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PROOF OF INSURANCE (2017) CLOSED C CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 01/19/2017 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 PHONE_ .g . ..... ..,,,... .�FAX r .... ..... .............. For Service Call: dAtC,N9.D,Br1503z97775648. f 111 NzJ.x03 97:1 ak318__�. Gales Creek Insurance Services a division of JD Fulwiler EMAIL 5727 SW Macadam Ave AM V0.%eventsQg'alescmek.com ING COVERAGE NAIC# ..........................................................N.G,,,,RE.....ts„„q,F,FGRD._.,. Portland,OR,97239 y °INSURER A:United States Fire Insurance Campan 21113 INSURED INSURER B: TheEsquires .....................�.......,.................................................... 7909 Quill Drive INSURER C: Downey,CA 90242 1NSUREF D,,:............................................................ .................................................................................................................................................................. INSURER E ....INSURER..F..�......................................................................................................................................w_.____w_w_._..w° 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 INISR ADINUKOBR PO�._.__-.._---T.__-__.--. TYPE OF INSURANCE 00Y EFF POLICY EXP LIMITS L,YR I�,m„$,�y0 POLICY NUMBER PbAMdnDPYYYYI fMMIIDOOYYYYI GENERAL LIABILITY EACH OCCURRENCE $ 1 000 000 O X.. COMMERCIAL GENE L AL IABILITY r I Ony 9a&fi pl $ 3N Q0 Q0 g I^ A I 9 �OCCUR MED EXP Ian one a son $ 5 000,00 TBD-TE-01212017 01/21/2017 01/22/2017 PERSONAL&ADV INJURY $ 1,000,00000 12:01 AM 12:01AM GENERAL AGGREGATE $ 2,000.000.00 POLICY ”E LIMIT APPLIES PER: .PRODUCTS C GEN'L AGGREGATE COMP/OP AGG $SINGLE LIMIT AU'O NOBIUT( ABILITY BODILYRJJURY(Per person) $ .._.....-I ............ ALL OWNED SCHEDULED accident) $ DAMAGE AUTOS AUTOS NON-OWNED �'±Caf T IBTY MAGE ._...._. HIRED AUTOS II......... AUTOS ,. ����...$ .. N $ B'O`B OCCUR EACH OCCURRENCE $ UMBRELLA L EXCESS LIA GGREGATE $ .... � pp,.... CLAlMS M,AD A...„.„.„. ..... DED r II RETENTION$ $ WORKERS COMPENSATION WC STAT U- II OTH - ANDEMPLOYERS'LIABILITY Y/N ._„-�TQF1Y.P.ffl1�A°.---,�_E,R ANY, L XECUTIVE[7 ..„E .... EC.L � M R EXCLUDED? N/A (Mandatory DISEASEA EMPLOYEE...................................................................... If yes,describe under „ T,g tj,,,Y,ty°6::�P'�'k_�RA:Y„ttlpfupuu E L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) THE CERTIFICATE HOLDER IS ADDED AS AN ADDITIONAL INSURED BUT ONLY WITH RESPECT TO LIABILITY ARISING OUT OF OPERATIONS OF THE NAMED INSURED DURING THE POLICY PERIOD, CERTIFICATE HOLDER CANCELLATION V�i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Automobile Driving Museum THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 610 Lairport St, El Segundo,CA 90245 AUTHORIZED REPRESENTATIVE Brigitt Whitescarver ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL I SURED - DESIGNATED PE SON O ORGANIZATION Policy Number: SRPG-1 01-0716/USS334206 Insured: The Esquires This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additio nal............................. mm....mm.................. ...... o Insured Persons) Or Organizations) City of El Segundo, its officials, and employees 350 Main Street El Segundo, CA 90245 .............................................................................. _ ......................................................................................................................................................... Information required to complete this Schedule, if not shown above will be shown in the Declarations. ..... .......... To the extent that any of the additional insureds Section II - WHO IS AN INSURED is amended to named herein are liable for occurrences arising out include as an insured the person(s) or organization(s) of the named insured's negligent acts or omissions, shown in the Schedule, but only with respect to liability the insurance afforded to the additional insureds for "bodily injury", "property damage" or "personal and under this endorsement is primary insurance over advertising injury" caused, in whole or in part, by your any other valid or collectible insurance which the acts or omissions of the acts or omissions of those additional insureds may have with respect to loss acting on your behalf: under any of the listed policies. Other insurance of any additional insured applicable to loss is non- contributory and excess over the coverage provided A. In the performance of your ongoing operations; or by this endorsement, and the amount of the B. In connection with your premises owned by or company's liability under this policy shall not be rented to you. reduced by the existence of such other insurance. CG 20 26 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 ❑ COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED - DESIGNATED PERSON O ORGANIZATION Policy Number: SRPG-1 01-0716/USS334206 Insured: The Esquires This endorsement modifies insurance provided under the following: . COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) � City of El Segundo, its officials, and employees 350 Main Street El Segundo, CA 90245 Information required to complete this Schedule, if not shown above will be shyown in the Declarations. Section II - WHO IS AN INSURED is amended to include as an 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 of the acts or omissions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 ❑ PAGE 3 USAA CASUALTY INSURANCE COMPANY ADDL INFO ON NEXT PAGE MAIL MCH-M-1 AMENDMENT TO (A Stock v.h POLICY NUMBER ie 9800 Fredericksburg Road - SoncAnt Antonio, Texas 78288 S��51�51]651 07 51lhkl 00275 49 62C 7101 5 CALIFORNIA AUTO POLICY POLICY PERIOD: (12:01 A.M. standard time) AMENDED DECLARATIONS EFFECTIVE JAN 03 gD14 TP MAR 24 2016 (ATTACH ) OPERATORS Named Insured and Address 01 ELIZABETH SUITS BRUNDIN 03 ERIC DAVID BRUNDIN 04 JOSHUA E BRUNDIN ELIZABETH SUITS BRUNDIN 7909 QUILL DR DOWNEY CA 90242-3441 VEH EAR' tI TRADE NAME 1 (e) MODEL BODY TYPE IDENTIFICATION NUMBER SYMU USE* ws�s C Ol ..k ° 03 93 HONDA ACCORD 4D DX 4 DOOR 1500 JHMCB7543PCO44741 P 05 98 FORD WINDSTAR MINIVAN 0 2FMDA5144WBA17674 P 06 99 GMC SUBRBN 1500 4 DOOR 7500 3GKEC16R5XG543945 P 97, 15, The Vehhicle(s described herein is principally garaged 'the above address nles��Rn�wisebstat�� Te VEH 03s OWN '"Y CA 90242-3441 e. vvhereV rarralufJ)O NE �t 24M2- 441 VEH 0 N�1rNE � a 2'-3441 +� p. VEH 06 DOWNEY CA 90242-3441 =rna a r d ' ad' �y' cr y those s era d may not ^tsa comb nod rvegard ess � the �utlran � cles For +whllc�h a prerx,I um bs I ste3 unless specifIcall�r authorized alsatarhere in tlwls rata Cy. COVERAGES LIMITS OF LIABILITY VEH ''VEH VEH VEM ("ACV" MEANS ACTUAL CASH VALUE) S o�6 5��61- NTH 6 6- T 197— p N AMOUNT ;PART A - LIABILITY BODILY INJURY EA PER $ 100,00 - ° - - - - ` - --- - - - - - - --- -- - - --- ------ --- --- EA ACC $ 300,00 1 CALIFORNIA EVIDENCE OF FINANCIAL RESPONSIBILITY PROPERTY DAMAGE EA ACC $ 50,OOC 1 Name and Address of Insured NAIC 25968 .PART B - MEDICAL PAYMENTS EA PER $ 5 ,OOC ERIC DAVID BRUNDIN PART C - UNINSURED MOTORISTS BODILY INJURY EA PER $ 100,00 7909 7909 UILL DR QUILL CA 90242-3441 EA ACC $ 300,00 . PART D - PHYSICAL DAMAGE COVERAGE COMPREHENSIVE LOSS ACV LESS D 50 COLLISION LOSS ACV LESS D 521 1 TOWING AND LABOR VEHICLE TOTAL PREMIUM 5' ELIZABETH SUITS BRUNDIN -------------------------------ADJUSTME T I ERIC DAVID BRUNDIN PART D - COMPREHENSIVE LOSS CHANGE1 VEH 03 JOSHUA E BRUNDIN TOTAL PREMIUM - S1 Insurance Company Y LOSS PAYEE Policy Number Effective Date Expiration Date 00275 49 62C 7101 5 09/24/16 103/24/17 VEH 07 NORM REEVES HONDA, CERRITOS CA Vehicle Make/Vehicle Identification Number Year ENDORSEMENTS: ADDED 01-03-16 - NONE GMC 3GKEC16R5XG543945 1999 REMAIN IN EFFECT(REFER TO PREVIOUS POLICY) - This policy provides at least the minimum amounts of liability insurance AOASA(01' y A099(01 required by the CA VEH CODE SECTION 16056 for the specified vehtpl �and named insureds and may •prOide coverage for other persons and other vehicles as provided by the Ifturance policy. NnITNE55 , we �a A h0511 RMF4p2POO g Iy Cl- Presider a - -_--- Virc�rl�rl:)-- -_- . _-__ ____RSM00 00 � � � M 44 r�"�u�C� l 1� N l I li � II VV ve caused this o icy to a sI ne n Secretary a an Antonio. 1"exas, on this data J. NU'A Y ,� 2f916 5000 C 05-12 Sloven Alan Benrw4 Secretary Alan W.KW,President 53383-05-12 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION u 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), IN ADDITION TO THE COST OF COMPENSATION, 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: U 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 Policy Number Expiration Date Name of Agent Phone# (certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with t e rovas ns of.A h� e r aeµm Y e� will automatically become void. Signature of Applicant 7—s- Date Tlte GG'' JJ JJ r Agreement for: ��.��;�� ' �)ew'% Dated, Reviewed b 1