PROOF OF INSURANCE (2018 - 2018) CLOSED A
�.CERTIFICATE, OF LIABILITY INSURANCE 12!06(2017
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION I T THE CERTIFICATE „ THIS
M
CERTIFICATE DOT AFFIRMATIVELY OR NEGATIVELYT ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. TI CERTIFICATE INSURANCE DOES NOT CONSTITUTE A CONT CT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,ANTHE CERTIFICATE ti
I ,_i Te If.ihe-
0 certificate holderIs an ADDITIONAL INSURED,
policy(les)must be endomed. If SUBROGA71ON
IS WAIVED,subject
termsand conditions lic , certain policies may require n endorsement. A statement on this certificate does not confer rights
certificate holder In ll o such m nt( ).
_ ...
.. w.-.
PRODUCER d1
BrianHuntInsurnc�Agency NAME:
(N�c,Brian Hunt, LI 02545 Ao
IAN*y(562)
si 9156P
"A � M
5693 WoodruffV� AO
DRISS
Lakewood, C90713
f IlNSUREu(1sr1)1A1FtliFreOtlWRDM'
INN S.rc,OV
E ...,NAIO
IN /RSR A .41W FsenIrnrp p
Cpps�� 2161
INSURED ALLISON, ROBBY INSURER
DBA ALLIS TRAINING INSU ERC:
PERSPECTIVES &SERVICES INSURER D:
4067 HA ICK ST STE 495 INSURER E:
w_ INSURER F
COVERAGES CERTIFICATE NUMBER: REViSIION Ni,1 iBEW
........�..._.�...-....�......_.�.........ERTL........... ......... .. ... ......LL...@ES. ....................................,........................,.,.,........,.,.,.,.,.,.,.,.,.,.,....._,.................,..�� .....,
FI S O C ® C OF IN SURA NCE LISTED RELO W 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 NTH 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.
VNd"JI4 ... '�YN,mI: LOUTS
OF INS,� „�hGA'il:°'S�WC}�Gi Gro0LIC1f'kW"! N�"ON.d I
tia kl ._. .. aNRAN N _�kNS LNCY Nu RM. .
... . ..... .._. ._., . _.. �._,.
DOO
A GENE LIABILITY1.
® L® 5 �N �IwN4lI �. 00.......
CLAIMS-MADE „W LIABILITY a dA mAIN��-,F„( }
7 7 5 „
COMMERCIAL IOIihdE�IAdw4L 'u OCCUGt I I��ri�person)
$ 300,000®1000
MED P(Any on
PERSONAL&ADV INJURY $ 1,000,000„
GENE AGGREGATE $
2,000,000
GEWL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000
,. . L,. I .. �.. JII)� ,. .�.,� operty $BiPr1,500
AUTOMOBILELIABILITY I wC� i� idl.”I iI Id"Nf
(d'a rrrm,ud anwy
Y AUTO ..........._._.a...:.........._..a.�...�..:..:,,.�..,...,.,,., BODILY INJURY(P ) $
ALL OWNED SCHEDULEDBODILY INJURY _
AUTOS AUTOS (Per }
NON-OWNED
MIRED AUTOS AUTOS (Per
PROPERTY DAWaIIIAG
accident) L $
$
UMBRELLA CUR EACH OCCURRENCE,,, $
CE AGGREGATE $
13 ....I
w .,......�. IORY.I,If1Fr�
YIN _. .�......
WORKERS CO S'LI A ILIT E.L.EACH ACCIDENT FR $
DrD RETENTION$ _
AND E PLOYS Ll E.14.DISEASE-G.=A EMPh..OYEG'. $
ANY PROPRIETO ARTNE ECUTIVE G
OFFIC EMBER EXCLUDED? N/AIN......_.
(Mandatory InNH)
If yes,describe under w.. ..
I�.E } N W:...(I�1,:1 S:N:.IOI10dkGukU .......................... EL DIS SE POLICY LIMIT 3
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DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional R® Schedule,It mom space required)
ADDL INSURED® CITY OF EL SEGUNDO ITS OFFICIALS AND EMPLOYEES
350 MAIN ST.EL SEGUINDO CA 90245
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CERTIFICATE HOLDER CANCELLATION
I f I I its, officials, I
SHOULD ANY O A DESCRIBED POLICIES CANCELLEDBEFORE
E EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVEREDI
360 Main St. El Segundo, ACCORDANCE WITH THE POLICY PROVISIONS.
A ® c SENTA E
I. --....W._.(.,,w................................................................................
1988-2010 ACCORPORATION. All rights reserved.
ACORD 2 ( / ) The ACORD name andlogo are registered marks of ACORD 1001496 132849.7 03-01-2012
CMP®4616.1
CMP-4616.1 ADDITIONAL INSURED
DESIGNATED PERSON OR . If the contract or agreementyou
ORGANIZATION and the additional insured is governed
This n r nmodifies insurance Cali rni ivil Code Sectionor
provided under the following:
PRODUCTS AND COMPLETED
OPERATIONS LIABILITYV ..w
FORM ° the insurance rovf
additional insured is the lesser of that which:
Policy
®Named ® II r satisfaction o
ALLISON, n r indemnity li tion
DBA ALLISON TRAINING by CaliforniaCivil o cion
PERSPECTIVES2782 or 2782.05 for your sole
4067 HARDWICK ST STE 495
liability; or
LAKEWOOD CA ® You are required contract or
agreement o provide fors c
additional insured.
addressName and of AdditionalIs
Person i ion: We have no dutyor indemnify the
additional insured under this nor n
until a claim or"suit" is n r to u .
® Any insurance provi to the
WHO IS AN INSURED is amended additional insured l only apply
o include, s an additional insured, i respect to a claim r
any person or organization s n in 61 suit" brought for damages for which
the Schedule ov ° but only with you areprovided coverage.
respect to liability for"bodily injury" 3. Withrespect to the insurance
or"property " caused, in afforded to the additional insured,
whole r in part, or " the followingis added to
performedr that additionalinsured
and included in "products-
completed r i n hazard".
If coverage r vided to the additional
However, r v is subject to insured is required contract or
the following: agreement, ill pay on behalf
of the additional insured ill be the lesser o
® The insurance afforded to the additionalamount of insurance:
insured only applies to the extent permitted
by IRequired contract
agreement; or
. If coverage r vided to the additional
insured is requiredcontract or b. Availablen lic I Limits
agreement, insurance rovfded to the Of Insurance shown in the
additional insured ill not be broader than Declarations.
that which you are required h contract
r agreement to providec if I
insured;
Page I of
CMP—4616.1
This endorsement shall not increase the
applicable Limits Of Insurance shown in the b. Regardless of any agreement between
Declarations. you and the additional insured, this
insurance is excess over any other
4. With respect to the insurance insurance whether primary, excess,
afforded to the additional insured, contingent or on any other basis for which
the following is added to Paragraph the additional insured has been added as
3. Duties In The Event Of an additional insured on other policies.
Occurrence, Offense, Claim Or
Suit of SECTION 11 All other policy provisions apply.
—GENERAL CONDITIONS:
The additional insured must:
a. See to it that we are notified as soon as
practicable of an "occurrence" or an offense
is may result in a claim. To the extent
possible, notice should include:
when and where the
"occurrence" or offense took place;
(2) The names and addresses of any
injured persons and witnesses; and
(3) The nature and location of any
injury or damage arising out of the
Sdoccurrence" or offense;
b. Tender the defense and indemnity of any
claim or" i " to us and to all other insurers
who may have insurance potentially vailable
to the additional insured; and
c. Agree to make available any other
insurance the additional insured has
for defense or damages for is
we would provide coverage under
SECTION 11 — LIABILITY.
5. With respect to the insurance afforded
the additional insured, the following
replaces SECTION 11 —LIABILITY of
Paragraph 7. Other Insurance of SECTION
I AND SECTION 11 —
COMMON POLICY CONDITIONS:
a. This insurance is primary to and will not
seek contribution from any other insurance
available to the additional insured, provided
that the additional insured is a named
insured under such other insurance.
Page 2®f 2
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ulllodplil " IIIIIINJqlry LARbdity S I OTAI)
$25,0100 pe pl N arow ii,11, :1u0M)per a:mha.cu.n enc,'-
Sj:j:Jft If"gjj.tjj.am�JJJIN41.' $1 SAW per pelaox.71aU:VS30AW Iper„occN:g;nwee
P U"" s if you µWS"w'" responsible Am anodw IIU Ip.wNr,,mo& VI.1UjNWry or du,.;"mh in a:N':m auk) WdenL IIU; SI^,wICI IPa'.PoYS Or'
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Vehicle total 6 rnonM pram'iun a Silk 10
Elantage $5"80
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CITY OF EL SEGUNDO
COMPENSATIONI
WARNING: TI
IS UNLAWFUL AND SUBJECTS AN EMPLOYERCRIMINAL PENALTIES
AND CIVIL I ),
IN ADDITION
FOR IN LABOR CODE § 3706, I , AND ATTORNEYS 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 theagreement
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 theagreement with the City of El Segundo is executed. My workers' compensation insurance
carrier and policy number are:
Carrier � ..., _ ..................... w _...... Policy Number Expiration Date
Name of Agent _ „q hone
(®) I certify that, in the performance f the work set forth in theagreement with the City of El 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 I must
immediately comply with os provisions
the
m�.n....t..will automatically become void,
Signature
Si nature of Applicant
ate
_m .a....._ �__ ..... . j!, I
Agreement for: ._..... n I n
Dated: r
Reviewed by:
1