PROOF OF INSURANCE (2017) CLOSED I
CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
III
09/01/2016
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 pollc,y(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 cONYACI ROBERT B RICE,JR.
NAME:
0181288 MC,No Ext) (818) 818 436-5988
PHONE 5
( 547 197.... �lA/G Nn) ( )
SARGEANT INSURANCE AGENCY,LLC ADDRFSS: ROBERT @SARGEANTINSURANCE.COM
INSURER A: INSURER(S)
MUTUAL INSURANICEGE % N..„
7740 PAINTER AVENUE,SUITE 210 AIC#
VVHITTIER CA 90602 LIBERTY ....... ........... ....,,.....
INSURED INSURER6: AMTRUST/TECHNOLOGY INSURANCE CO 42376
BARTEL ASSOCIATES,LLC INSURER C. INDIAN HARBOR INSURANCE COMPANY 36940
411 BOREL AVE INSURER D:
SUITE 101 INSURER E;
SAN MATEO CA 94402-3525 INSURER F:
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,
IN R SUBP POLYCV EFt. 'Pa1tY°EXF>
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
COMMERCIAL GENERAL/\I , E 2'OO)'0D0 CLA MS-MADEOCCUR PREM SES(Ea occurrence) $MED EXP(Any one person) $ 10,000
A X BKS(17)57297374 09/01/2016 09/01/2017 PERSONAL&ADVINJURY $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4.000,000
PRO. ❑ COMP/OP AGG $
POLICY IECr Loc PROOUCrs $ 4,000 000
AUTOMOBILE LIABILITY COMBINEDI�SWGIX IMIT $ 1,000,000
.' .......................—...w.w...W . ..w..._._......................................,..,....,
_ ANY AUTO BODILY INJURY(Per person) $
'0' AUTO ED AUTOSULED X BAS(17)57297374 09/01/2016 09/01/2017 BODILYINJURY(Peraccident) .....................................................................
_.. T. NON-OWNED ..igF"t'i i�T°I'1Y`bAR�EA n.:..................................$..................................................................
HIRED AUTOS AUTOS (Par„acrGlPnP)..........................
$
UMBRELLA LIAR OCCUR EACH OCURRENCE . $
...
EXCESS LAB CLAIMS-MADE AG C ., ..
DED RETENTION$ '�/f ry $
WORKERS COMPENSATION XI STATUTE II ERH
AND EMPLOYERS'LIABILITY 1'0001000
B OFFICER/MEM ER EXCLUDED?PROPRIETOR/PARTNER/EXECUTIVE Y� NIA X TWC3571825 09/01/2016 09/01/2017 E.L EACH ACCIDENT $
(Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under 1,000,000
DESCRIP'T'ION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S
MISC.PROFESSIONAL LIABILITY $5,000,00b PER CLAIM
C MPP001715212 09/01/2016 09/01/2017 $5,000,000 ANNUAL AGGREGATE
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
CERTIFICATE HOLDER IS HEREBY NAMED AS AN ADDITIONAL INSURED BY CONTRACT ON POLICY#BKS(17)57297374 AND#BAS(17)57297374
AS RESPECTS TO OPERATIONS OF THE NAMED INSURED ONLY.SEE ATTACHED FORMS CG8672.COVERAGE UNDER POLICY#BKS(17)
57297374 AND#BAS(17)57297374 IS PRIMARY AND NON-CONTRIBUTORY ABOVE ANY OTHER INSURANCE THE CERTIFICATE HOLDER(S)MAY
CARRY.30 DAY NOTICE OF CANCELLATION.
CERTIFICATE HOLDER CANCELLATION
City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS.
EI Segundo, CA 90245
AUTHORIZED REPRESENTATIVE
ROBERT B.RICE,JR iiztib&r - P, Ric.-
I
1905-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
BARTEL-ASSOCIATES, LLC
CG 86 72 10 02
POLICY NUMBER: BKS(17) 57297374
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED—OWNERS, LESSEES OR
CONTRACTORS—COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
City of El Segundo
Location and Description of Completed Operations:
All operations of the Named Insured
Additional Premium:
Included
(If no entry appears above,information required to complete this endorsement will be shown in the
Declarations as applicable to this endorsement.)
SECTION II—WHO IS AN INSURED is amended to include as an insured the person or organization
shown in the Schedule,but only to the extent you are held liable due to"your work"at the location
designated and described in the schedule of this endorsement for that insured and included in the
"product-completed operations hazard".