Loading...
PROOF OF INSURANCE (2017 - 2017) CLOSED '= CERTIFICATE OF LIABILITY INSURANCE UA TE(MM/°°/YYYY) �-" I 03/08/2017 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 pollcy(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). PRODUCER G NAAME Gr' Hector M.Diaz-Colon 2079 ISSAtlant c Blvd.,Solutions Ste I E-MAIL PHONE 888.45 .....�.- n... .c.....m..... 1..�aX - -M F'lIw conta c .. .. r .........o i .323".576.4552 IA AIL c dci-Ins .. ... ears 57 4426 .^. Monterey a , A..9....1...7..54 ............... ...... .......................,.. ,,,, . .....I..NSUlRER(S)AFFORDING...c...o.,...vE ucE ..................... ..,...... NAI G# I NSURER A:MaXu. m Indemnity C .,,.,.,.... 26743 INSURED on y INSURER B i Imann Forensic Investigations, LLC. INSURER C: PO Box 4373 INSURER D R E,. . Covina CA 91723 ENSURE Tm_�_ .......... - .........................� .... ...........,. RF: 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 SAID CLAIMS. @ COMMERCIAL GENERA INSURANCE IABILITY EACH OCCURRENCE S 1,990,999 .... �AA1NOL D BDG..39. ,.POLICYEFF Fmont yy oLIGVNUMBER /rxvrt I } T'o"' lt '0 LIMITS .X..,k...,,.. CLAIMS-MADE , L. . L I.......,.,._ X. f OCCUR 08422-03 12/171201612/17/20178'rw,Is,FSaceurrep±,;ca).,.......,5 100,000 III ........... .._.�_._.�....�............m.....,,..- MED EXP(Any one person) S 5,000 m PERSONAL&ADV INJU....,...._, ............... '_X_N'I'.AGGREGATE PLIMIIT APPLIES PER: GENERAL AGGREGATE Y S _ 2,0,0 ,009 �....._., JECT LOC PRODUCTS..-..........MP _ ... PoO.__._ POLICY ti0 OTHER: Errors&Omissions G S 1,000, 000 AUTOMOBILE I OWNEDTOABILITY SCHEDULED BODILY INJURY P J'S ELI�1 B r person) S i ( e... �...—I AUTOS PROPERTY DAMA�.�'E ) S . AUTOS ONLY r accident HIRED NON-OWNED AUTOS ONLY ,._,.. AUTOS ONLY ICI L�._.._.. R).....................W.— S _I Pow ac,cdrtlrrm,,,, ��__........................................ ---- ,.... ..u...ESLLALIAB OCCUR �E�H!?!��CYRRENCE REGATES LIAR GG XCES CLAIMS-MADE .,,_..._._.................. ............ EXCESS QED RETENTIONS S OFF ER r1 B W NH EXCLUDED? !NIA Y II N/A �.......�..5 H ACCIDENT ...... H.....-�,.5 'W R'KCAIS COMPENSATION E L.E O ICI If yu.,describe auoOr E,L.DISEASE-EA..EMPLOYEEI,.$-_,..................................... D.�SCRV TION OF OPERATIONS'bellow E.L.DISEASE E POLICY LIMIT r S I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) REGARDING THE ABOVE REFERENCED GENERAL LIABILITY INSURANCE POLICY, THE CERTIFICATE HOLDER IS INCLUDED AS AN ADDITIONAL INSURED, BUT ONLY WITH RESPECT TO THE NEGLIGENT ACTS, ERRORS OR OMISSIONS OF THE NAMED INSURED. CERTIFICATE'.HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 348 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN I Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: BDG-3008422-03 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location(s)Of Covered Operations Or Organization(s) City of El Segundo Various Locations 348 Main Street El Segundo, CA 90245 Information required to complete this Schedule, if not shown above, will be shown in the Declarations A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for"bodily injury", "property This insurance does not apply to "bodily injury" or damage" or "personal and advertising injury" "property damage"occurring after: caused, in whole or in part, by: 1. Your acts or omissions; or 1. All work, including materials, parts or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work" out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of the same project. 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. CG 20 10 04 13 ©Insurance Services Office, Inc., 2012 Page 1 of 2 C. With respect to the insurance afforded to these 2. Available under the applicable Limits of additional insureds, the following is added to Insurance shown in the Declarations; Section III—Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the most we applicable Limits of Insurance shown in the will pay on behalf of the additional insured is the Declarations. amount of insurance: 1. Required by the contract or agreement; or CG 20 10 04 13 ©Insurance Services Office, Inc., 2012 Page 2 of 2 CN TOO j; ' LU t 0 tn' cq cn i z CL 0 V ��, E V) i J co C2 Z z �tb in�is Ni LU 0 > ct cc wg W, . ,lo r A�� �� UL UZ J wcnui n I � Other Household Driver(s) In addition to the Principal Driver(s)and Assigned Driver(s),your premium may be influenced by the drivers shown below and other individuals permitted to drive your vehicle, This list does not extend or expand coverage beyond that contained in this automobile policy. The drivers listed below are the drivers reported to us that most frequently drive other vehicles in your household. STEVE TILLMANN Principal Driver&Assigned Drivers Your premium may be influenced by the information shown For each automobile,the Principal Driver is the individual for these drivers. who most frequently drives it. Each driver is designated as an Assigned Driver on the household automobile that he or she most frequently drives. COVERAGE AN D LIMITS See your policy for an explanation of these coverages. A Liability ...................................... Bodily Injury 100,0001300,000 -................. W rrr ................ Property Damage 100,000 $231,70 C Medical Payments 5,000 $16.18 .......................................................... ....................................... D 1000 Ded Comprehensive $14.69 G 1000 Deductible Collision $112.17 ...................................................................... ............................................... H Emergency Road Service $3.10 .__................. .... ....... .. ......... ........................................ U Uninsured Motor Vehicle Bodily Injury 100,0001300,000 $35.29 U1 Uninsured Motor Vehicle Property Damage $4,00 A nount Due X41'713 The claim experience on your make and model of vehicle If any coverage you carry is changed to give broader has resulted in a reduction to your vehicle rating group for protection with no additional premium charge,we will give comprehensive coverage. you the broader protection without issuing a new policy, The claim experience on your make and model of vehicle starting on the date we adopt the broader protection. has resulted in a reduction to your vehicle rating group for collision coverage. DISCOUNTS These adjustments have already been applied to your premium. __........ w............................................................ —______...............__................. .......... Multiple Line Multicar r Vehicle Safety _......_._ _.. Driving Safety Record (continued on next page) Policy Number:342 5877-C29-75C Page number 3 of 5 Prepared August 24,2016 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 (_) 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# ( I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, 1 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 kh `rprov ioa s or the agreement will automatical-l.y.. .becom_e..,..void Signature of Applicant .. Date _. ) , Agreement for Dated; 211 V1,� ` ..................... __.�:w ............. .YY............................ Reviewed by: �_~�