PROOF OF INSURANCE (2018) CLOSED DONOGOL-01 MlP QQ $
'
DATEInCERTIFICATE OF LIABILITY INSURANCE I 0311212018
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).
B p Holder&Ass,Associates
5tt cT _...................................
PRODUCER NAM
Sui
'ter 5 AssOciiates Insurance Agency,Inc. N'11DNE FAX
(AIC, Eid1:(714)733$200 AAI,No):(714)252$253
Cypress,CA 90630 W46s:
IN:SURER('S)AFFORDING COVERAGE NAIL 0
IN'SURERA:Phi'ladelphia Insurance Companies
INSURED INsuRER D.:Allianz 211873
The Lakes at EI Segundo INSPIRER c:
400 S.Sepulveda BI. INSURER D,.
El Segundo,CA 90245
ENSURERE.
INSURER F!
COVERAGES CERTIFICATE NUMBER: REVISION NUMBED:
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.
IL'R TYPE OF INSURANCE IINSD"ADOLS D POLICY NUMBER POLICY yYYLJM POLICY EXP LIMITS
A X COMMERCIAL GENERAL LIABILITY EACHOCCURRENCS: S 1,000,000
CLAIMS-MADE X OCCUR X PHPKI674604 07/01/2017 07/01/2018 PR AGEToR Do=rre�) $ 100,000
MED EXP(Any one person) s 5,000
PERSONAL,S ADV INJURY $ 1,0'00,000
GE'N'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 3,000,000
X POLICY PES _ LOC PRODUCTS-COMP/OP AGG $ 3,000,000
OTHER, $
A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000
(Ea pCpdent)X ANY
$
OWNED AUTO
SCHEDULED PHPKIS74604 07/01/2017 07/01/2016 BODILY,INJURY(Per person) $
AUTOS ONLY AUTOS L� BODILY INJURY,(Per acadenl)„$
X AUTOS ONLY X �R% N~9' I R��ERTY�IDAMAGE $
Igo �� S! I'1
B UMBRELLA LIAR X OCCUR EACH OCCURRENCE S 20,000,000'
X EXCESS LIAB CLAIMS-MADE SSE162'93343 07/01/2017 07/01/2018 AGGRE'GAT'E $ 20,000,000
DED X RETENTION$ $
WORKER'S COMPENSATION, I PEROTH-
ANO EMPLOYERSS'LIABILITY YIN STATUTE, ER
ANY PROPRIETORPARTNERE CUTIVE L N I A
(Man a JMZVF „EI.,,EACHACCIDENT $
E L-DISEASE-EA EMPLOYEE: $
If yyes dosaft uncler
DESCRIPTION OF OPERATIONS Low E I. DISEASE-POLICY LIMA'T $
A Liquor Liability 11PIRIP11<1674604 07/01/2017 0710112018 Each OccurlAggregate 1,000,000
i I
DESCRIPTION OF OPERA'T'IONS I LOCATION'S A VEHICLES 1ACORD 101,Additional Remarks Schedule,mry be attached N more space is required)
RE:400 S.Sepulveda Blvd.,EI Segundo,CA 90245.
City of EI Segundo is Additional Insured perform CG20260413.
ER1fIF'ICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
C Of EIS undo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Attn:Recreations and Parks
350 Main Street
EI Segundo,CA 902453895 AUTHORED REPRESENTATIVE
9T. v —v� _
ACORD 25(2016103) ®1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: PHPK1674604 COMMERCIAL GENERAL LIABILfrY
CG 20 26 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED
PERSON R 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 EI Segundo
Information required to complete this Schedule, if not shown above,will be shown in the Declarations.
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. Required by the contract or agreement; or
1. In the performance of your ongoing operations;
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
1. The insurance afforded to such additional applicable Limits of Insurance shown in the
insured only applies to the extent permitted by Declarations.
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 0413 0 Insurance Services Office, Inc.,2012 Page 1 of 1
DATE(MM/DD/YYYY)
ACI AR& CERTIFICATE OF LIABILITY INSURANCE
03/19/2018
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 CONTACT
NAME,
PHONSelf Insured Solutions ( No, Ell: (800)592-0047 FAX
No,W: (800)592-2541
Administrator,California Restaurant Mutual Benefit Corp. p `RFK: siscerts@selfinsuredsolutions.tom
430 N Vineyard Ave..#102 INSURER(S)AFFORDING COVERAGE NAIc#
Ontario,Cpl 91764 INSURER& California Restaurant Mutual Benefit Corp.*
INSURED INSURER B: State National Insurance Company 12831
Donovan Golf Courses Management,Inc. INSURER C:
Affiliate of California Restaurant Mutual Benefit Corp. INSURER D:
c/o Bowermaster&Associates P.0.Box 6026 INSURER E:
Cypress,CA 90630 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 EQUIREMENT,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.
I S MMEFF POUCVEXP
R COMMERCIAL NSURANLABIUTY INSR POLICY NUMBER IM
TR D MM D"y") ... LIMITS
EACH OCCURRENCE j$ I
CLAIMS-MADE OCCUR DAMAGE TO RENTED $
PREMISES(Ea o=rrence)
MED EXP(Anyone person) $
t............ .�
PERSONAL&ADV INJURY $
AGGREGATE $
PROJECT LOC PRODUCTS GE?IPOLICY AGGREGATE LIMIT APPLIES PER: GENER
COM
OTHER
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
ANYOWNED SCHEDULED BODILY INJURY
AUTOS AUTOS (Per accident) $
HIRED AUTOS NON-OWNED PROPERTY DAMAGE
AUTO (Per amident)
UMBRELLA EACH OCCURRENCE $
EXCESS L AB AB CLAIMS-MADE F717 AGGREGATE $
DED (RETENTION$ $
WORKERS COMPENSATION X WCSTATU- OTH-I
AND EMPLOYERS'LABILITY YM ! TORY LIMITS ER
A ANY OFFICFJME BERR EXCLUDED?EXECUTIVE N N/A X II, 4517-1682 01/01/2018 01101/2019 E.L.EACH ACCIDENT1 $1,000,000.00
(Mandatory in NH) E.L DISEASE-EA EMPLOYEE $1,000,000.00
Ilyes,describe under ....
E
DESCRIPTION OF OPERATIONS below .L DISEASE-POLIcrLIMIT $1,OD0,000.00
BEXCESS WORKERS COMPENSATION I( I rNDE-0864486-17 01/01/2018 01/01/2019
�
AND EMPLOYERS LIABILITY Applicable to WC Statutory Limits and Employers
Liability Limits.
DESCRIPTION OF OPERATION'S/LOCATION/VEHICLE'S(Attach ACORD 101,Additional Remarks Schedule,if more space Is required)
Re:Golf Course:The lakes at EI Segundo—400 S.Sepulveda Blvd.
••Waiver of Subrogation applies-see attached•'
*Complies with the requirements of the Director of Industrial Relations under the provisions of Sections 3700 to 3705,inclusive,of the Labor Code of the State of California,holder of Master Certificate
of Consent to Self-Insure No.4517
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POuaES BE CANCELLED BEFORE
City of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Attn:Recreations and Parks ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street, AUTHORIZED REPRESENTATIVE
EI Segundo,CA 90245-3895
A.Seegmiller
m 1988-2010 ACORD CORPORATION. All rights reserved
ACORD 25(2014/01) The ACCORD name and logo are registered marks of ACORD
WORKERS COMPENSATION AND EMPLOYERS LIABILITY California Restaurant Mutual Benefit Corp.
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS
We have the right to recover our payments from anyone liable for a covered injury. We will not enforce our right against th
person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a
written contract that requires you to obtain this agreement from us.)
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. ,, M
Schedule
Name of Person or Organization:
City of EI Segundo
Attn:Recreations and Parks
350 Main Street
El Segundo
CA 90245-3895
Insured: Donovan Golf Courses Management,Inc. Policy No.: 4517-1682