay for each "loss" at each location is the Garagekeepers Coverage Limit of Insurance shown in the Schedule for that location. Prior to the application of this limit, the dam- ages for "loss" that would otherwise be pay- able will be reduced by the applicable de- ductibles stated in the schedule for "loss" caused by: a. Collision; or b. With respect to Garagekeepers Coverage- Comprehensive Coverage: (1.) All perils. 2. The maximum deductible stated in the Schedule for Garagekeepers Coverage Comprehensive Coverage is the most that will be deducted for all "loss" in any one event. 3. Sometimes to settle a claim or "suit ", we may pay all or any part of the deductible. If this happens you must reimburse us for the deductible or that portion of the deductible that we paid. E. Changes in Conditions The Other Insurance Condition is amended as follows: For any covered "customer's auto ", this en- dorsement provides primary insurance. AC 99 37 03 10 F. Additional Definitions As used in this endorsement: 1. "Customer's auto" means a land motor ve- hicle, "trailer" or semitrailer, lawfully within your possession for service, repair, storage, safekeeping, "transporting" or "towing ", with or without the vehicle owner's knowledge or consent. A "customers' auto" also includes any such vehicle left in your care by your "employees ", and members of their house- holds, who pay for services performed. 2. "Loss" means direct and accidental loss or damage and includes any resulting loss of use. 3. "Garage operations" means the ownership, maintenance or use of locations for the pur- pose of a business selling, servicing, repair- ing, parking, storing, "transporting" or "tow- ing" "customer's autos" and that portion of the roads or other accesses that adjoin these locations. "Garage operations" also include all operations necessary or inciden- tal to the performance of garage operations. 4. "Work you performed" includes: a. Work that someone performed on your behalf; and b. The providing of or failure to provide warnings or instructions. 5. "Transporting" or "Towing" includes: in transit, on hook or undertow. All terms and conditions of this policy apply unless modified by this endorsement. AC 99 37 03 10 Includes copyrighted material of Insurance Services Office, Inc, with its permission Page 3 of 3 COMMERCIAL AUTO AC 99 37 0310 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM SCHEDULE Location No. Coverages Limit Of Insurance For Each Location Comprehensive $ 600,000 minus $ 1,000 deductible for each "customer's auto" for all 2 perils subject to $ 2,500 maximum deductible for all such "loss" in anyone event. Collision $ 600,000 minus $ 1,000 deductible for each "customer's auto ". LOCATION WHERE YOU CONDUCT "GARAGE OPERATIONS" Location No. Address 2 2755 LOMITA BLVD TORRANCE CA 905055224 Premium 1 $ 795 DIRECT PRIMARY COVERAGE OPTION Indicate below with an "X" if the Direct Primary Coverage Option is selected. ❑ DIRECT PRIMARY INSURANCE If this box is checked, Garagekeepers Coverage is changed to apply without regard to your or any other "in- sured's" legal liability for "loss" to a "customer's auto" and is primary insurance. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. This endorsement provides only those coverag- parking, storing, "transporting" or "towing" it es: in your "garage operations" under: 1. Where a Limit of Insurance is shown for a. Comprehensive Coverage that coverage in the Schedule; and From any cause except: 2. For the location shown in the Schedule. (1) The "customer's auto's" collision B. Coverage with another object; or 1. We will pay all sums the "insured" legally (2) The "customer's auto's" overturn. must pay as damages for "loss" to a "cus- tomer's auto" or "customer's auto" equip- ment left in the "insured's" care while the "insured" is attending, servicing, repairing, AC 99 37 0310 Includes copyrighted material of Insurance Services Office, Inc, with its permission Page 1 of 3 LDOC 16020 INSURED COPY ACP BA 3018980895 916044873 00 28383 b. Collision Coverage Caused by: (1) The "customer's auto's" collision with another object; or (2) The "customer's auto's" overturn. 2. We will have the right and duty to defend any "insured" against a "suit" asking for these damages. However, we have no duty to defend any "insured" against a "suit" seeking damages for "loss" to which this in- surance does not apply. We may investigate and settle any claim or "suit" as we consider appropriate. Our duty to defend or settle ends for a coverage when the Limit of Insur- ance for that coverage has been exhausted by payment of judgments or settlements. 3. Who Is An Insured The following are "insureds" for "loss" to "customer's autos" and "customer's auto" equipment: a. You. b. Your partners (if you are a partnership), or members (if you are a limited liability company), "employees ", directors or shareholders while acting within the scope of their duties as such. 4. Coverage Extensions The following applies as Supplementary Pay- ments. We will pay for the "insured ": a. All expenses we incur. b. The costs of bonds to release attach- ments in any "suit" against an "insured" we defend, but only for bond amounts within our Limit of Insurance. c. All reasonable expenses incurred by the "insured" at our request, including actual loss of earnings up to $250 a day be- cause of time off from work. d. All court costs taxed against the "in- sured" in any "suit" against an "insured" we defend. However, these payments do not include attorneys' fees or attor- neys' expenses taxed against the "in- sured". e. All interest on the full amount of any judgment that accrues after entry of the judgment in any "suit" against an "in- sured" we defend; but our duty to pay in- terest ends when we have paid, offered to pay, or deposited in court the part of AC 99 37 03 10 the judgment that is within our Limit of Insurance. These payments will not reduce the Limit of Insurance. C. Exclusions 1. This insurance does not apply to any of the following: a. Contractual Obligations Liability resulting from any contract or agreement by which the "insured" ac- cepts responsibility for "loss ". But this exclusion does not apply to liability for "loss" that the "insured" would have in the absence of the contract or agree- ment. b. Theft "Loss" due to theft or conversion caused in any way by you, your "employees" or by your shareholders. c. Defective Parts Defective parts or materials. d. Faulty Work Faulty "work you performed ". 2. We will not pay for "loss" to any of the fol- lowing: a. Tape decks or other sound reproducing equipment unless permanently installed in a "customer's auto ". b. Tapes, records or other sound repro- ducing devices designed for use with sound reproducing equipment. c. Sound receiving equipment designed for use as a citizens' band radio, two -way mobile radio or telephone or scanning monitor receiver, including its antennas and other accessories, unless perma- nently installed in the dash or console opening normally used by the "custom- er's auto" manufacturer for the installa- tion of a radio. d. Any device designed or used to detect speed measurement equipment such as radar or laser detectors and any jam- ming apparatus intended to elude or dis- rupt speed measurement equipment. 3. We will not pay for "loss" caused by or re- sulting from the following. Such "loss" is ex- cluded regardless of any other cause or event that contributes concurrently or in any sequence to the "loss ": Page 2 of 3 Includes copyrighted material of Insurance Services Office, Inc, with its permission AC 99 37 03 10 LDOC 16020 INSURED COPY ACP BA 3016960695 916044673 00 28384 a. War, including undeclared or civil war; b. Warlike action by a military force, in- cluding action in hindering or defending against an actual or expected attack, by any government, sovereign or other au- thority using military personnel or other agents; or c. Insurrection, rebellion, revolution, usurped power, or action taken by go- vernmental authority in hindering or de- fending against any of these. D. Limit Of Insurance And Deductible 1. Regardless of the number of "customer's autos ", "insureds ", premiums paid, claims made or "suits" brought, the most we will pay for each "loss" at each location is the Garagekeepers Coverage Limit of Insurance shown in the Schedule for that location. Prior to the application of this limit, the dam- ages for "loss" that would otherwise be pay- able will be reduced by the applicable de- ductibles stated in the schedule for "loss" caused by: a. Collision; or b. With respect to Garagekeepers Coverage- Comprehensive Coverage: (1.) All perils. 2. The maximum deductible stated in the Schedule for Garagekeepers Coverage Comprehensive Coverage is the most that will be deducted for all "loss" in any one event. 3. Sometimes to settle a claim or "suit ", we may pay all or any part of the deductible. If this happens you must reimburse us for the deductible or that portion of the deductible that we paid. E. Changes in Conditions The Other Insurance Condition is amended as follows: For any covered "customer's auto ", this en- dorsement provides primary insurance. AC 99 37 03 10 F. Additional Definitions As used in this endorsement: 1. "Customer's auto" means a land motor ve- hicle, "trailer" or semitrailer, lawfully within your possession for service, repair, storage, safekeeping, "transporting" or "towing ", with or without the vehicle owner's knowledge or consent. A "customers' auto" also includes any such vehicle left in your care by your "employees ", and members of their house- holds, who pay for services performed. 2. "Loss" means direct and accidental loss or damage and includes any resulting loss of use. 3. "Garage operations" means the ownership, maintenance or use of locations for the pur- pose of a business selling, servicing, repair- ing, parking, storing, "transporting" or "tow- ing" "customer's autos" and that portion of the roads or other accesses that adjoin these locations. "Garage operations" also include all operations necessary or inciden- tal to the performance of garage operations. 4. "Work you performed" includes: a. Work that someone performed on your behalf; and b. The providing of or failure to provide warnings or instructions. 5. "Transporting" or "Towing" includes: in transit, on hook or undertow. All terms and conditions of this policy apply unless modified by this endorsement. AC 99 37 03 10 Includes copyrighted material of Insurance Services Office, Inc, with its permission Page 3 of 3 NATIONWIDE MUTUAL INSURANCE COMPANY 1100 LOCUST ST DEPT 1100 DES MOINES, IA 50391 -2000 COMMERCIAL GENERAL LIABILITY DECLARATIONS Policy Number: ACP GLO 3016960695 Named Insured: VAN LINGEN BODY SHOP INC - DBA VAN LINGEN TOWING Address: 2755 LOMITA BLVD TORRANCE CA 90505 -5224 Agent: WORLDCLASS INSURANCE SERV 84 -05485 -002 Address: ROCKLIN CA 95765 PRODUCER: STEPHEN KENT PRIDDLE 05485 RENEWAL Policy Period: From 01/19/16 to 01/19/17 12:01 A.M. standard time at the address of the named insured as stated herein. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. LIMITS OF INSURANCE GENERAL AGGREGATE LIMIT other than products - completed operations) $ 2,000,000 PRODUCTS- COMPLETED OPEfATIONS AGGREGATE LIMIT $ 2,000,000 PERSONAL AND ADVERTISING INJURY LIMIT $ 1,000,000 EACH OCCURRENCE LIMIT $ 1,000,000 DAMAGE TO PREMISES RENTED TO YOU LIMIT (any one premises) $ 100,000 MEDICAL EXPENSE LIMIT (any one person) $ 5,000 Retroactive Date (CG0002 only) The Named Insured is: CORPORATION Business of the Named Insured is: TOWING Audit Period: ANNUAL ENDORSEMENTS ATTACHED TO THIS POLICY SEE COMMERCIAL GENERAL LIABILITY FORMS AND ENDORSEMENTS SCHEDULE Replacement or Renewal Number ACP GLO 3006960695 TOTAL ADVANCE PREMIUM $ 1,282.00 Countersigned By Authorized Representative GL -D (10 -98) DIRECT BILL LDOC 16021 INSURED COPY ACP GLO 3016960695 916044673 78 0028288 NATIONWIDE (MUTUAL INSURANCE COMPANY MUTUAL COMPANY CONDITIONS ENDORSEMENT POLICYHOLDER MEMBERSHIP IN THE COMPANY (Applicable Only to Policies Issued by Nationwide Mutual Insurance Company in States other than the State of Texas) Because this policy is issued by Nationwide Mutual Insurance Company (the "Company "), the first named insured listed on the declarations page ( "named insured ") is a member of the Company issuing the policy while this or any other policy issued by the Company is in force. While a member, the named insured is entitled to one vote only — regardless of the number of policies issued to the named insured — either in person or by proxy at meetings of members of the Company. The annual meeting of members of the Company will be held each year at the Home Office of the Company in Columbus, Ohio, at 10 a.m. on the first Thursday of April. If the Board of Directors of Nationwide Mutual Insurance Company should elect to change the time or place of that meeting, the Company will mail notice of the change to the member's last known address. The Company will mail this notice at least 10 days in advance of the meeting date. This policy is non - assessable, meaning that the named insured is not subject to any assessment beyond the premiums required for each policy term. POLICYHOLDER DIVIDEND PROVISIONS The named insured is entitled to any Dividends which are declared by the Board of Directors of the Company in accordance with law and which are applicable to coverages provided in this policy. POLICYHOLDER MEMBERSHIP IN THE COMPANY IN TEXAS (Applicable Only to Policies Issued by Nationwide Mutual Insurance Company in the State of Texas) 1. MUTUALS — MEMBERSHIP AND VOTING NOTICE. The named insured is notified that, by virtue of this policy, the named insured is a member of the Nationwide Mutual Insurance Company of Columbus, Ohio, (the "Company ") and is entitled, as is lawfully provided in the charter, constitution, and by -laws to vote either in person or by proxy in any or all meetings of said Company. Each member is entitled to only one vote regardless of the number of policies owned. The annual meetings of the members of the Company are held in the Home Office, at Columbus, Ohio, on the first Thursday of April, in each year, at 10:00 o'clock a.m. 2. MUTUALS — PARTICIPATION CLAUSE WITHOUT CONTINGENT LIABILITY. No Contingent Liability: This policy is non - assessable. The named insured is a member of the Company and shall participate, to the extent and upon the conditions fixed and determined by the Board of Directors in accordance with the provisions of law, in the distribution of dividends so fixed and determined. IN WITNESS WHEREOF: Nationwide Mutual Insurance Company has caused this policy to be signed by its President and Secretary, and countersigned by a duly authorized representative of the Company. Secretary SP 00 0101 08 —In 4AA- President Page 1 of 1 ACP GLO 3016960695 INSURED COPY 916044673 78 0028289 NATIONWIDE MUTUAL INSURANCE COMPANY 1100 LOCUST ST DEPT 1100 DES MOINES, IA 50391 -2000 COMMERCIAL GENERAL LIABILITY SCHEDULE Policy Number: ACP GLO 3016960695 Item No., Location Code Premi�rr�'u Rates Advance Pc °emiur�n and Description of Hazards No. Basis OTHER PR /CO OTHER PR /CO 001A CA -003 10073 GROSS SALES PER THOUSAND AUTOMOBILE REPAIR 95,000 4.643 3.368 $441 $320 OR SERVICE SHOPS CG2268 20621 EARL ST TORRANCE CA905033008 002A CA -003 10073 GROSS SALES PER THOUSAND AUTOMOBILE REPAIR 65,000 4.643 3.368 $302 $219 OR SERVICE SHOPS CG2268 2755 LOMITA BLVD TORRANCE CA905055224 Total Advance Other and PR /CO $743 $539 TOTAL ADVANCE PREMIUM $1,282 NOTE: For classes based on payroll each Executive Officer, Sole Proprietor or Partner may be subject to a fixed amount. GL -DS (12 -93) DIRECT BILL LDOC 16021 INSURED COPY ACP GLO 3016960695 916044673 78 0028290 NATIONWIDE MUTUAL INSURANCE COMPANY 1100 LOCUST ST DEPT 11 DES MOINES, IA 50391 -2000 COMMERCIAL GENERAL LIABILITY FORMS AND ENDORSEMENTS Number: ACP GLO 3016960695 Period: From 01/19/16 To 01/19/17 Named Insured: VAN LINGEN BODY SHOP INC - DBA Form Date Title CG0001 0413 COMMERCIAL GENERAL LIABILITY COVERAGE FORM CG2106 0514 EXCLUSION - ACCESS OR DISCLOSURE OF CONFIDENTIAL OR PERSONAL INFORMATION CG2144 0798 LIMITATION OF COVERAGE TO DESIGNATED PREMISES OR PROJECT CG2147 1207 EMPLOYMENT - RELATED PRACTICES EXCLUSION CG2155 0999 TOTAL POLLUTION EXCLUSION WITH A HOSTILE FIRE EXCEPTION CG2167 1204 FUNGI OR BACTERIA EXCLUSION CG2170 0115 CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM CG2268 0997 OPERATION OF CUSTOMERS AUTOS IN PARTICULAR PREMISES CG3234 0105 CALIFORNIA CHANGES CG7023 1096 EXCL- ASBESTOS, ELECTRO- MAGNETIC RADIATION, LEAD AND RADON CG7033 0393 TWO OR MORE COVERAGE FORMS OR POLICIES ISSUED BY US CG7306 0909 CALIFORNIA DEFINITIONS - AUTO AND MOBILE EQUIPMENT CG7420 1211 EXCLUSION - SUBSIDENCE OF LAND IL0017 1198 COMMON POLICY CONDITIONS IL0021 0908 NUCLEAR ENERGY LIABILITY EXCLUSION IL0270 0912 CALIFORNIA CHANGES - CANCELLATION AND NONRENEWAL 13614 1185 SPECIAL CONTINUATION PROVISION IMPORTANT NOTICES IN0001 1215 CONSUMER COMPLAINTS AND INFORMATION IN5017 0593 IMPORTANT NOTICE FOR RENEWAL POLICIES GLDF (02 -93) DIRECT BILL LDOC 16021 INSURED COPY ACP GLO 3016960695 916044673 78 0028291 CG 21 44 (07 -98) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LIMITATION OF COVERAGE TO DESIGNATED PREMISES OR PROJECT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Premises: ALL LOCATIONS SPECIFICALLY SCHEDULED ON THE POLICY Project: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) This insurance applies only to "bodily injury," "property damage," "personal and advertising injury" and medical ex- penses arising out of: 1. The ownership, maintenance or use of the premises shown in the Schedule and operations necessary or incidental to those premises; or 2. The project shown in the Schedule. Copyright, Insurance Services Office, Inc., 1997 CG 21 44 (07 -98) ACP GLO 3016960695 LDOC 16021 INSURED COPY 78 0028292 COMMERCIAL GENERAL LIABILITY CG 2170 01 15 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. M 111 This endorsement modifies insurance provided under the following; COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY A. If aggregate insured losses attributable to terrorist acts certified under the federal Terrorism Risk Insurance Act exceed $100 billion in a calendar year and we have met our insurer deductible under the Terrorism Risk Insurance Act, we shall not be liable for the payment of any portion of the amount of such losses that exceeds $100 billion, and in such case insured losses up to that amount are subject to pro rata allocation in accordance with procedures established by the Secretary of the Treasury. "Certified act of terrorism" means an act that is certified by the Secretary of the Treasury, in accordance with the provisions of the federal Terrorism Risk Insurance Act, to be an act of terrorism pursuant to such Act. The criteria contained in the Terrorism Risk Insurance Act for a "certified act of terrorism" include the following; 1. The act resulted in insured losses in excess of $5 million in the aggregate, attributable to all types of insurance subject to the Terrorism Risk Insurance Act; and 2. The act is a violent act or an act that is dangerous to human life, property or infrastructure and is committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. B. The terms and limitations of any terrorism exclusion, or the inapplicability or omission of a terrorism exclusion, do not serve to create coverage for injury or damage that is otherwise excluded under this Coverage Part. All terms and conditions apply unless modified by this endorsement. CG 2170 01 15 ® Insurance Services Office, Inc., 2015 Page 1 of 1 ACP GLO 3018980895 LDOC 16021 INSURED COPY 78 0028293