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PROOF OF INSURANCE (2018 - 2018) CLOSED DRMAU-1 OP ID:C6 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) `� I 05131/2017 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(lies) 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 NAMCf CT Carole S.Mitchell BBrakkerame $Chafn66 Ins.Brokers NO,PHONEN 310-524-1357 FAX No 949 313-3323 carole.ITlltch.... tm....,_.i .._. 100 Wilshire Blvd.f!700SS, I el( si us Santa Monica,CA 90401 License#0 7 C ?d Darla Gray ADDRI ................ INSUR'ER(SI_AOROVNGCOVGrdAGE ..., ..— NAIC$ .,,... INSURERA:Westchester Surplus Lines Ins INSURED Dir.Maureen Ss soon INSURER B: P O Box 2028 Palos Verdes Peninsula,CA 90274 INSURERC: INSURER D: INSURER E. INSURER F: - COVERAGES CERTIFICATE NUMBER: 1 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. NSR ...TYPE OF IN iMNSD 'NIVD POLICY NUMBER _ l(MW01YO�YPY�YYE"�i') IVFM/ . ...... ..... .. ..., GILIOCD'YEX , %NSR' T INSURANCE P'M"YYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 .,._._............... MEEXP(Any occ:ul,rUrarW'�r) „ $ ......__ X Acid I Ins SDE �X�OCCUR X X G2427042T005 07!0112017 D 07!0112018 �IAMACL'1OI�k one person) $ 50,0,00 5,000, X Prof&Pollut-CLM PERSONAL&ADV INJURY $ 1,000,000' ..... II llf:IMI � IES PER: �GENERAL AGGREGATE .$ 2,000 000 I XPSN yAGGREGATE LIMIT APPL,,,, I � __.._ P'IGd PRODUCTS OMP/OP AGG $ 2,000 0(10 OTHER eltaLPIlydl'p AUTOMOBILE LIABILITY _NR_Q-dtn_iL_. Is __...__.._ ANY AUTO BODILY INJURY(Per person) $ u .,. AAUSCHEDULED B ODILY INJURY (Per accident)en i $ TOS ` L__ NON-OWNED ty OPF0,YDAM $ HIREDAUTOS AUTOS , ................ $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB „CLAIMS-MADE AGGREGATE $ ED I, RETENTION$ PERWOR $ ... AND ERP OYE PEN' STATUTE FR T H SATION ANY PP�OP'Rwii P'OR LIABILITY Y I'N -- L'}'NFFIG"'MPMEMSL�12dPN+R7"NI:RIE,dIIr,C'I,1.G.h'NJI:: N/A ENT $ EXCLUDEW E.L.DISEASECEA. ..__...YE _._._. ...,,,_. ....�.,,...�... (Mandatory ry In NR) EMPLOYEE $ MACRdaASa' .-- -__.._........ hl' es'„describe.graer' ,. } VON M,-0KRATIONS tvlonw E.L DISEASE-POLICY LIMIT $ A Professional Liab. G24270427005 07101/2017 07/01/2018 Prof.Liab 1,000,000 A Contractors Poll. G24270427005 07/01/2017 07101/2018 Pollution 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,AddlOonal Remarks Schedule,maybe attached If more space is required) Policy Provides 30 days notice of cancellation except 10 days for non ayment Applicable Endorsements Attached are Applicable'where required by Written Pontr,act CERTIFICATE HOLDER CANCELLATION C-ELSEG 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. Attn:City Clerk 35 Main St et 90245 ..,AUTHORIZED REPRESENTATIVE ... ... .... .. . . ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Named Insured I Endorsement Number Dr. Maureen Sassoon Policy Symbol Policy Number Policy Period Effective Date of Endorsement ECP I G24270427 006 07/01/2017 to 07/01/2018 V 07/01/2017 Issued By(Name of Insurance Company) Westchester Surplus Lines Insurance Company .................. Insert the policy number. The remainder of the information is to be completed only when this endorsement is Issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ENDORSEMENT-OWNERS, LESSEES OR CONTRACTORS (PRIMARY AND NON-CONTRIBUTORY) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE CONTRACTOR'S POLLUTION LIABILITY COVERAGE SCHEDULE: Name of Person or Orclanization: Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. .............................. (If no entry appears above, Information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) SECTION II-WHO IS AN INSURED is amended to include: A. SECTION II -WHO IS AN INSURED is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to bodily injury or property damage occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs)to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) That portion of your work out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. The coverage provided hereunder shall be primary and not contributing with any other insurance available to those designated above under any other third party liability policy. ENV-3101 (08-04) Includes copyrighted material of Insurance Services Office, Inc.with its permission Page 1 of 1 VNamed Insured Endorsement Number Dr. Maureen Sassoon Policy Symbol Policy Number Policy Period Effective Date of Endorsement ECP G24270427 006 �I 07/01/2017 to 07/01/2018 07/01/2017 Issued By('Name of Insurance Company) Westchester Surplus Lines Insurance Company Insert the policy number. The remainder of the Information Is to be completed only when this endorsement is Issued subsequent to the preparation ofthe policy. THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ENDORSEMENT OWNERS, LESSEES OR CONTRACTORS—SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE CONTRACTOR'S POLLUTION LIABILITY COVERAGE SCHEDULE: Name of Person or Organization: Any person or organization that is an owner of real property or personal properly on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you,wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. SECTION II -WHO IS AN INSURED is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds,the following exclusion is added: 2. Exclusions This insurance does not apply to bodily injury or property damage occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed; or (2) That portion of your work out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. ENV-3100(08-04) Includes copyrighted material of Insurance Services Office, Inc.with its permission Page 1 of 1 ADDITIONAL INSURED ENDORSEMENT—PRODUCTS-COMPLETED OPERATIONS HAZARD Named Insured Endorsement Number Dr. Maureen Sassoon Policy SymbolPolicy Number Policy Period Effective Date of Endorsement ECP G24270427 006 07/01/2017 to 07/01/2018 07/01/2017 Issued By(Name of Insurance Company) Westchester Surplus Lines Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTOR'S POLLUTION LIABILITY COVERAGE PART SCHEDULE Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. J (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section II—Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for bodily injury or property damage caused, in whole or in part, by your work performed for that additional insured and included in the products-completed operations hazard. All other terms and conditions remain the same. ENV-3225(10-08) Page 1 of 1 ADDITIONAL INSURED ENDORSEMENT—PRODUCTS-COMPLETED OPERATIONS HAZARD PRIMARY&NON-CONTRIBUTORY Named InsuredI Endorsement Number Dr. Maureen Sassoon Policy Symbol Policy Number Policy Period Effective Date of Endorsement ECP G24270427 006 07/01/2017 to 07/01/2018 07/01/2017 Issued By(Name of Insurance Company) Westchester Surplus Lines Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTOR'S POLLUTION LIABILITY COVERAGE PART SCHEDULE Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you, wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section II—Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for bodily injury or property damage caused, in whole or in part, by your work performed for that additional insured and included in the products-completed operations hazard. Furthermore, the coverage provided hereunder shall be primary and not contributing with any other insurance available to those designated above under any other third party liability policy. All other terms and conditions remain the same. ENV-3226(10-08) Page 1 of 1 Named Insured Endorsement Number Dr. Maureen Sassoon Policy Symbol Policy Number Polley Period Effective Date of Endorsement ECP I G24270427 006 107/01/2017 to 07/01/2018 07/01/2017 Issued Ey(Name of bsuranco Company) We Surplus Lines Insurance Company Insert the policy number. The remainder of the Information Is to be completed only when this endorsement is Issued subsequent to the preparation of the policy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART SCHEDULE _q_Mg of Person or Oroanizatiom, Any person or organization that is an owner of real property or personal property on which you are performing operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of such person or organization to you,wherein such request is made prior to commencement of operations. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or your work done under a contract with that person or organization and included in the products-completed operations hazard. This waiver applies only to the person or organization shown in the Schedule above. All other terms and conditions remain the same. ENV-3143(03-05) Includes copyrighted material of Insurance Services Office,Inc.with Its permission Page 1 of 1 CA INSURANCE IDENTIFICATION CARD (STATE) COMPANY NUMBER COMPANY 10914 Kemper Independence Insurance Company POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE RB220068 09/01/2017 09/01/2018 YEAR MAKEIMODEL VEHICLE IDENTIFICATION NUMBER 2016 BMW 328 I SU WBA8E9G57GNT84508 AGENCY/COMPANY ISSUING CARD BUSINESS PROFESSIONAL [PH: 650-341-4484] 339 SEVENTH STREET #L HOLLISTER CA 95023 INSURED MAUREEN SASSOON PO BOX 2028 LROLLING HILLS CA 902740000 SEE IMPORTANT NOTICE ON REVERSE SIDE ......................... ...................... ................................... THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your Agent/Company as soon as possible. Obtain the following information: 1. Name and address of each driver, passenger and witness. 2. Name of Insurance Company and policy number for each vehicle involved. ACORD 50(1/83) 0 ACORD CORPORATION 1983 CA INSURANCE IDENTIFICATION CARD (STATE) COMPANY NUMBER COMPANY 10914 Kemper Independence Insurance Company POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE RB220068 09/01/2017 09/01/2018 YEAR MAKE/MODEL VEHICLE IDENTIFICATION NUMBER 2014 HOND CR-V EX 2HKRM3H59EH548165 AGENCY/COMPANY ISSUING CARD BUSINESS PROFESSIONAL [PH: 650-341-4484] 339 SEVENTH STREET #L HOLLISTER CA 95023 INSURED rMAUREEN SASSOON PO BOX 2028 TROLLING HILLS CA 902740000 SEE IMPORTANT NOTICE ON REVERSE SIDE ................. .. ...... ..... .. .... .... .... ..... .......... ............. ..... ...,.....,....,,.,,,,,,......, THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your Agent/Company as soon as possible. Obtain the following information: 1. Name and address of each driver, passenger and witness. 2. Name of Insurance Company and policy number for each vehicle involved. ACORD 50(1/83) 0 ACORD CORPORATION 1883 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 EI 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 EI 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 EI Segundo, I will not e 1ploy 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 w ������p rovo�soar�t��agreement will automatically become void. Signature of Applicant Date Print Name Agreement for: Dated: _� tj Reviewed by; w u: y,�