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PROOF OF INSURANCE (2018 - 2018) CLOSED TIFFHOM-01 K00U LILY CERTIFICATE OF LIABILITY INSURANCE DAT6 912 DIYYYY) THIS CERTIFICATE...IS......ISSUED..... ..AS....A.....MATTE.R....OF....I.N.FORMA...........................N............................................................................................................................... ............................................. 6/912017 TION O LY 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. ........................................................................... .............. ... ...m .................................................................................................................................................... ....................................... 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 rIQ is tot cert/ Icate holder In lieu o such end....o....r...s....e... ments). . ............. ....................... PRODUCER License#0757776 52� ncT Karen Gourley HUB International Insurance Services Inc. PHONE FAX 909 8390 University Ave. INC,No,Emit )912-6438 (WC,Na). Suite 300 %i=ssr Karen.Gotirle'y hub'interilational.cont Riverside,CA 92501 INSURERIS)AFFORDING COVERAGE NAIL 4 INSURERA:Philaclelphla Indemnity Insurance Company 18058 INSURED INSURER 8: Tiffany Home Care DBA:Always Right Home Care INSURERC: 9700 Reseda Blvd.,Ste 105 INSURER D: Northridge,CA 91324-5516 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 INSR ADDL SUBRI POLICY EFF POLICY EXP _LTR TYPE OF INSURANCE INS D POLICY NUMBER IMMIDDI 000 IM WD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH;OCCURRIIrd0. 5 1,000,000 X CLAIMS-MADE OCCUR PHPK1666029 06/15/2017 06/15/2018 DAMAGE TO R[:x:R gd 100,000 � PPEMI�ES RC;�,aa;adrl��eraaaw�) S X Retro Date 6/15/03 MED FXP(Any ur7al lauosoln1 $ 5,000 Pr RSONAL&ADV IN.IUR')' $ 1,000,000 GIENT AGGREGATELIMIT Alf`i'''I IF r�PER GENERAL AG(aREG4TE S 3„000,000 X P(TLUCY PRO- ; LOC PRODUCTS"COMPIOPAGG S 3„000,000 OTHERS ................Y........,.,.,.,...,....,.,.,,.�.._..,.,.,...,.,.,.,.,.,.,.,.,.,.,.,.,.,.......,.,.,.,.,.,.,.........,.,.,.,.,.,.,.,.,...,.,.,...,.,.,.,.,.,.._.,...,.,.......,.,.,...............,.........................,.,................ ................................,.,.,.,.........,.,.............�.,.,...................,.........,.,.....................,.,.,.,....................................... ...,.,.,.,.,.,.,.,.......,.,.,.,.,.....,.,.,.,.,.,.,.,.,.,.�..._..w.., A AUTOMOBILE LIABILITY COMBINED SINGLE WOO 1,000,000 Ica aocPOF r t) 5 ANY AUTO iPHPK1666029 06/15/2017 06/15/2018 BODILY INJURY IPclr)aev:a'cnr 5 OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY V&r accidernP S HIRED NE"ag�d"r�dhy1 .N I"af'tC,'!N"'ER'IY DA�MAf.rl X AUTOS ONLY X ALi'f�,'�a�(,SP Y �If'Ie€ac,mdunlB $ $ UMBRELLA LIAB OCCUR EACH C'CC(,ARE:N(;E 'S EXCESS LIAR CLAIMS-MADE AGGREGATE S. IDi..0 RETENTION 5• 1. S WORKERS COMPENSATION PER 0fl'1- ANDEMPLOYERS'LIABILITY Y/N $1,AlUi�E ER Y PROPRIETOR/PARTNER/EXECUTIVE E L EAr,H A(;�C,IDf N'I S 1:'.)Fp'P�C:d�:RIMEMBER EXCLUDED? N/A andatory in NH) E L DISEASE•EA E?AF'L'(YEE 5 VfyyR'l5,Ud�.'acsoe ual'1�ooy CJF:�'S(:;R'IP:1"()1M'd()F(NITRATIONS bailow E 1, DIBEA SE rw'')i,k'Y V WIT' $ A Prof.Liability PHPK1666029 06/16/2017 06/15/2018 1,000,000 Ea Incidnt A Retro Date:6/15/03 '"HPK1666029 06/15/2017 06/15/2018 3,000,000 Agg. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) For Information Purposes Only Coverage includes Sexual/Physical Abuse or Molestation$1,000,000/$3,000,000,Retro Date:6/15/03. Certificate Holder is included as Additional Insured per policy terms and conditions as respects Senior In Home Care Project for the City ... ................... .................................................................................................................... .......................................................................................................................................... CERTIFICATE HOLDERCANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Ci of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City 9 ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo,CA 90245 .................................. ......m.. ..m..m..... m......................... AUTHORIZED REPRESENTATIVE 400,1 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rightsre es rved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PHPK1666029 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATE PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): City of E1 Segundo 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 is added to organization(s) shown in the Schedule, but only Section III —Limits Of Insurance: with respect to liability for "bodily injury", "property If coverage provided to the additional insured is damage" or "personal and advertising injury" required by a contract or agreement, the most we caused, in whole or in part, by your acts or will pay on behalf of the additional insured is the omissions or the acts or omissions of those acting amount of insurance: on your behalf: 1. Required by the contract or agreement; or 1. In the performance of your ongoing operations; or 2. Available under the applicable Limits of 2. In connection with your premises owned by or Insurance shown in the Declarations; rented to you. whichever is less. However: This endorsement shall not increase the 1. The insurance afforded to such additional applicable Limits of Insurance shown in the insured only applies to the extent permitted by Declarations. law; and 2. If coverage provided to the additional insured is 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 26 04 13 © Insurance Services Office, Inc., 2012 Page 2 of 6 TIFFHOM-01 RMCATEER CERTIFICATE OF LIABILITY INSURANCE DATE 1012(MM/7/20172017 Y) 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 CONTACT NAME: All Insurance Underwriters Inc. PHONE FAX 2600 Sumerian Drive (Arc,No,Ext):(813)343-3100 I'ATc,Na):(81'3)343-3090 Suite 101 E-MAIL iic y�aiuinc.com Land O Lakes,FL 34638 ADDRESS.p olINSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Security National Insurance Company INSURED INSURER B: Tiffany Homecare Inc dba Always Right Homecare INSURER C: 9700 Roseda Blvd Ste 105 INSURER D: Northridge,CA 91324 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER„ _.rrrrrrrrr ..�.....�....w..w..w.. w .�__.----- �....ww �. 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 LTROF INSURANCE INSp 'YB ._ POLICYUMBER IMMRDrJYYL91YYI Id��SL,t„TCYd yyl LIMITS INNSR TYPE ADDL ISUIBIR N POLICY.... COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person),$ PERSONAL&ADV INJURY $ G(EN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ PRO- PRODUCTS _ C'+'011"'W IRO PRODUCTS-COMP/OP AGG JI:.CT OTHI'R AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT' $ IEa accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED I"�'ROIa'EY��'Y""�V'DAMAGE $ HIRED AUTOS AUTOS (Perac�oidenl) S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE S DI'I.ri R"LTEN7*NS 5 WORKERS COMPENSAIMN PER 1:>'I'U M. AND EMPLOYERS'LIAB(LITYSTAR"UTLr. X i'R A ANY PROFRIE'rORlT"'ARTNER/E',XCCUTIVi' v/N X SWC1142361 03/01/2017 03/01/2018 EL EACHACCIDENT s 1„000„000 4';FFYCFRA0EMB R'EXCLUDED? [—N] N/A (Mandatary in NH) EL DISEASE-EA EMPLOYEE $ 1,00'0,000 Yi yyars.oJescarY„r.u.dntper J@ SCRIPT ON T;7T(a,F fiRAxl'POWS lreyoly E V DIS[ASE, 1"101-Ii';'Y'IAMI"q' S 1,00'0,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Waiver of Subrogation in favor of: City of EI Segundo 350 Main Street EI Segundo,CA 90245 . ................................._ .. .. .. ............................................................. CERTIFICATE HOLDER CANCELLATION ....................................... SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City CitMain Street ACCORDANCE WITH THE POLICY PROVISIONS. EISegundo,CA 90245 ............ ..m............................................................................................... AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rig .. ........ved............ hts reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 01-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy.We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 0%of the California workers'compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Cit of EI Segundo EI �egundo, CA 90245 Specific waiver per written contract. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 3/1/2017 Policy No. SWC1142361 Endorsement No. 0 Insured Tiffany Homecare, Inc. (A Corp.) Premium$ 197581 Insurance Company Security National Insurance Company Countersigned by .................... WC 04 03 06 (Ed.01-84)