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PROOF OF INSURANCE (2018 - 2019) CLOSED . CERTIFICATE OF LIABILITY INSURANCE 04/2512018 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 CERTWICATE HOLDER IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed i If SUBROGATION IS WAIVED,subject to the germs and cwWRions of ttw policy,certain policies may require an endorsement A statement on thb cortlfleeee does not confor rights to the conHleate holder In lieu of such endorsenwnt(s). PRODUCER 00'4TJtCr Jim Hussey swehirm PRONE Ate: 310.547.4433 310.547.4445 d:IN�G».Nrt. . Hussey Insurance Agency Inc. APOW1, 1000 N western Avenue,Suile 202 IN.EFSl AFFORDING C V RAGE MAIC s San Pedro, CA 90732 State F arm Genual Insuranoe Company 25151 e , State Farm Mutual Automobile Inwranoe Company 25178 VtBGarn Raoowschl R c a State Farm Fre and Casualty Company 25143 .,.. ,._ 1924 Vakecito Drive � R D San Pedro. CA 90732 IN$URRVA r .COVERAGESISO CERTIFY THAT THE POLICIESCERTIFICATE OFCNUMBER: $NSU CELISTED BELOW HAVE"BEEN iSSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDMON 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 CLANS. INTYPE SKI NINAet]t UUM LTR��COMMERCIAL MURAL IJMIl1T/ Of INSURANCEsur t F s 1.000.000 � Sfi 300.000 - I _ Eswlses�s- s , MED Exp is 5.000 A Y Y 92-E9-N288-8 04/01/2018 04/01/2019 aAOVINJURY s 1.DO0.000 EUMIT LOC GENERALA TE S 2.000,000 prrN"4 AK"i�"att't 4idu'G' II I C9TYtCtt N Ls C _.. ." S 1,000.000 -w..._ _.... $ �AUTOMOe1LE LNa1LrrY SCHEDULED IED. . -. _ if I mn INJURY fear lD�r 1 I 1„ „YQd WT S ANYAUTO ILY 585 8919-D27-75 11!2912017 11/292018 4100 B AUTOSONLY BOOXY INJURY flt1 S 1,o�0,000 HIREO OS Y T LY �il�t:o-e6,WAVE S 1,000.000 IS uMerw uAe A,OCCUR EACH ODCLRRDO;T ) A EKC xa LIAs 1 txAlMs c> ' t T'� x . ' Dr'p . 9fTr°r'TtOPJS t 64 AND C rirrlu D r� � N MIA Y 92-E9-W882.9 04!1(312018 05!1612019 ��CH W dNSAATWN .ray �d wcw iot ,rrEt UTIYL TY Ya t..n.. 'tt . 1.000.000 fMm "1n N H) gg�� � � :t:tNTwr'tP'�rl"l, s 1,000.000 Irkt: ��t r rtAw l'f AA.K tw�4�w, E L.DISEASE-POLICY LIMIT. _ w ft ..... S 1.000,000 DESCRIPTION OF OPERATIONS f LOCATIONS r VINIC S(ACORD i4r,AOMMM RMmrlw Sc NG^may be&VMFwa rr MM tern h ra pu j EVeI'tC 4!2912018 S 4/27/2018 CERTIFICATE H'O'LDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN city of El Segundo ACCORDANCE VITA THE POLICY PROVISIONS. 350 Main Street EI Segurdo. CA 90245 AUMORUED 59NIATM ®1988'-2'018 ACORD 1 PO'RATION. AN rigt is reserved,. ACORD 25(2016103) The ACORD name and Ingo are registered marks of ACORD t t w2 1� 6 1011 0 1 DAMIUMOD""In , ACC>I?V CERTIFICATE OF LIABILITY INSURANCE 04116120111 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 cortificate holder is an ADDITIONAL INSURED,the policy(les) must be end ed, It SUBROGATION 15 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 cridor"n n1(s). .............rrrrrrrrrrrrrr'. ---r r 1.- I , ,�0_ Ct)NJACLT Jim H,ssey .S019: Hussey Insurance Agency Inc, PHONE 310547-4433rA WCAV�Exl)� .111111111 .. 1111 ........... 1000 N. Westem Ave, Suite 2202 EAMIL '1( 'SL' AR)Revs11rn,2�'-, Y, San Pedro, Ca, 90732 INSUREMS)AFFORTWOxC V UGE NAIL V INSURER A.State Farm Genaril 4)suranwr Carnp--viy 25151 INSURED William Racowschi 1924 Vallecito Dr, San Pedro, Ca. 90732 oNSURER E. SUftCRr_ -C-6—vERAGES CERTIFICATE h1t;W6iR: REVISION NUMBER: AB H POLICY THIS'fiF0—CERTIPY THAT THE POLICIES OF: INSURANCE LISTED BELOW HAVE STEN ISSUED TO THE INSURED NAMED OVE FOR R T E PERIO0 INDICATED, NOTWITHSTANDING ANY REOUIREMENT, TERP.1 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 TEERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. —1ADUL SIJ54� 'r'F fitit jCy EXP A X COMMERCIALS4AGENERAL LIAMLITY y ,i,I. N trrrva a<s d > I t.r i II w'U0O CLAACAOt (x-V--- 92-E9N2888 11410112018 XGF: , LIMMi I . S 1,000,00000 UL AEGATE Li,Wn' CGRRCI' APPLIES PER NUOAGM-rATE I 2,09-par 1111._ :CT 0 3 4 AUTO OINLE UASILITYNru 1,000,001D ANY AU10 259 7655 8-754 1112SIZOIS ,,2WU,S 1111. _1111. AU OvN&D sci-ir-OLILEL! i AUTJd AUIUS BODKY INJURY(Per;A,�Jw NON QIANFI) 141RC4 kiffos tk1T0S X UMBRELLA Ll AB OCCUR 92-NX-6733-0 1010712016 1=712018 1,000,4D4 1EXCESSLIAD '%,A11Ar MAOF 'Ir reI 10�N WORKERS COMPE"ATION AND EMPLOYERTUARILITY Y1 N Al,y J,W)VE .1 CMENT 1,000,000 N?AY 92-E9 6829 04116120ig 0411&2019 AC-- (Nlawialary,n N14) 9,opo,4G4 DESCRIPTION of OPOWATIoWS i LOCATIONS.'VEMCLE3(ArORD 101,A"H0081 RWnWko fthadkft.may be H.Ched 4 moraGPM*IS requkad) CERTIFICATE HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIIIIED POLICIES BE CANCELLED BEFORE 350 Main St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo.Ca 90245 ACCORDANCE WITH THE POLICY PROVIStONS, AUIZ11OR R6 » C}94 ACORD CC IIS RATION.Ail eights reserved, ACO RD 25(2014101) The ACO RD name and logo are registered marks of ACORD 1001486 132849.9 02-04-2014 Policy No. 92-E9-N288-8 CMP-4860.1 Page 1 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY CMP-4860.1 ADDITIONAL INSURED— DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 92-E9-N288-8 Named Insured: William Racowschi 1924 Vallecito Drive San Pedro,CA 90732 Name And Address Of Additional Insured Person Or Organization: CITY OF EL SEGUNDO, ITS OFFICERS,OFFICIALS,EMPLOYEES,AGENT AND VOLUNTEERS 350 MAIN STREET EL SEGUNDO, CA 90245 1. SECTION 11 — WHO IS AN INSURED of b. If coverage provided to the additional in- SECTION ll — LIABILITY is amended to in- sured is required by a contract or agree clude, as an additional insured„ any Berson or ment, the Insurance provided to the organization shown in the Schedule, but only additional insured will not be broader than with respect to liability for "bodily injury", that which you are required by the con- property damage", or"personal and advertises tract or agreement to provide for such ad- ing injury" caused, to whole or in pail, by: ditional insured; and a. Premises And Ongoing Operations c. if the contract or agreement between you Your acts or omissions or the acts or and the addI tlonal insured is governed by omissions of talose acting on your behalf: California Civil Code Section 2782 or 2782.05, the insurance provided to the (1) In connection with your premises;or additional insured is the lesser of that, (2) In the performance of your ongoing which: operations; or (1) Is allowed for the satisfaction of a de- b. Products–Completed Operations fense or indemnity obligation by Cali- "Your worm" performed for that additional fornia Civil Code Section 2782 or insured and included in the "products- 2782.05 for your sole liability; or completed operations hazard". (2) You are required by contract or However, Paragraph 1. above is subject to the agreement to provide for such addi- following: tional insured. a. The insurance afforded to the additional We have no duty to defend or indemnify the insured only applies to the extent permit- additional insured under this endorsement un-, ted by law; til a claim or"suit" is tendered to us. Q.Copyright,State Farm Mutual Automobile Insurance Company,2013 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. CONTINUED CMP-4860.1 Page 2 of 2 2. Any insurance provided to the additional in- (3)The nature and location of any injury sured shall only apply with respect to a claim or damage arising out of the "occur- made or a "suit" brought for damages for rence" or offense; which you are provided coverage. This endorsement shall not increase the ap- b. Tender the defense and indemnity any plicable Limits Of Insurance shown in the claim or "suit" to uss and to all other insur- Declarations. ers who may have insurance potentially available to the additional insured; and 3. With respect to the insurance afforded to the additional insured, the following is added to c. Agree to make available any other insur- SECTION II—LIMITS OF INSURANCE: ance the additional insured has for de- If coverage provided to the additional insured fense or damages for which we would is required by contract or agreement, the most provide coverage under SECTION 11 we will pay on behalf of the additional insured LIABILITY. will be the lesser of the amount of insurance: 5. With respect to the insurance afforded the ad- a. Required by the contract or agreement; or ditional insured, the following replaces SEC- b. Available under the applicable Limits Of TION II — LIABILITY of Paragraph 7. Other Insurance shown in the Declarations. Insurance of SECTION 1 AND SECTION II — COMMON POLICY CONDITIONS: This endorsement shall not increase the ap- plicable Limits Of Insurance shown in the a. This insurance is primary to and will not Declarations. seek contribution from any other insur- 4. With respect to the insurance afforded to the ance available to the additional insured, additional insured, the following is added to provided that the additional insured is a Paragraph 3. Duties In The Event Of Occur- named insured under such other insur- rence, Offense, Claim Or Suit of SECTION II ance. --GENERAL CONDITIONS: b. Regardless of any agreement between The additional insured must: you and the additional insured, this insur- a. See to it that we are notified as soon as ance is excess over any other insurance practicable of an "occurrence" or an of whether primary, excess, contingent or on fense which may result in a claim. To the any other basis for which the additions in- extent possible, notice should include: sured has been added as an additional in- (1) low, when and where the "occur- sured on other policies. rence"or offense took place; There will be no refund of premium in the event (2) The names and addresses of any in- this endorsement is cancelled. ,lured persons and witnesses; and All other policy provisions apply- CMP-4860.1 1007042 148020 08-26-2014 - 0,Copyright,State Farm Mutual Automobile Insurance company,2013 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. PolicyNo. 92-E9-N288-8 CMP-4787 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY CMP-4787 WAIVER OF TRANSFER OF RIGHTS OR RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 92-E9-N288-8 Named Insured: William Racowschi 1924 Vallecito Drive San Pedro, CA 90732 Name And Address Of Person Or Organization: City of EI Segundo, its officers, officials, employees, agent and volunteers 350 Main Street EI Segundo, CA 90245 The following is added to Paragraph 10.b. of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: We waive any right of recovery we may have against the person or organization shown in the Schedule because of payments we make for injury or damage arising out of: a. Your ongoing operations; or b. "Your work" done under contract with that person or organization and included in the "products- completed operations hazard". This waiver applies only to the person or organization shown in the Schedule. All other policy provisions apply. CMP-4787 1006225 137715.1 11-19-2013 O,Copyright,State FarmMutual Automobile Insurance Company,200'6 Includes copyrighted material of Insurance Services Office,Inc.,with its permission, 0411712018 10: 57 1 INSURANCE PAGE 02/02 DATE iMM1DDA"" CERTIFICATE OF LIABILITY INSURANCE _ 1 411712018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE FOLDER. 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 THI: ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificat4a holder is an ADDITIONAL INSURED,the polloy(ies) must have ADDITIONAL INSURED Pr AsIons or be endorsed. If SUI ROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does prat cp er ri0httr to the certificate holder In lieu of such endorsemantt.), r.ONT'Aca^r Ix et BAWL: — CARPENTER ._..... DAVE CARPENTER INSURANCE~ ��,,r,nn� 310-325-43565 1 It's.No)t 310.326-7037 22$660 Crenshaw Blvd. #203 I" " ar�rTT Torrance,CA 90500 INSURERIS,)AFTr1F4.OINO COVERAGE � Arc-#—, .. 0688275INSUAERA. UNITED STATES LIABILITYINS.CO. INSURED — INSURER D TTP TRAINING IN)7URER c � 1024 VALLECITO DRIVE IH IrJE �taSlrRa a SAID PEDRO CA 90732 COVERAGES C'ERTIFICAT'E NUMBER; REVISION NUMBER' THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED Aeow 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 TEFWS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. p R Abut;SUOR,. � . POLIC" POLICY F-xp TYPE or INSURANCE ] t1) LIMITS11t r layY '. COMMERGMI.GENERAL UABIWYY FµACH OCCAMENC.9 1,QOQ�QQQ CLaIMs MAdE 0 OCCUP P rIEa IIeiil l�°.D $ NA f � _ MED EXP(Arsy one mrson) S A X PROFESSIONAL F-&O SP 1568170 41MG12018 4/1012019 PERSONAL&ADV INJURY $ NA raaCNI" AGGREGATE LlMrr APPLIES PER: � ENCMAL AGGREGATE � S 1.000.000 PRO- POLICY 0 JECT Q LOC PFtODUCTS'COMPlOPAGO $ — NA 2 3TiR' $ AUTOMOBILE LIABILITY C,C)114i1NEb rNOLE LVt AGT S ANY AUTO �B01 ILY INJURY(Per penton) $ t7WN® SCHEDULED BODILY INJURY(Paraeddent) $ AUTOS ONLY AUTOS HIRED NON-OWNED P OP'EriTYfSIdAGE $ AUTOS ONLY AUTOS ONLY I sides:l $ A$ „ UMBRELLA IJABOCCUR 5-MADE — EACH OCCURRENCE $ EXCESSI.IAa AGGREGATE $ , DIED I J R, FN-rlEira s WONKETIE COr ftNSA IDN 1 I STATt)TEL. ER Aai KMPLOYEFW LIABILITY — ANY PROPRIE'Y WPARTNEWENEOUTNE Y f N C.L.EACH ACOMENT S QFFICEsiAWEMB $3 EXCLUDED? � NIA (Mandahary In rlH) E.L.DISEASE-FA EMPLOYEE $ If y descdba undor C2E�aI� rT1DN or op eRATIONS bal,. E.L.DISEASE-POLICY(IMIT $ I DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 11611,Addlllon*Remarks Sahedule,may be a!)aehed M mora apace Is Mqulred) PROFESSIONAL SERVICES-TRAINING CERTIFICATERTCERTIFICATEHIOLDER ... CANCELLATION SHOULD ._�. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE PXPIRATION DATE T"FRE'OF', NOTICE WILL BE DEUVEFW-D IN ACCORIJANCE WON THE POLICY PROVISION$, AUTHORM90 REPRESENTATIVE 90II.2015 AC64 6 R'PErI'ATibm All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks Of.ACORO Policy No. 92-E9-W882-9 i 787 Page THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY CMP-4787 WAIVER OF TRANSFER OF RIGHTS OR RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: SCHEDULE Policy Number; 92-E9-W882-9 Named Insured: William Racowschi 1924 Vallecito Drive San Pedro; CA 90732 Dame And Address Of Person Or Organization: City of EI Segundo, its officers, officials, employees, agent and volunteers 350 Main Street El Segundo, CA 90245 The following is added to Paragraph 10.b. of SECTION I AND SECTION 11 — COMMON POLICY CONDITIONS: We waive any right of recovery we may have against the person or organization shown in the Schedule because of payments we make for injury or damage arising out of: a. Your ongoing operations;or b. "'your work" done Linder contract with that person or organization and included in the "products- completed operations hazard". This waiver applies only to the person or organization shown in the Schedule. All other policy provisions apply. CMP-4787 1006225 13T715.1 11-19-2013 ®,Copyright,State Farm Mutual Automobile Insurance Company,2fl08 incudes copyrighted mnatedal of insurance Services office,Inc.,v iM its permission.