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PROOF OF INSURANCE (2018) CLOSED DATE / Y)AC CERTIFICATE OF LIABILITY INSURA CE 03/02/2017
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 NAMEACT' Gabriel Oh _
Western Pacific Insurance Group i °N! . I
_ivc. 7.Ez :425.361.7454..... . ._ C,Not.425.9993053 ........
16300 Mill Creek Blvd.Suite 208 EMAIL
Mill Creek,WA 98012 -°'-lap ��s.°--gam stetDpaclg.dDl�+
INSURER($)AFFORDING COVERAGE NAIC N
..............................._.,.,...-....,.,.,... INSURER A: Sentinel Insurance ViOn"tl7afY..N.....................................................................
Toyer Strategic Consulting,LLC
INSURED
3705 Colby Ave Suite 3 INSURER C
Everett,WA 98201
INSURER E
INSURER F:
COVERAGES CERTIFICATE NUM'BE'R: REVISION NUMBER..
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
� TYPE OF INSURANCE ADS&SU�,rl'„........�.- POLICY NUMBER 4'156U0dY_0Y0"A�..i......--._. .........................�-�,...,-.
INSR I
PO CY E.XP� �.��..m....
I IMMdODfYY'YY) LJMITS
GENERAL LIABILITY AEACH OCC7`REY31E'f7�`�1$ 1 .00 mop .wwwwww...WWW
�° r
1 I 5 000
x
COMMERCIAL CLAIMS-MADE OCCUR LIABILITY PREMISES
�OCCUR MED EXP )(AnY one person 15„1 1,,,,,,,,,X000 ..,m,,,,,,, .
52SBAIX1115 03103/2017 03103/2018 PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE I$ 2,000,000
GEN AGGREGATE MI APPLIES PER: �PRODUCTSOMP OPAGG.. ,S ZQQ,( �Q„
POLO LOC I CUMBNEO SYNEMI
AUTOMOBILE LIABRXTY I� (Ea accident)
ANY AUTO BODILY INJURY(Per person) S
ALL OWNED ..........i SCHEDULED
AUTOS AUTOS BODILY INJURY(Per accident) S
w_ NON-OVINED -P�9CiPECt1' ,XSEm._.m..........�........
HIRED AUTOS „ AUTOS Per arwenl
UMBRELLA LiAS OCCUR F EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTIONS I $
N!A �.. .....I WC STATU- OTH-
AND
ERF/PART ER/EXECUTIVE YIN EL ACH Ir•CCIDENT EAR_._.____...............................................�,
WO-HERS COMPENSATION
EACH ACCIDENT $
(Mandatory in NH) I E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
ETA Rdlfitil0e E,L..DISEASE-POLICY LIMIT S
$1,000,000
Professional Liability 1_ F_ 52SBAIX1115 03/03/2017 03/03/2018
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required)
City of El Segundo,its affiliates and subsidiaries are listed and additional insured
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.
El Segundo,CA 90245-3813
AUTHORIZED REPRESENTATIVE
Gabriel Oh
©1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: 52SBAIX1115 COMMERCIAL GENERAL LIABILITY
CG 20 18 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED -
MORTGAGEE, ASSIGNEE OR RECEIVER
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Person(s) Or Organizations) Designation Of Premises
City of El Segundo and any affiliates All projects of the Named Insured
per written contract
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 C. With respect to the insurance afforded to these
include as an additional insured the person(s) or additional insureds, the following is added to
organization(s) shown in the Schedule, but only Section III—Limits Of Insurance:
with respect to their liability as mortgagee, If coverage provided to the additional insured is
assignee, or receiver and arising out of the required by a contract or agreement, the most we
ownership, maintenance, or use of the premises will pay on behalf of the additional insured is the
by you and shown in the Schedule. amount of insurance:
However: 1. Required by the contract or agreement; or
1. The insurance afforded to such additional 2. Available under the applicable Limits of
insured only applies to the extent permitted by Insurance shown in the Declarations;
law; and
whichever is less.
2. If coverage provided to the additional insured is
required by a contract or agreement, the This endorsement shall not increase the
insurance afforded to such additional insured applicable Limits of Insurance shown in the
will not be broader than that which you are Declarations.
required by the contract or agreement to
provide for such additional insured.
B. This insurance does not apply to structural
alterations, new construction and demolition
operations performed by or for that person or
organization.
CG 20 18 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 1
��01 CERTIFICATE OF LIABILITY INSURANCE I DATEIMMIDDIYYYY)
_ 03/17/2017
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(les)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 CONTACT Jerry Goebel
StateFarm Slate Farm Insurance � 1d°Ep.kx1'l" 515 832 4066 1 � 515 832 4067
1209 Superior St E PMAILSS. jeny.goebel.t2lg@sta'lefarn),com
Webster City IA 50595 INSURER(SI AFFORDING COVERAGE NAIL A
INSURER A: Stale Farm 25143
INSURED
_INSURER 6
David&Heather Toyer INSURER C:
1807 Navajo St INSURER D: 1
Burlington IA 52601-3492 INSURER E: {'
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.
NNSR ADDLISUSRX POLIOY EX,P '--
L,TTI, TYPE OF INSURANCE POLICY NUMBER POd 'tM li LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S
CLAIMS MAD£ -UAMA IU HLNIEU OCCUR P EMI ES To occurrancq)„-, S
MED EXP(Any one person) S
PE'R'SONAL 0 AOV INJURY S
GEN'tAGGREGATE LIMIT APPLIES PER: yf GENERAL AGGREGATE $
POLICY 17 ECT LOC 1 PRODUCTS-COMPIOP AGG S
OTHER. S
AUTOMOBILE LIABILITY Y 1256247AO715E 01/07/2017 07/07/2017 a MBINEO SINGLE LIMIT S
�-ANY ALTO BODILY INJURY(Per person) S 1.000.000
A OWNED SCHEDULED BODILY INJURY(Per S 1,000,000
AUTOS ONLY AUTOS ( l
HIRED NON-OWNED PROPERTY DAMAGE S 1.000.000
AUTOS ONLY AUTOS ONLY pP Rperddrr7'1
S
UMBRELLA LIAO OCCUR EACH OCCURRENCE S
EXCESS LAB HCLAIMS-MADE AGGREGATE S
D I RETENTIQNS $
WORKERS COMPENSATION PEH O'pH-
AND EMPLOYERS'LABILrrY YIN �ST----7UT.E L-1„„0
ANY PROPRIETORIPARTNERIEXECUTIVE
OFFICERIMEMBER EXCLUDED'! NIA EL.EACH ACCIDENT S .,
(Mrrrldatory In NH) E.L.DISEASE-EA EMPLOYEE S
Ues dosoibe under
S4IRIP+TION OF OPERATIONS below a E.L.DISEASE•POLICY LIMIT $
DESCRIPTION OFOPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Rcmarts Schedule,may be attached N morn space Is required)
CERTIFICATE H'O'LDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Et Segundo ACCORDANCE WITH THE POLICY PROVISIONS.
City Hall 350 Main S
t AUTHOR E ESria EI Segundo CA 90245-3813 r' pilACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
1001486 132849.12 03.16-2016
IOWA INSURANCE CARD
Bible FaimMiaual
Automobile I,Co. 25143 F--j Slate Fafm File
IL—i and CmAualiy Go,
INSURED TOYER,DAVID 8,HEATHER MUTL
POUCY NUMBER 125 6247-AO7.15E EFFECTIVE VOL
YR 2007 MAKE FORD JAN 07 2D17 'ro JUL 07 2017
MODEL F$50 VIN IFTpW110671(c91693
AGr,NT JERFIYGOEBFI. 2076-02E
WE 8$T E A C Y,IA 60695
EIAERQNCY PHONE (615)832.4066 NAIL 25178
A C 0260 GSOO III R1 U w
THE COVERAGE PROVIDED BYTHE POLICY MEETS THE
MINIMUM LIABILITY LIMITS PREStnISED By LAWL
SEEREVERSESIDE FOR A1301TIONAL COVERAGE INFORMATION
li
CITY OF EL SEGUNDO
OS' COMPENSATION DECLARATION
WARNiNG: FAILURE TO SECURE E S' C PSTI 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 COT OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN LABOR CODE§3706, INTEREST•, AND ATTORNEY'S FEES.
I Wfkrm under ponalty of perjury under the lawn of Calliornoe one of the foliowirg declarations,
I_ }I halve And wll maintain a certificate of con sent of self•in.3uro for workers'compensation,issued by the Llirrjcttx
of Indo.mirial Refatio is as provided fox by L abtx Cude§3700 for Ott parfcaxouv=of the work,act forth the egrcsamwtl
with the City of El Segundo
Policy No µ,.. _., .u...
{ )I have and will maintain workers'oxw"nsation ineura iwvr as faquired by Labor QxJM Q 3700 for tint pnrfum i ice
0 the work for which the agreement with the City of C-1 Segundo is executed.My workers'eomponsoon inr;urmnrw
carrier and poriicy number are:
o;imrmiem , . ...,,. .. �, ., . .- ", Pink:y Niiirnber f°xpiraCion Ilr'',h ie
NNaiiirma i I ra t Phone ,......
I certify thKt, ITT the pnripr1tWC0 of thM WLVk stA mmi on oie sarimmeot wltlh me Uty of Ell Segaendu, I will not
pl®y any pemon in any manner so as to bacome subject to the wc*ers' eompensattiosn laws of California, anti
4 agrees Chet, 9 1 should becomes sut.>leo3 to the workers' q npansatiort provialon® of Labor Code § 3700 1 must
d t Imnedlate h Cam Icy wit w,..„l.
hos e x o
s r wi
. uuimatically b® nt;void,
3)h Signature of Applicant fate
t>Ao
Agreetnellt for: e �,-
Hated 3
Reviewed by'
1