Loading...
PROOF OF INSURANCE (2018 - 2019) CLOSED Policy Number: Date Entered: 02/07/2018 AC R" CERTIFICATE OF LIABILITY INSURANCEI DAT j2DD/ 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 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 rights to the certificate holder in lieu of such endorsement(s). I PRODUCER CONTACT COLLINS INSURANCE AGENCY N,AIIAP4 PHONE520 S. EL CAMINO REAL STE 300 � ,I, ialc,r�o,, -5072 (650)342-6461 fl .... . (650),3.4.2,,,.................... E•MiAIL SAN MATEO, CA 94402 INSURER(S)AFFORDING COVERAGE NAIL# _ INSURER A:Farmers Insurance Exchange he_ INSURED TDardanelle Group Inc, INSURER B:w&s6amm World Insurance Company .................. ............................... INSURER C 106 S. Catalina Avenue INSURER D: Redondo Beach, CA 90277 INSURER E I INSURER F t 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 INS Rgudk, _. TYPE OF INSURANCE ., I.NSP.14kYR...... LPC)"W".IG' IEF Air4'Y&r4"dE10.Y. POLICY NUMBER MMdODlyYYY IG,M,MlL1OPYYYP, LIMITS . . MCLAIMs-MADEERALuOCCUR 604327926 ............... . ���arl�;DAMACW"rFa�I�.ABILITY EACH E .,...a..2,"OOO,OOOWWWWWu A .C.o.� X 01/15/2018 01/15/2019 ,�'�elsns $ 75,000 000 _. MED ExP(AnP,..°".e..Pe.[s"4."?.............E....5..(...................................................... PERSONAL&ADV INJURY $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,OO,000 POLICY n 4 TS COMP/OP AGG $ 2,000,000" a LOC PRODUC l OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 2,000,000 (FR,qCC dont) ANYAUTO X 604327928 01/15/2018 01/15/2019 BODILY INJURY(Per person) $ A OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTOS HIRED 'AUTOS ONLY AUTOS ONELYY Pmr�9C PI�,r9po)hMF4C'L�. $ $ UMBRELLA LIAB OCCUR EACHCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DFD I I RETENTION $ WORKERS COMPENSATION IPER STATUTE I ERH AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNER/EX ENT (Mandat M in N R EXCLUDED?ECUTIVE ❑ NIA E�L,DISEASE C®A EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS belowE L DISEASE-POLICY LIMIT $ Professional BRLO.O. 5094.....................................................0............................. 7/13/20177 07/13/2018 B Liability/E&O $1,000,000 .......................I.................I.,................. ............www_. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of E1 Segundo, its officials and employees are listed as Additional Insured CERTIFICATE HOLDER CANCELLATION City of E1 Segundo 350 Main Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo, CA ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE N ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Produced using Forms Boss Plus software. www.FormsBoss.com; Impressive Publishing,LLC 800-208-1977 POLICY NUMBER: 604327928 BUSINESSOWNERS BP 04 48 01 97 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESSOWNERS POLICY SCHEDULE* Name Of Person Or Organization: CITY OF EL SEGUNDO ITS OFFICIALS AND EMPLOYEES * Information required to complete this Schedule, if not shown on this endorsement, will be shown in the Decla- rations. The following is added to Paragraph C. Who Is An Insured in the Businessowners Liability Coverage Form: 4. Any person or organization shown in the Schedule is also an insured, but only with respect to liability arising out of your ongoing operations or premises owned by or rented to you. BP 04 48 01 97 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 ❑ 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. 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 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 employ any person in any manner so as to become sub iect 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 immediate) comply I w ith thosens or the agreement automatically become void. Signature of Appllcant Date Print Name Agreement for Dated: I Reviewed by: ~ '