Loading...
PROOF OF INSURANCE (2018 - 2018) CLOSED L .0-1 DATE(MM/DD/ CERTIFICATE OF LIABILITY INSURANCE 1 12/13/201717 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 L.41ra b•a"+CT DELG 3122ADO GROUC#102 NPP (805 495-2330 (805)497-6616 YP DNIL srucetdelgadsgrop,com Westlake Village, CA 91362 INSU'RERIS,) AFFORDING COVERAGE NAIL# I ,SIIRIF,R.A TRUCK INSURANCE EXCHANGE INSURED B & B Drapery Service I INst,)IaER B TRUCK INSURANCE EXCHANGE 575 Mary Ann IIM5,0ERD Redondo Beach, CA 90278 INSURER D: I IRE F IRFR F i 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 INSN .0u, U.KoPOLICY EFF POLICY EXP LTR TYPE OF INSURANCE INySR WVn POI,,,IC'YNUNIBER (MM/r)D=YY1 wwor/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000 "'Q0.0, I X" DAMAGE 10 kE1v"{'Eu COMMERCIAL GENERAL IJABIIJI'Y _ PREMISES(Fa occurrencel $ 10,000 CLAIMS-MADEX OCCUR I MED EXP(Anyone person) $ 5,000 A , 60505-86-29 11/29/17 11/2 9/18�PERSONAI, &ADV INJURY $ 1,000,000 AM BEST #: 002174 GENERAL AGGREGATE $ 2,000,000 ��L�; PR t lr'a L I P " PRODINT� COMP/OPAGG :$ 2,000,000 G�Erd'LAt,;GRECAAF �ER: ROOU .� Pot rb AUTOMOBILE LIABILITY ED 9U40JLE LIMIT (F.acnr.,eddonn ANYAUTO BODILY INJURY(Per person) $ ALLOWNEDSCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS /PerrcrddRnM1 �. UMBRELLA LAB OCCUR MADE Ar GRE�CrURR,ENCE$ OCCUR EACH O E r E $ ._,. B GATE .,., $ .,.. ... ., EXCESS LIA 1 11 WORKERS EMPLCOMPENSATION RETENTION X WC STATU OTH- B OFFICER/MEMBER EXCLUDED? 'N/A EL EACH ACCIDENT T $ .....1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE � B0946-04-86 12/05/1712/05/18 r (Mandatory In NH) AM BEST #: 002173 E L DISEASE-EA EMPLOYEE $ 11000,000 If es,describe under � SCRIPTInNOFOPERATIONSt>elo„u I ...., I ,rJISFASF-POI.ICYIIMI g� 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) The City of E1 Segundo is named as additional insured as required by written contract. 10 DAYS NOTICE OF CANCELLATION FOR NON PAYMENT OF PREMIUM. 30 DAYS WRITTEN NOTICE OF CANCELLATION TO THE ADDITIONAL INSURED BELOW, CERTIFICATE HOLI2ER. AN =,l„ATION The City Of E1 Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Clerk ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street, Room 5 El Segundo, Ca 90245 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD �rj INFINITY,. December 01,2017 B & B Window Coverings 575 Mary Ann Dr Redondo Beach,CA 90278 RE: POLICY NUMBER: 504-61007-5324-001 INFINITY SELECT INSURANCE COMPANY NAIC 20260 AUTOMOBILE INSURANCE COVERAGE TO WHOM IT MAY CONCERN: , Please be advised that B & B Window Coverings has/had coverage with our company under policy#504- 61007-5324-001. The effective dates of the policy covering the vehicles are from 11/16/2017 to 11/16/2018 12:01AM CST.The current term of this policy is from 11/16/2017 to 11/16/2018. At this time our Infinity policy does not show any lapses in coverage. The rated drivers listed on the policy are/were as follows: Birnbaum,Jorge Santiago DL#C3141844 Loera,Antonio DL#A8458884 Flores,Juan R DL#B9918195 Birnbaum,Viviana Alicia DL#C3919540 liabilityy Covera es: BI-1000000/1000000 PD-1000000 MED-5000 RA-75/75 UMBI- 1000000/10000(50 2009 Chevrole Express 61500 I GCFG 15X091183098 COL-500 w/CDW COM-500 2005 Ford Econoline E150 I FTRE14W95HA53477 COL-500 w/CDW COM-500 2011 Chevrole Express G1500 I GCSGAFX9B 1126269 COL-500 w/CDW COM-500 2006 Honda Odyssey Ex 5FNRL38446B416148 COL-500 w/CDW COM-500 If you have any questions,please feel free to contact any of our Customer Service Consultants at 1-800-722- 3391. Sincerely, c. Joy Lietch Manager,Specialty Auto CORPORATE OFFICE: 22014TH AVENUE NORTH,BIRMINGHAM,ALABAMA 35203 (205)870.4000 (800)782-2040 www.infinityauto.com Member of Infinity Property and Casualty Corporation 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: U 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. 5 iff y y�" t9 U 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� U ell; �?�/SU 4l� -4-4 t^�, Policy Number Expiration Date �2 �_ ` Name of Agent �L 6/� _ Phone# p ��' L_J I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not employ 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 with thvisions the agreement will automatically become void. Signature of Applicant r , Date (IvA� Agreement for: R I Dated: amu' Reviewed by a 1