Loading...
PROOF OF INSURANCE (2018) CLOSED Policy Numbor; Date Entered: 3/16/2017 CERTIFICATE OF LIABILITY INSURANCE D3 /16/22017 017Y) I 3/16 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). mm. PRODUCER CONTACT L_ COLLINS INSURANCE AGENCY NAME: & apftla,Srl (650)392-6461 Not. (650)342-5072 520 S. EL CAMINO REAL STE 300 E-MAIL SAN MATEO, CA 94402 ADDRESS;_ dWSURER(S)AFFORDING COVERAGE NAICp, INSURED The Dardanelle Group Inc. Western World rn suranrecb Company IN.SURr:RA,;Farmers Insurance Exchange INSURER B: I +'syrax!rz c 106 S. Catalina Avenue INSURER D Redondo Beach, CA 90277 INSURER E: INSURER'S r: COVERAGES CE'R'TIFICATE 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. ILT..R TYPE OF INSUR yy, POLICY,WaUiM,U,ER µ ^^ y _, COMMERCIAL ANCE . ... .iN"�?'SMJ1UCVUfl .....tAhh 10PAJ^lYYY P066CY 4X Y. 5.............._...,.,.,.,.,.,. ....__ _ ... " GENERAL LIABILITY EA>,HOCCURRENCE R C LIMIT 000 o' 2,,000, RGIAL GENE fn1RE E wnn pn+a S"7 x CLAIMS-MADE , occuR 604327928 01/15/2017 of/ls/zole praEJ,1J9ES sPor) S5,000 5 Prtr,srNAt. A1ro' INnua'a'w' g 2,000,000 C'ITIN'G J4GGRLGJ1,Ti;,LIMIT APPLIES PER: GENERAL AGGREGATE 3 4,00,000 Pow.ICY PRO- JECT LOC PRODUCTS-COMPIDPAGG ,5 2,000,000 q1"biER': S _.......W AUTOMOBILE ANY AUTO ABILITY _...... .................... ..... ;609327928 .. Ol/15/2017 401/15/2019 BODILY INJURY(Per Gp rson) 3 2,000,000 mca:d'rnd r, 0 A AUTOS ONLY AUTOS BODILY INJURY(Per accident)OWNED SCHEDULED P denq!$ HIRED NON-OWNED PRoPC-R'PYD✓"✓,h Or AUTOS ONLY AUTOS ONLY gear'accldonl) S UMBRELLA LIAB Id) AGGREGA Ul'kR E)rCE '$OCCUR EACH On.�C. O C ESS 1Ll. _......_ TL �D ASCTrfJ"r S L1AOC: .. WORKERS� ,. ,.,..:.._ STATUTE � S ANO EM L COMPENSATION ❑ pi) E,L.EACH ACCIDENT ORRe ANY PR P)R ETER EXCLUDED? A E.L.DISEASE-Flt EMPLOYEE,.S YIN ANY PROPRIETOR EXCLUDED: Myymno3to In N'H S „Dt�sld N OF OPERATIONS bawidbw ......................_ R"R:1,DISEASE-r>4y&pR"eY LIMIT Professional 'BRL0007103 07/13/2016 107/13/2017 B 'Liability/E&O $1,000,000 I DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached U more space Is required) City of E1 Segundo, its officials and employees are listed as Additional Insured �„. CERTIFICATE HOLDER CANCELLATION 0 City of E1 Segundo 350 Main Strcot SHOULD ANY OF THE AROVF nFSCRIRFn POI MIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo, CA 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 Produced using Forms Boss Pius software. www-FormsBoss.com; Impressive Publishing800-208-1977 POLICY NUMBER: 604327928 BUSINESSOWNERS BP 04 48 0197 THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESSOWNERS POLICY SCHEDULE* Name Of Person Or Organization: CITY OF EL SEGUNDO ITS OFFICIALS AND EMPLOYEES * Information required to complete this Schedule, if not shown on this endorsement,will be shown in the Decla- rations. The following is added to Paragraph C. Who Is An Insured in the Businessowners Liability Coverage Form: 4. Any person or organization shown in the Schedule is also an insured, but only with respect to liability arising out of your ongoing operations or premises owned by or rented to you. BP 04 48 0197 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 ❑ 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: ( ww )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# 1 certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not e ploy any person in any spanner so as to become subject to the workers' compensation laws of California, and agree that, if II should beco subject to the wor rs' compensation provisions of Labor Code § 3700 1 must immediately comply ' t e pr visio s or the e nt ill a matically become void, Signature of Applicant Date ell Agreement for: Dated: -1 ... Reviewed by: Y 1 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1'18g IMS=-CIA A notary public or other officer completing this certificate verifies only the identit3r of the individual who signed the document to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document. State of California ) County of ) On before me, , Date me and Title of the Officer personally appeared Insert Ida /'I (=' p Y pp Name(s)of Signers) who fribeddto to me on the within the of satisfactory to me thatl�hO/ t�rellh�� e outed the s In . actor r evidence p s whose ) /ar subscribed Instrument and �,� the ire ., is/Fier/their aut,itori ed capacity(ies), and that by bitr1her/their signature(s)on the instrument the person('s), or tide entity upon behalf of which the person(s)acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. 1:1 Mall yoNt;tr IS 1,I! WITNESS my hand and official seal. Notary pratyl+i�_Ca IIfornla Ws ArFrgedes Count, C111'sdnn#21843W 53ti" y — o My Comm,Catrlfes Mar 22,2021 Signature Sir azure o;Notary Public Place Notary Seal Above OPT101VAL Though this section is optional, completing this information can defer alteration of the document or fraudulent reattachment of this four to an unintended document. Description of Attached Document Title or Type of Document: - i ca, � r "� i� ��rtf s� LL Document Date: Number of Pages: Signer(s) Other Than%med Above: Capacfty(fes) Claimed by Signer(s) Signer's Name: Signer's fume: i :Corporate Officer —Title(s): —_j Corporate Officer— Title(s): :.Partner— -7,Limited M,General :­'Partner — i 1 Limhed r`i General f-Individual 7 Attomey in Fact _Individual L.Attorney in Fact Trustee 1 Guardian or Conservator ' 'Trustee LI Guardian or Conservator C.Other: L Other: Signer is Representing: Signer Is Representing: ©2D14 National Notary Association- wwvr•NafionalNotary.org - 1-8oD-US IJOTARY(l-800-876-61327) Item:9b9D7