Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
PROOF OF INSURANCE (2018 - 2019) CLOSED CO/�Q® � DATE(MMIDDIYYYY)
...................
�wl`y�"� ^ ILITY A'c ^ 1�' C 0211212018
THIS CERTIFICATE IS ISSUED ASMTTER OF CERTIFICATE INFORMATION ONLYAND CONFERS NS ORANC[...'ON THRIGHTS E 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 INSU E , ."u
RED, 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 endorsements).
_._._,. _ _.�.. ......., _..........._ _ .._.._.._._..._
PRODUCER CONTACT NAME: Michelle Carl
Prodigy insurance Services,Inc PHHON��tl Mra„ 818-541-7870 FAX Np):, 818-541-7875
3701 Ocean View blvd,STE D E MfrIM"
AhanRCSS: Michelle@Prodigylns.com
Montrose,CA 91020
Y
'
I, I Ar PORDING 4..
A07k: NAIC#
.,
INSURER A... Stillwater Insurance Company 25180
INSURED INSURER B, Capitol Specialty Insurance Corporation 10328
Carol Beck DBA:CDB Golf Properties IN SURER r:
324 18th St INSURER D 1
INSURER E:
Manhattan Beach CA 90266 wsuRER 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 CONTRACTOR 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
NSURANCE ............... �ADfAG
ICY
I/ S,ti'.41kZ' ..._.w...._..............L.. Mfp
..... IiV.9POLICY NUMBER dMOLIDhYEFF POLICY
Y EXP
TYPE OF LIMITS
..... "u,
C MM
AL LIABILITY
AL NER 1,000,000
DAMAGE 10 PEN rLU
EACH OCCURRENCE S
CLAIMS-MADE ��'" ��,OCCUR PREMISES(Ea occurrence) 5
MED EXP(Any one person) S
A X BP8317 02/12/2018 02/12/2019 PERSONAL a ADV INJURY $ 1,000,000
X4 IPEO
re(wa�';Yaq1nJaGq;LIMIT APPLIE SPER: GENERAL AGGREGATE " m S 2,000.000
1;Q' ,
1000, Loc r5C)IJdYY i MI r 6 00,000
I
CTk+k',ae
5
AUTOMOBILE LIABILITY Yv7fIIhJd'a'k w;iIgt+;r t.@':LIhfiV4
td:ti aex'ltdent)
ANY AUTO BODILY INJURY(Per person) 'S
ALL OWNED iI SCHEDULED BODILY INJURY(Per accident) S'
AUTOS AUTOS
. NON-OWNED k4w1 I-"M;I,,I u'iAhdM.+I
HIRED AUTOS ., i AUTOS Iln{.r,rw,;;.ir'�IaasylF
t.
,. .... UMBRELLA LIAB .....,,w,....................................................,.,.,.,.,.,.,.,............ ....__.
OCCUR EACH OCCURRENCE: S
EXCESS LIAB ALttla AGGREGATE r
WORKERS COMPENSATION
....
__ NwYd¢Ihh I
AND EMPLOYERS'LIABILITY STATI ITE. FORH-
k'!N
ANY PROPRIETOR/PARTNERIEXECUTIVE E L EACH ACCIDENT S
,OFFICER/MEMBER EXCLUDED? f ��N 8 A
(Mandatory in NH) EL DISEASE-EA EMPLOYEE S
I{xR:?,d6a+;LR1tl'I!Y'Pd,M u,Rde4
dr rk k'Xrrp;Nd',Yd+d.k .,,..,. .,...O below _F LC"I br,a Pm JI IIC:Y'LIMIT 5
, ..Y..... 7�. .....................��...;'fl'd,;f:t.Adur*ra',�.�...............,,..___.__.. ........... ............ .... ..............
B Professional Liability SUB173912-01 02/12/2........... . .,_-
PER OCCURRENCE 51,000,000
018 02/12/2019I GENERALPOLICY
OL_ICY
AGGREGATE $1,000,000
......................... ..............................
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
The city of EI Segundo is listed as an additional insured on the general liability policy
...�..................................w.....�
CERTIFICATE HOLDER CANCELLATION
m........... ...._. ........._..................
SHOULD ANY OF THE ABOVF DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE T EREOF, NOTICE WILL BE DELIVERED IN
The City of EI Segundo ACCORDANCE WITH THE POLICY P VISIONS
P'
350 Main St �' r
AWJi 1'kIOX�kX"r".M� k;&"^'0":S@- "f l'V'Y„ ✓'�
a
EISe undo . .. ..._.. CA 90245-3813 ..........___....._..... ....................................,., ........... ,...-.. .....,........r
©1988-2014 ACORD CORPORAT'1O _Ajl rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
BUSINESSOWNERS
SB 04 36 01 17
THIS ENDORSEMENT CHANGES YOUR POLICY. PLEASE READ CAREFULLY.
BLANKET ADDITIONAL INSURED
AND BLANKET INSURANCE SU OGATION WAIVER
This endorsement modifies insurance provided under your BUSINESSOWNERS COVERAGE FORM
Section II—Liability is amended as follows: -Z2A--,
The following is added to Paragraph C.Who Is An Insured:
Any person or organization in a written agreement with you requiring indemnification is an additional insured
on your policy with regard to their respective business interest. However, coverage applies only to liability due
to "bodily injury", "property damage", or "personal and advertising injury" caused, in whole or part, by your
acts or those performing operations on your behalf, or in connection with your franchise, equipment, or part of
premises used by you and listed in your declarations, or, if a vendor, likewise when liability arises from "your
product" as distributed or sold in the vendor's regular course of business. Coverage does not apply to liability
resulting from the additional insured's sole negligence.And there is no coverage for structural alterations, new
construction, and demolition steps performed by or on behalf of additional insureds.
Insurance coverage afforded, limits, and the most we will pay on behalf of additional insureds is:
1. Only up to the extent permitted by law;
2. Not broader than your agreement with the additional insured; and,
3. Available under applicable limits of insurance shown in declarations; or whichever is less.
However, insurance afforded to vendors does not apply to:
1. Any express warranty unauthorized by you;
2. Any product physical or chemical change made intentionally by the vendor;
3. Demonstration, installation, service or repair, except on vendor's premises for your product's sale;
4. Package or label changes, use as a container, a part, or ingredient of another thing by the vendor; or,
5. Those who supply products, ingredients, or partof containers, in or affecting your products.
In addition, agreements with additional insureds must be effective during the policy term; and, must be
executed prior to"bodily injury", "property damage", or"personal and advertising injury". A person's or
organization's status as an additional insured under this endorsement ends when your ongoing operations,
occupancy or lease with that additional insured is complete.
Section III—Common Policy Conditions is amended as follows:
A. The following is added to Paragraph A. Cancellation 2. and supersedes any provision to the contrary:
Additional insureds listed in declarations will be informed of coverage changes and given written notice at least:
1. 10 days before cancellation effective date if we cancel for premium nonpayment; or,
2. 30 days before cancellation effective date if we cancel for any other reason; and,
3. 30 days before expiration if we elect not to renew this policy.
B. The following is added to Paragraph H. Other Insurance and supersedes any provision to the contrary:
Primary And Noncontributory Insurance(Blanket Insurance Subrogation Waiver)
This insurance is primary to, and will not seek contribution from, other insurance available to an additional
insured provided:
1. The additional insured is a named insured under such other insurance; and,
2. You have a written agreement stating your insurance would be primary and would not seek
contribution from other insurance available to the additional insured.
SB 04 36 01 17 Page 1 of 1
Includes copyrighted material of Insurance Services Office,Inc.with its permission
001000000000000031718043 000013
STILLWATER INSURANCE GROUP
PRODIGY INSURANCE SERVICES INC
3701 OCEAN VIEW BLVD STE D
MONTROSE CA 91020-1646
We appreciate your business !
PLEASE NOTE THIS UPDATED NUMBER:
TO REPORT A CLAIM PLEASE CALL 1 (800) 220-1351
CDB Golf Properties
324 18TH ST
MANHATTAN BEACH CA 90266-4653
r-1
Ln
M
r-I
O
N
N
O
O
O
19
w
_ � a
�i
a
U av'i Ln u
04
� w Q EQ H
N w
A
v vwi :jQ) U
Fl O O 4j EO H
H a'
PQ CIA >1 �4 x
r� W 0) o w H U
rzi cc��� > .� a Uri x
F U 44
HH www � 0Cc) P ZO
3 � 0o W � riw ww
a w
b CNx
W a M W H
001000000000000031718043 4380A
Stillwater Insurance Group
A 4905 Belfort Road,Suite 110
STILL'S ATER Jacksonville,FL 32256
855-712-4114
INSURANCE COMPANY
NEW
BUSINESS OWNER POLICY DECLARATIONS
Named Insured and Mailing Address Policy Number BP8000317
CDB Golf Properties
324 18TH ST Agency—and Service Contact
MANHATTAN BEACH CA 90266-4653 PRODIGY INSURANCE SERVICES INC
(818)541-7870
Policy Period 02/12/2018 to 02/12/2019 12:01AM Standard Time at the Premises location
**THIS POLICY DOES NOT COVER EARTHQUAKE OR FLOOD DAMAGE **
In return for timely payment and subject to all policy terms and conditions, we agree with you to provide insurance as
stated in this policy,declarations,and every applicable form and endorsement.Also:
• Amount of insurance limits shown are not stackable across locations or buildings;
• With respect to Business Liability and Medical Expenses—each claim paid reduces the amount of insurance
provided during the applicable annual period;and,
• If coverage limits or deductibles are indicated as"included"refer to policy provisions for coverage,
conditions,and amount of insurance details.
PREMIUM AND FEES
.Annual Premium $ 370.05
Terrorism - Certified .Acts $ 3.80
Policy Fee - New Business $ 50.00
Total Annual Premium & Charges: $ 423.85
SB DS 01 11 17 1
001000000000000031718043 OOOOB
SECTION I • PROPERTY: Coverages, Forms, Limits & Deductibles Applicable for Specified Premises
Premises/Location 1, Building 1 324 18TH ST, MANHATTAN BEACH, CA 90266
Square Feet: 0 Building Limit Annual Increase: 40
Use: Management Consulting
Additional Insured: City of El Segundo
350 MAIN ST, EL SEGUNDO, CA 90245-3813
Coverage Form Number Limit Deductible
Business Personal Property (BPP) BP 00 03 07 13 $15, 000 $1,000
Business Income BP 00 03 07 13 12 Months 72 Hours
Accounts Receivable BP 00 03 07 13 $10,000 $1,000
Arson Reward SB 04 02 05 15 $10,000 None
Extra Expense BP 00 03 07 13 12 Months None
Fire Department Service Charge BP 00 03 07 13 $2,500 None
Fire Extinguisher System Recharge BP 00 03 07 13 $5, 000 None
Fur, Jewelry or Patterns Theft or Damage BP 00 03 07 13 $2,500 $1, 000
Lock Replacement SB 04 06 05 15 $1, 000 None
Pollutant Clean-up and Removal BP 00 03 07 13 $10,000 $1, 000
Valuable Papers and Records BP 00 03 07 13 $10,000 $1, 000
SECTION I PROPERTY: Coverages, Forms, Limits & Deductibles Applicable Per Policy
Coverage Form Number Limit Deductible
Computer Operations Interruption BP 00 03 07 13 $10,000 72 Hours
Electronic Data Damage BP 00 03 07 13 $10, 000 $1, 000
Forgery or Alterations BP 00 03 07 13 $2,500 $500
SECTION II - LIABILITY AND MEDICAL EXPENSES: Coverages, Forms & Limits Applicable Per Policy
Additional Insured: City of El Segundo
350 MAIN ST, EL SEGUNDO, CA 90245-3813
Coverage Form Number Limit
Medical Expense - $10, 000 Any One Person BP 00 03 07 13 Included
Personal & Advertising Injury BP 00 03 07 13 Included
Business Liability - Per Occurrence BP 00 03 07 13 $1, 000,000
Business Liability - Aggregate BP 00 03 07 13 $2, 000,000
Business Liability - Prods-Completed Ops BP 00 03 07 13 $2, 000,000
Damage to Premises Rented to You BP 00 03 07 13 $100,000
SB DS 01 11 17 3
001000000000000031718043 OOOOB
SECTION III - ADDITIONAL FORMS: Applicable to All Premises and Coverages
Coverage Form Number
Calculation Of Premium BP 05 01 07 02
California Fraud Statement IL N 018 09 03
California Privacy Statement PRIVACY CA 05 12
Exclusion - Punitive Damages SB 04 03 08 14
Exclusion of Loss Due to By-Products of Production or Processing SB 04 17 08 14
Operations
Cap on Losses From Certified Acts of Terrorism BP 05 23 01 15
Disclosue Pursuant to Terrorism Risk Insurance Act BP 05 is 01 is
California Disclosure Notice FNIC DN CA 01 06
Primary and Noncontributory - Other Insurance Condition BP 14 88 07 13
Exclusion - Fungi or Bacteria (Liability) BP 05 77 01 06
Blanket Additional Insured & Subrogation Waiver SB 04 36 01 17
California Changes BP 01 55 05 17
Employment-Related Practices Exclusion BP 04 17 01 10
Exclusion - Access or Disclosure of Confidential or Personal BP is 05 05 14
Information and Data-Related Liability
Exclusion of Certified Acts of Terror - Nuclear, Biological, BP 05 26 01 15
Chemical, or Radiological
Signed: ,I-
by: Mark O. Davey, CEO
SB DS 01 11 17 5
001000000000000031718043 OOOOB
A R INSURANCE BINDER DATE(MM/DDffY-YY)
1 02/12/201,18
THIS BINDER IS A TEMPORARY INSURANCE CONTRACT,SUB!ECT TO THE CONDITIONS SHOWN ON PAGE 2 OF THIS FORM.
AGENCY COMPANY BINDER#
Prodigy Insurance Services, Inc Nationwide Insurance Comf,,)arly PA 3008634534
3701 Ocean View Blvd, Suite D I nATE EIPI:I TIME DATE (,XPIRATPON TIMI
Montrose, CA 91020 02/12/2018 1 12:01 IIIX : kM03/12/2018
PIVI
pflo 4 FAX
IN",I"r�.xq:(818)54 1-7870 tAIC,��o 1,,(818),541-7875 TI IIS UII IS ISSUED TO EXI :ND COVURAUZ IN TI Ir ABOVE NAMED UC)MI'A10
CODE:52839 SUB CODE: PI I XPIRING,POLICY ft
AGr,NdY DESCRIPTION OF OPERATIONS I VEHICLES I PROPERTY(Including Location)
Y,5TOM
TOM"
LR I U;
INSURED AND MAILING ADDRESS
Carol Beck
324 18th St
Manhattan Beach, CA 90266
-COVERAGES
TYPE OF INSURANCE COVERAGEIFORMS DI DUCT liW- COINS% AMOUNT
I PROPITIRry cAUSFS 04 1,01,S
I
Ell,�I, 1 kWijPlI, �xl
GENERAL LIABILITY ](x,'0jIflfl NCIL
i;6:..PJIhtILItC`I(wl PAWN61h H"
CM:iiiA?Al,I VV31ure Rt N I,N D I'M MIGs
(,LAINAS,MAI)IL 0GICIURI ItrfLIJ (Allv''Iiejpu,oi[1
TW.': &ADV INJURY S
GIFINI.IRAI
tLIROL)Afl IC*�CLAIMS-II PreGIA)CI'S COMPiOVIAGG,
VEHICLE LIABILITY COW IINI 1)1,71ftd 1:LINAI I S
ANYAllITO U+NIfl 0 INJURY 11107 owl.o,o 250,000
OWN1.0 ALI US ONI Y -)Ull,v 01SURY aujounir 5 500,000
X sclii ouLl DAI-1105 PROMLIRWIDAMAGI, 5 100,000
I I IIHI.DAUCG ONLY I PiO MILNTS $
NON OWNI D ALFICjS ONI Y I I IERSONAL LUI I IRC7
UNINSURED I001 01RIS I
mora„o iPi R,1,11 Ill S
VEHICLE PHYSICAL DAMAGE DED 'J,11 0 �I�l I GA%;1lVA(lJI,
X COLLI'SION 1000 2013 Jeep Grand Cherokee STAH DAMOUNT S
_jy,1 0 r I il N I HAN CO). 1000 1, 1C4RJEBGODC539217
GA
RAGIL LIAITI IT'Y ALI 10 ONI Y-LA ACCIDLINIl' 5,
ANY ALI Y 0 011ir-IR lHAN A010 ONLY
I A' IA��l„MDI I'll
A G G R L 0A I E
EXCESS LIABILITY I ACt I OCCURRI.NI 5 11,000,000
X I-11I I A I(_)HKI AGGREGAIIl, $
�)iilioP: [I Wq UMINN 1, A,1:ORIVI IN I HO OAW FLA4 Cl V1,;,1011 N4Skfl<D 11;1:
I'l.I Y S TA 10 R'
WORKER'S COMPENSATION I 4 Ac!C:00N I
AND
EMPLOYER'S LIABILITY L I. DIGIA',V, [A EII OYI 1: S
L_ 1311.,&ASU�I L JOIT S
.
......... ...........
SPECIAL Fl E-S
CONDITIONS IS
OTHER
COVERAGES LS1IMAY Lf01AL PRI.IAIUM
.... ..........
NAME t ADDRESS
AD1ffIQN,`fl. f I OSS PAY1 L IvQk
I LOSS PAYAIFII E
I
I OAN
AUn ICIRIZIFID REPIRESIEWwwr.
....................... ——--___-
Page I of 2 @ 1993-2016 ACORD CORPORATION. All rights reserved.
ACORD 75(2016103) The ACORD name and logo are registered marks of ACORD
Printed by on February 12,2018 at 04:35PM
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 1 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.
C_J 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#
X► I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not
employ any person in any mariner 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 § 37'00 1 must
immediately cpNywitnto � � e reernent will automatically become void,
Signature Appli � r
ma�Date :� :��
Print Name
Agreement for: li!-)fb
Dated: _!
Reviewed by* ,,,., _M.,..._...