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PROOF OF INSURANCE (2018 - 2018) CLOSED
Y I DATE(MMIDD/YYVY) CERTIFICATE OF LIABILITY INSURANCE 04/12/2018 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 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). PRODUCER 'CONTACT' Rebecca Huddle NAME; Becky Huddle Insurance Agency PHONE 916-789-7500 FAX 916-789-2545 IAdC.N+s,. wul INC,Nol: 729 Sunrise Ave Ste 504 E�MAIN staff.rhuddle farmelsa enc A,DORCSS,. ° g y•com Roseville CA 95661 INSURER(S)AFFORDING COVERAGE NAIC9 INSURER A:MID CENTURY INSURANCE 21687 INSURED INSURER B: Lotus Communications INSURER C: 737 W 31st St Unit A INSURER D: San Pedro,CA 90731 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 POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY SAID CLAIMS. NSR AWLiSUORi POLICY EFF POLICY EXP LTR TYPE OF INSURANCE I I' POLICYNUMBER IMMIDD/YYYY) I;MWDWYYYY)� LIMITS COMMERCIALGENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE O OCCUR 60669-02-33 10/01/2017 10/01/2018 (JAMAVL TO RENTED PREMISES.(Eaocc. ccurrenre) $ 100,00„ �I MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2,000000 POLIO PRO LOC PRODUCTS-COMP/OPAGG $2,000 Jt.r,T ,000 AUTOMOBILE LIABILITY LiLi C)�BB„xp•ddEDt�rrd!GLEd,IMIl.1 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS $, ,i AUTOS ONLY AUTOS BODILY INJURY(Per o ) AUONLYHIRED Rg0PEw1"YgLkIMMAbE . .. $ AUTOS ONLY TOS . . $ III UMBRELLA LABOCCUR I0..-..,J EAqHOCCURRENCE $5,000,000 A EXCESS LIABCLAIMS-MADE, 60669-09-68 10/01/2017 10/01/2018 AGGREGATE $5,000,000 DEO F—V RETENTION$ $ WORKERS COMPENSATION PER Q S ACCID",ERH AND EMPLOYERS°LIABILITY A ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N A0949-23-59 10/01/2017 10/01/2018 ..L .. $ 1,000,000 OFFICER/MEMBEREXCLUDED? ❑ NIA (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY $ 1,000,000 ®Q0 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) 30-DAY NOTICE OF CANCELLATION,10-DAY NOTICE OF NON-PAYMENT OF PREMIUM WAIVER OF SUB:workers'comp ADDITIONAL INSURED(COMPLETED OPERATIONS):The City of EI Segundo y CERTIFICATE HOLDER CANCELLATION CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 MAIN STREET, ROOM 6 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. EL SEGUNDO,CA 90245 AUTHORIZED REPRESENTA VF pig„•. '� ,� I ©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 Web Software.www.FoffnsBoss.com(c)Impressive Publishing 800-208.1977 POLICY NUMBER: 60669-02-33 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 Lotus Communications 737 W 31st St Unit A San Pedro, CA 90731 I END ENT CHANGES THE POLICY. PLEASET CAREFULLY ADDITIONAL INSURED - OWNERS, L SSES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: The City of EI Segundo CG 20 37 07 04 POLICY NUMBER: 60669-02-33 BUSINESS OWNERS POLICY Lotus Communications 737 W 31st St Unit A San Pedro, CA 90731 THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. ADDITIONAL INSURED—OWNERS, LESSEES OR CONTRACTORS This endorsement modifies Insurance provided under the following: BUSINESS OWNERS POLICY SCHEDULE* Name of Person Or Organization: The City of EI Segundo "Information required to complete this Schedule, if not shown on this endorsement, will be shown in the Declarations. The following is added to Paragraph C, Who is An Insured in the Business Owners Liability Coverage Form: 4.Any person or organization for whom you are performing operations is also an insured, if you and such person or organization have agreed in writing in a contract or agreement that such person or organization be included as an additional Insured on your policy. Such person or organization is an additional insured only with respect to liability arising out of your ongoing operations performed for that insured.A person's or organization's status as an insured under this paragraph ends when your operations for that insured are completed or the contractor's agreement is terminated. ' I DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 03/22/2018 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 have ADDIT'ION'AL 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)" PRODUCER CONTACT IIII:4 NAME: Bristol Bay Insurance PHONE 1 Income Tax -9��Ngy rt)EDw 800WCARSON STSTE21nBRISTOLBYINSURANCE.COM......... ( )0)533-8098 �31..0}..Sj36gg1 1�.p. S. INSURER(S)AFFORDING COVERAGE NAIC t TORRANCE CA 90502-2100 INSURERA: NATIONAL GENERAL INSURANCE CO 23728 INSURED INSURERS: TOPA INSURANCE COMPANY 18031 JOSE GOMEZ JR INSURER C DBA: LOTUS COMMUNICATIONS,LLC INSURERD'; 2084-B CENTRAL AVE INSURER E DUARTE CA 91010 INSURERF: 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, —HE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. _IMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. 1NT TYPEOFINSURANCE ACS`"L1SLIt�Y....................................POLICYNkMB'E,,,, POLICYEFF POLICY EXP .................................................... , R (MMIDDIYYYYI_IMM1OD1YYYY1 LIMITS ...0COMMERCIAL LIABILITY Or",�'kl�)�'�'iVl"Ilrl"r•n' a GENERA....... I, ....�........ ................................................... •ulltq',„+.ttpjtl' G.......L...� h'i.VGr_1L.1" M"'Ip li',1lilml rL.MIbL'•a 0.0 :Y VeYh l'•p.�,I'',��',na�rrn:'tu:r.��lnj $ .................., PI I Y I/'�,I F;^.i;.r p•,i.,it 1.L:....�................�.:.......................................................................- :Iil`o4ll Ili PI II' .... 111111, ( flllii�'I u ;, I.f,��1'im,ll", 'rf;ll,ill^,,Ia,,�.,• ti........................................................................ AUTOMOBILE LIABILITY $ 1'000,000 R�9f+IIf'I°.1 Mf Jr,GY V.IprVl X ^'l`a'i r', N 71'•II'v`Irti,ullRt p', Lr,.r;,+nli $ 1,000,000 A R I'' X , 114 Ln..A x I: Y Y 2003433956 11/11/2017 11/11/2018 I.rl ull'; IRi.u)f 'r f'.i-r',ir•l.nuV $ 1,000,000 Xdill fV lr I ... 11V_Bd ldkld1�+..I.... $ 1,000,000 .... ... ............ DEDUCTIBLE $ 1000 I ;• Y Y XL 6609018-00 11/21/2017 11/21/2018 b%I r $ 5,000,000 .... AB � ,,r'i II it I � 41 B X EXCESS LIAB � 5,000,000 ( V .II. III Y""ltd�'r l''y. If�.:.il �.. .......,. WORKERS COMPENSATION ',,TH AND EMPLOY RS'LA LITY Y!N .............i..��P.#..I,i,„' .0> ANY PR PR OFFIICERIMEMIn BEREXCLUDF_DXECUTIVE N/A N LLIL.%�i...��.lti�.i.f..l..'....r.l...p....$ „ Ifyes,descnbe under ..........f.................................................................................................. DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached Ifmore space Is required) LICENSE#967691 CERTIFICATE HOLDER CANCELLATION CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 MAIN STREET ROOM 6 ACCORDANCE WITH THE POLICY PROVISIONS. EL SEGUNDO CA, 90245 AUTHORIZED REPRESENTATIVE EDWARD L HARAZIN U ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Iry N FARMERS II N S U IIR A I14 C III,,,, WC 99 06 19 WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY Named Insured * Lotus Communications * 737 W 31st St U n it A * San Pedro, CA 90731 Effective Agent A0949-23-59 2017 Date 10/01/2017 95-39-R6A Policy Number Policy of the Company Year WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - BLANKET We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization for which you perform work under a written contract that requires you to obtain this agreement from us. The additional premium for this endorsement shall be 3.0 % of the Workers' Compensation premium otherwise due for the state(s) listed below on such remuneration, subject to a minimum charge of 250 . All written contracts in the state(s) of: This endorsement is part of your policy. It supersedes and controls anything to the contrary. It is otherwise subject to all the terms of the policy. Countersigned Authorized Representative 93-6369 1ST EDITION 9-07 WC990619A J6369111 PAGE 1 OF 1