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PROOF OF INSURANCE (2015 - 2015) CLOSED DONGOL-001 LETI CERTIFICATE OF LIABILITY INSURANCE DATD/YYYY) I 6//30/230/2014 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 PRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. RTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to -arms 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). CONTAPRODUCER (888) $25-432211 NAME: Tien Le Bowermaster&Associates PHONE 888-825-4322 20 FAX P.O. Box 6026 MAIADDRESS; tNe�u aoWermaster.om ( "° 714-252-8253 10805 Holder Street-Suite 350 c,,No,Ext):888-825-4322 ovc ) Cypress,CA 90630 INSURER(S)AFFORDING COVERAGE NAIC# YP INSURER A:Philadelphia Indemnity Insurance 18058 INSUREDCompany The Lakes at EI Segundo INSURER B:Fireman's Fund Insurance Com an 21873 Lane Donovan Golf Partners, LLC INSURER C:California Restaurant Mutual Benefit Corp. 400 South Sepulveda Boulevard INSURER D: EI Segundo, CA 90245- 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 DOLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS ILTR v TYPE OF INSURANCE ADDU SUf3VY POLICY NUMBER (MMIDD/YYYY) (MMID Y EXP POLICY EFF POLIO l�/ DIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE putr:r.) $ 1,000,000 OAMAGE W'CA X COMMERCIAL GENERAL LIABILITY X IPHPK1196110 7/1/2014 7/1/2015 $ 100,000 CLAIMS-MADE M X I OCCUR MED EXP(Any one person) $ 5,000 X CGL Deductible-$1,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 3,000,000 POLICY I 'II�FA I X I LOC Liquor Liability $ 1,000,000 AUTOMOBILE LIABILITY COPABWE'D SBNGiLE LIMIT 1,000,000 (E,aacc,idonl) $ ANY AUTO ry IPHPK1196110 I 7/1/2014 7/1/2015 BODILY INJURY(Per person) $ ALL OWNED p SCHEDULED BODILY INJURY(Per accident) $ AUTOS P AUTOS X HIRED AUTOS XVI NON-OWNED PROPER I Y DAMAGE $ f AUTOS (Per accident) $ ............... .,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,....... -,.,._r.,.""•__.,.,.,__.,..,_..............................................___ ....,__......................................... X UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 20,000,000 B EXCESS LAB CLAIMS-MADE SSE00057939993 7/1/2014 7/1/2015 AGGREGATE $ 20,000,000 DED I X I RETENTION$ NII $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY I IMITS ER C ANY PROPRIETOR/PARTNER/EXECUTIVEYIN ICRO1144517-2015 1/1/2014 1/1/2015 EL EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? Y] NIA (Mandatory in NH) EL DISEASE-EA EMPLOYEE! $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 1,000,000 ........... ..........................I.........,.,.,.,.,.,.,.....,.,..................,..............,.,....._........................._......... DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Re:400 S.Sepulveda Blvd.,EI Segundo,CA 90245. City of EI Segundo is named Additional Insured per form CG20260413. CERTIFICATE HOLDER I CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of EI Segundo a THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Y g ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Recreations and Parks 350 Main Street AUTHORIZED REPRESENTATIVE EI Segundo, CA 90245-3895 � (,w ��---- --� ©1988-2010 ACORD CORPORATION. All rights reserved, ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PHPK1196110 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED 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 El Segundo Attn: Recreations and Parks Information required to complete this Schedule, if not shown above, will be shown in the Declarations. V 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. In the performance of your ongoing operations; 1. Required by the contract or agreement; or 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 applicable Limits of Insurance shown in the 1. The insurance afforded to such additional Declarations insured only applies to the extent permitted by 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 1 of 1 LETI DATE(MM/DD/YYYY) EVIDENCE OF PROPERTY INSURANCE 6/30/2014 THIS EVIDENCE OF PROPERTY INSURANCE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ADDITIONAL INTEREST NAMED BELOW. THIS EVIDENCE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS EVIDENCE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE ADDITIONAL INTEREST. ` ( CNN COMPANY A) Exl)�(888)825-4322 I master&Associates Philadelphia Indemnity Insurance P.O. Box 6026 Attn: Cash Department 10805 Holder Street-Suite 350 One Bala Plaza, Suite 100 Cypress, CA 90630 Bala Cynwyd, PA 19004 AIC No ADORCM CODE: 1 SUB CODE1 AGENCY DONGOL-001 CUSTOMER ID# INSURED The Lakes at El Segundo LOAN NUMBER POLICY NUMBER Lane Donovan Golf Partners, LLC �PHPK1196110 400 South El Segundo, CAI9024 Boulevard EFFECTIVE DATE EXPIRATION 1/2015 TE CONTINUED OF(-,' Sepulveda � ( TERMINATED IF CHFCKFI.} THIS REPLACES PRIOR EVIDENCE DATED: PROPERTY INFORMATION LOCATION/DESCRIPTION The Lakes at El Segundo Golf Course -400 South Sepulveda Blvd,El Segundo CA 90245 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 EVIDENCE OF PROPERTY INSURANCE 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 COVERAGE INFORMATION COVERAGE/PERILS/FORMS AMOUNT OF INSURANCE Building-Special(Including Theft)Replacement Cost 0, I DEDUCTIBLE 8,877' 2,500' Business Personal Property-Special(Including Theft)Replacement Cost 5,526,021 2,500' b. et Business Income Including Extra Expense 5,241,833 72 Hour Blanket Inland Marine/Golf Carts/Equipment-Actual Cash Value 5,996,215, 1,000 REMARKS(Including Special Conditions) Evidence CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ADDITIONAL INTEREST NAME AND ADDRESS MOR frA EE ADDIFIGNAI..INSURED LOSS P.AYFE City of EI Segundo E 0AN# attn: Recreations and Parks 350 Main Street EI Segundo,CA 90245- AUTHORIZED REPRESENTATIVE ACORD 27(2009/12) ©1993-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD