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PROOF OF INSURANCE (2015) CLOSED_— � 0 ate, CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDlYYYY) F09/1612015 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 Choices Insurance Agency / Jordan Walt 617 High St. Suite 205 NAME: Jordan Walt PHONE I 503- 653 -8287 FAX No: 503 -653 -7869 .EXfl; ADDRESS: jwalt@choicesins.com INSURERS AFFORDING COVERAGE NAIC # Oregon City, OR 97045 INSURERA: Ironsh re Indemnity_, Inc. _ EACH OCCURRENCE INSURED INSURER B: CLAIMS -MADE FI OCCUR INSURERC; Law Office of Donna R. Evans INSURERO: _.. DAMAGE TO RENTED PREMISES (Ea occurrence) 2615 190th Street, Suite 210 Redondo Beach, CA 90278 INSURERE: INSURER F: COVERAGES CFRTIFICATF NUMBER- 00000000 -0 REVISION NUMBER: 7 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. INSR L_ TYPE OF INSURANCE ADDL INgD SUER POLICYNUMBER MWDO //YYYY MMIDDY� I LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS -MADE FI OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ i MED EXP (Any one person) $ $ PERSONAL & ADV INJURY GEN'LAGGREGATELIMIT APPLIES PER: S GENERAL AGGREGATE _ ( - __ JECT LEI LOC POLICY � PRO PRODUCTS - COMP /OP AGG S S IOTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT !Ea ac cdent) I $ S ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED ~BODILY INJURY (Per accident), AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE - Per accident) i $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S $ EXCESS LIAB CLAIMS -MADE I AGGREGATE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORlPARTNERlEXECUTIVE PER OTH- I STATUTE ER E L. EACH ACCIDENT .__ ._. ----- - ._ ..._.. -- -- $ --.__. ---- --.-_----- OFFICER/MEMBER EXCLUDED? El in NH) N / A E.L. DISEASE - EA EMPLOYE S S i(Mandatory Ifyes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT A Professional Liab. JL10428101 09/25/2014 09/2512015 Per Claim/Agg i DESCRIPTION OF OPERATIONS ! LOCATIONS ! VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) t< City of El Sedundo , 350 Main Street El 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. REPRESENTATIVE ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Printed by JVVW on September 16, 2015 at 07:58AM Sandoval, Lili From: D'kstra Martha Sent: Wednesday, September 23'20l54k55PK4 To: Sandova[U|i C« Carpenter, Greg; King, David; [heng,Misty Subject: ~ Donna This is to confirm that we will not require Donna Evans to furnish a waiver of subrogation for Workers' Compensation or automobile insurance. Please expedite this PSA. Martha