Loading...
PROOF OF INSURANCE (2018) CLOSED DATE(MM/DDIYYYY) AC"R"'r�;yr � CERTIFICATE OF LIABILITY INSURANCE 9/21/2117 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 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 Bolton & Company ('AMEa+c'r 3475 E. Foothill Blvd., Suite 100 PHONE FAX Pasadena, CA 91 107 4ALC,_ Q Eart1: (626)799-7000 I(A/c.No): (626)583-2117 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# www.boltonco.com 0008309 Q INSURER A: Hiscox Insurance Company Inc. 10200 INSURED I INSURER B: State National Insurance Company.Inc 12831 Choura Events 540 Hawaii Ave. INSURER C: Torrance CA 90503 INSURERD: INsuRER E INSURER F: COVERAGES CERTIFICATE NUMBER: 37855605 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. IL�R ... A P TYPE OF INSURANCE INSp V'Vn POLICY NUMBER IMWOMYYYYI IMM rDY CXr"pt'1°'y'Ybp LIMITS . .. A �" COMMERCIAL GENERAL LIABILITY ✓ US LIEN 2731012.17 5/6/2017 5/6/2018 EACH OCCURRENCE $ 1000000 P R___....... '^ CLAIMS-MADE OCCUR Jtr�K MIE 5,,.0(Ea'� ,rIl�,nr,,) $ 300000 ... PRFS„ MED EXP(Any one person) $ 10000 PERSONAL&ADV INJURY $ 1000000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2000000 ^�POLICY • I jE O F—] LOC pUp PRODUCTS-COMP/OP AGG $ 2000000 0'1 HER: $ A AUTOMOBILE LIABILITY US UAE 2731080.17 5/6/2017 5/6/2018 II COMBINED SINGLE LIMIT $ (Eip acclalenty 1000000 ✓ ANY AUTO BODILY INJURY(Per person) $ OWNED LL- SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS .... HIRED NON-OWNED P. ..... ..-W-.._-.� ItOf°Era{'"fY IJAMAGE $ AUTOS ONLY AUTOS ONLY „(Per,Ioc.uia'lrn�ay $ A EXCESS L ABAB [Z]OCCUR MADEUS LEN 2731013.17 5/6/2017 5/6/2018 EACHOCCURRENcE $ 5000000 ......,......,.,..,...............D..,.. pp ....................................................................................... $ 5000000 DED ✓I RETENTION$10,000 $ B WORKERS COMPENSATION HSW272813317 5/6/2017 5/6/2018 STATUTE oraH AND EMPLOYERS'LIABILITY .. ..�___ _.I. ANYPROPRIETOR/PARTNER/EXECUTIVE ��Y/N'y' E L.EACH ACCIDENT $ 1000000 OFFICER/MEMBEREXCLUDED7 N/A (Mandatory In NH) E L.DISEASE-EA EMPLOYEE'. $ 1000000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1000000 A Equipment Floater US LIEN 2731012.17 5/6/2017 5/6/2018 3,593,360 A Commercial Auto US UAE 2731080.17 5/6/2017 5/6/2018 Comp/Collision$1,000 Deductible DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) GL Additional Insured&Primary wording applies per form EGLE4316CW0315 attached,only if required by written contract/agreement. Additional Insured(s):City of EI Segundo,its officials and employees. The certificate holder is included as GL additional insured per EGL E4316 CW(03/15)attached. CERTIFICATE HOLDER CANCELLATION Cit of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Y 9 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Clerk ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street, Room 5 EI Segundo, CA 90245-3813 AUTHORIZED REPRESENTATIVE i John Guthrie ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 37655605 1 CHOUEVE-Cl 1 17-18 GL, AUTO, UM, WC, IM Bolton Certificate Processing 1 9/21/2017 8:13:56 PM (PDT) I Page 1 of 2 US UEN 2731012.17 Hiscox Insurance Company Inc. 40 H I S COX Additional Insured — Person or Oroanization In consideration of the premium charged and on the understanding that all other terms, conditions and exclusions remain unchanged, it is agreed that this endorsement modifies only the terms and conditions of the Coverage Part(s)listed below: COMMERCIAL GENERAL LIABILITY COVERAGE PART el SCHEDULE � -� Name of Person or Organization(Additional Insured) 1. All of your clients when required by written contract. 2. All owners, operators and managers of premises where you conduct your operations, when required by written contract or per Certificates on file. I. It is agreed that WHO IS COVERED is amended to include the person or organization stated in the Schedule above as an additional insured,but only to the extent of such additional insured's liability for bodily injury,property damage or personal and advertising injury caused by or arising from your acts or omissions or the acts or omissions of those acting on your behalf: A. in the performance of your on-going operations;or B. in connection with your premises owned by or rented to you. However,if coverage provided to the additional insured is required by a contractor agreement,the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement or that which you would have been entitled to under this Coverage Part,whichever is less. II. For the purposes of coverage provided by this endorsement only, HOW MUCH WE WILL PAY is amended to include the following: If coverage provided to the additional insured is required by a contract or agreement,the most we will pay on behalf of the additional insured is the amount of insurance: A. required by the contract or agreement;or B. available under the applicable Limits of Insurance stated in the Declarations; whichever is less. Any payments we make under this endorsement will be a part of and not in addition to the applicable Limits of Insurance stated in the Declarations. The title of the endorsement is solely for ease of reference and forms no part of the terms and conditions of coverage. G q�R��A� q� �` Includes copyrighted material of Insurance Services Office,Inc.,with its permission. 37855605EgL1-94E.VE;Q �3JJ5)8 GL, AUTO, UM, WC, IM I Bolton Certificate Processing 1 9/21/2017 8:13:58 PM (PDT) I Page 2 of 2 Page I of