PROOF OF INSURANCE (2017) CLOSED Oct, 19. 2016 110 40AM No, 0166):Kl-P' 1 OP ID.KC
CERTIFICATE OF LIABILITY INSURANCE y � DATE 101
1 o119120/61
016
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 holier 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 end'orsernent(s).
PRODUCER C P IN1ACT ..................................
Parker General Ins_Services PHONE
Joe F. Darker
559-224-82T7
IP
CA Insurance License 0$45437 w�raNE 559-22a-8222
5094 N.Fruit,#101 ¢+ �'I� 'I, WC
Fresno,,CA 93799r�lss'.
Joe F.Parker _ `IN_S.U.RERIpS}AF F.
oRDiNrJ CovrRA
C� _..
NiAIC n
SColon yInsuran ee Company
INSURED Ga ry v.Bufkin Computer INSURER e I Consulting
1374 N.Linden Avenue INSURER
C u
Fresno,CA 93728 INSURER D
INSURER 9:
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/1NY 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.
.N AN.^ W sUG, FOLI�CY NUMBE.t�',�.....,.� �.. @M�D PMmv yyy LIMITS
�.
INSR
LTrt TYPE OF INSURANCE
. _ M�YY"Y'"�
A X COMMERCIAL GENERAL LIABIuTY EACH QCCUR H'.SM"�d4iE $ 1,0010,,000
YI CLAIMS-MADE OCCUR X GL000943401 03/01/2016 03/0112017 UA'� k; ! �^�n,1 g: 100,000
PS �0I ,N &A0V INJURY $ 3,0........
..
l)'EXP(An one r maw6� 5„000
._m ...._.. PERS .,..,,. II0,000!
uENLAOrE......A..rE APPLIES PER: GN
AG AP
POLCY I PR]UULTCO PDPA
OIHER! 7'`O 'OO,dO00000
I
AUTOMOBILE LIARILrrY CGMpIRdC IS$INGI F I„IMI°I' __ ........
(Ea ac"Id'-An $
ANY AUTO BODILY INJURY F'rY rmmo n)
ALLOWNED AUTOS TUS AUTOS DULED BOD)L 'INJl (O&�ccidrnf) $
• AUf°OS nopriiw OF Mr4Jt 6„ $
AUTOS NO OWNFD ��._.....L. .,_. .........,
_...-.-...
UMBRELLA LIA6 OCCUR EA4H f4t;C,URFtENCE $
. EXCESS LU1B fl� I:„LAI'A,'iw'^I'�ADE ._.._.
AOID6�CCATC �
AND EMPLOYERS'LABID ..._-. - pp $
R ION d$ li .�.---. .,, ........ . ...........
,I Ii 4
WORKERS AT Y� _ P' R K”"C.VOtl:MEFf7 d R hi
nN r x+F I7P IETCer IARTNLr�UCCIµl nJ� E.L,EA(,
p $
1I,'riF n d a t Hry in NH),O;KL',0..UDF'rYr N I A r.' .DISEASE EA I»Iatlk"E,
dMEmndatomy Iry N♦'C)i Obi e 3
Utl'W�I ,de5Glba YNnd�r ....., _.
UE's"CRIPTION OF d~rA ve E.":..DISEASE-f'OLICY LIMIT S
LC=SCREPY]pN OF OPERATIONS!LOCATIONS 1 V!_HlCLE3 {ACORD 107,Additional Remark-r.60hogU1B,play be attached if more space IS rgryUlYad)
Certificate Holder is named as an additional insured.
n
I
CERTIFIC'A'TE HOLDER CANCELLATION
CITYE-1
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS.
Venus Wesson ......................
350 Main St, AUTHORYEO REPRESENTATIVE
El Segundo, CA 90245
Iw
Q 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
Oct. 19. 2016 11 :41AM No, 0166 P. 2
Policy Number. GLOOD943401
THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED -
ONERS, LESSEES OR CONTRACTORS ^ SCHEDULED
PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PAPT
SCHEDULE
14Eiiiie of-Additional I d C'nsur'e d. ., .
. ocs�+n(s)or Crganizatirara(s)
(Additional Insured). Location(s)of Covered Operations:
City of EI 'Segunrio Work performed by named insured during the
350 Main Street policy term
El Segundo, CA 90245
It is further agreed that this insurance shall b'e..Prima._ ribI
ry and Non-Contributory but only in the event of
a Named Insureds sole negligence.
A. SECTION 11--WHO IS AN INSURED is amended to include as an additional insured the person(s)or
organization(s)shown in the Schedule for whom you are performing operations when you and such person
or organization have agreed in writing in a contract or agreement that such person or organization be
added as an additional insured on your policy.Such person or organization is an additional insured only
with respectto liabilikyfor"bodily injury","property damage'or`personal and advertising injury"caused,in
whole or in part, 0y:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your behalf;
in the performance of your ongoing operations for the additional insured(s)atthe location(s) designated
above.
A person's or organization's status as an additional insured under this endorsement ends when your
operations for that additional insured are completed.
B. With respect to the insurance afforded to these additional insureds,the following additional exclusions
apply:
This insurance does not apply to_
Additional Insured Contractual Liability
"Bodily injury"or"property damage"for which the additional insured(s)are obligated to pay damages by
reason of the assumption of liability in a contract or agreement.
Finished Operations at Work
"Bodily injury"or"property damage"occurring after.
1. All work, including materials, parts or equipment furnished in connection with such work, on the
project (other than service, maintenance or repairs) to be performed by or on behalf of the
additional Insured(s) at the location of the covered operations has been completed; or
2. That portion of"yourwork'out of which the injury or damage arises has been put to its intended use
by any person or orga,,nization.
Negligence of Additional insured
"Bodily injury" or"properly damage"arising directly or indirectly out of the negllgence of the additional
U156-0310 Includes copyrighted material of ISO Properties, lnc„ Page 1 of 2
with its permission.
Oct. 19. 2016 11 :41 AM No. 0166 P. 3
101 GL 0006434-02
EN DT.#001 EFF;08/3012016
in3ured(5).
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
U156-0310 includes copyrighted material of ISO Properties, Inc., Page 2 of 2
with its permission.
Oct 18 2016 12:37 HP Fax page 2
FARMERS
Evidence of Insurance/Lienholder Interest INSURANCE
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PolTryNumber: 18300-50-40 Underwritten By: Mid-Century Insurance Company
Policy Edition: 2nd 6301 Owensmouth Ave.
Effective: 8/17/2008 12:01 ANi Woodland Hills,CA 91367
Expiration: Continuous until cans;ealled Your Agent: Nicole M Lerno
Expiration Time. 12:01 AM 7636 N Ingram Ave Ste 102
Insured: Gary Bufkin Fresno,CA 9371'-6200
1374 N Linden Ave (559)999-9005
Fresno,CA 93728-2320 FAX:(559)921-5200
nierno @farmersagent.com
Vehicle information
Year Make Model VIN
2003 Isu2u Rodeo 4D 4X4 4S2DM58W234304721
Coverages
Coverage T yp e Lima eductible Covera g e T yp e limit/Qeduct ible
Bodily Injury Liability $250,000 each person Collision $1,000 Deductible
$500,000 each accident Additional Equipment $1,000
Pro er, Damage Liab.i.lity r. , O each accident Urinsured Motorist Property
Medical Coverage Not Covered Damage With Collision Covered
Uninsured Motorist Bodily Injury $250,000 each person Towing and Road Service Covered
$500,000 each accident Other Covered
Comprehensive $1,000 Deductible
Lienholders andAdditional lrterests
Additional Interest Loam Number
City of El Segundo Not Applicable
350 Main St
El Sgndo,CA90245-3813
This evidence is subject to all of the terrrs,conditions and limitations set forth in the polity and endorsements attached to It.It is
furnished as a matter of information only and does not change,modify or extend the policy in any way.Itsupersedes a II previously issued
certificates.
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farmers.corn
25-8976 9.13
Page 1 of 2
Oct 18 2016 12:37 HP Fax page 3
Evidence of Insurance/Lienholder Interest(continued)
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Loss payable provisions
(Applicable only if lienholder is named,and no other Automobile loss payable endorsement is attached to the policy)
It is agreed that any payment For loss or damage tothe vehicle The lienholder shall do whatever is necessary to secure such
described in this policy shall be made on the following basis: rights.No subrogation shall impair the right of the lienholder to
1. At ouroption,loss or damage shall be paid as interest may recover the full amourtof its claim.
appear to the policyholder and the lienholder shown inthe We reserve the right to cancel this policy at anytime as provided
Declarations,or by repair of the damaged vehicle. by its terms_In case of cancellation or lapse we will notify the
2. Anyactor neglect of the policyholder ora person actingon lienholder at the address shown in the Declarations.We will give
his behalf shall not void the coverage afforded to the the lienholder advance notice of not less than 10 days from the
lienholder. effective date of such cancellation or lapse as respects his
3. Change in title or ownership of the vehicle,or error in its interest.Mailing notice to the loss payee is sufficientto effect
description shall not void coverage afforded to the cancellation.
lienholder. The following applies as respects any loss adjusted with the
The policy does not cover conversion,em bezzlement or mortgagee interest only:
secretion of the vehicle by the policyholder or anyone acting in 1. Any deductible applicable to Comprehensive Coverage shall
his behalf while in possession under contract with the not exceed$250.
lienholder. 2. Any deductible applicable to Collision Coverage shall not
A payment may be made tothe lienholder which we would not exceed$250.
have been obligated to make except for these terms.In such
event,weare entitled to all the rights of the lienholder to the
extent of such payment.
10/16/2016
Authorized Representative
e Date
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farmers.com
25.8976 9-13
Page 2 of 2
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),
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:
(_)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.
(_J 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#
X l certify that, in the performance of'the work set forth in the agreement with the City of El Segundo, I will not
oy 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 t9 thew ricers' compensation provisions of Labor Code § 3700 1 must
immediately comply with those provision r the ee ent will automatically become void.
Signature of Applica Date a-
Agreement for:
Dated: b"q ,
Reviewed by-,"'?
1