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PROOF OF INSURANCE (2018 - 2019) CLOSED (2) OP ID: MN I DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY ITY I S NI�CE 0311812018 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(las)must be andorsed� 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 Ileu of such andorsement(s), PRODUCER CONTACT Michelle Now ell NAM�Alliance Mgt.S Insurance SerW PHONE Vara Cru760-471-7118 NA -471-9378 SP1760 PAA � L w M� #0737966 SacoA 907 p :mnowell( arrliscar .com 1 Michelle A. IOYWa11 cUSIVQR lc#;WYEN.N- _.... .... . INSURERIB,AFFORDING COVERAGE NAIC# INSURED i, yonn A" c s w „ INSURER A:Acceptance Casual Ina Com 10349 815 S Central Ave#20 Glendale,CA 91204 .INeURER a INSURER C INSURER D: ............................................................................................. ... ..,.,.................................m......mm........................"""'......... INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED SF,LOW HAVE SEEN IS'SU'ED TO THE INSURED NAMED A13OVE FOR THE POLICY PERIOD IN'DIC,ATED. NOTWITHSTANDING ANY REOUIREMEN'T, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHtCIq THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE'.AFFO'RDE'D BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE -rERd+MS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWWN!MAY HAVE SEEN REDUCED BY PAID CLAIMS, LTR TYPE OF INSURANCE IN T POLICYNUMBER y «dMMl'DDd YYN1 BMMIODry YY, S DDL. UB'R. PoLI " I�1""" i°DI i Y F ®. .,_. ... LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 A X....,-COMMS TIAL GENERAL LIABILITYOCCUR x CP00980505 03/06/2018 03/06/2019 'MED EXPS� oneM..........a..............W.r_ 100,000 ADE IXJ x . rs&Omission ( person)....ww.w.._S.Ww..�... , E„r�D _..�„ PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE S 5,000,000 �.,., LIMIT APPLIES PER: NGMOPAGG 4 $ µ1,000,00^IT 0 JTrlVPLOCPOLICY ra AUTOMOBILE LI ILI COMBINED SIE LIMIT $ ANY AUTO accident) B DILY INJURY(Per person) $ ALL OWNED AUTOS -BODILY INJURY(Per accident) $ SCHEDULED AUTOSPROPERTY a........... HIRED AUTOS (PER ACCIDENT) NON-OWNED AUTOS $ a UMBRELLA LIAR CUR EACH OCCURRENCE $ EXCESS LIARC LAIMS-MADE AGGREGATE S DEDUCTIBLE a.......................................... RETENTION S $ WORKERS COMPENSATION I WCSTAT - AND EMPLOYERS''LIABILITY I IS ANY dEXECUTV( EACH ACCIDENT aOFFICEWMEMBER EXCLUDED? ❑INIA (Mandatory R E.L.DISEASE-EA EMPLOYEE $ Des descrift under . SdRIPTNONOFOPERATIONSbeGo E .DISEASE-POLICY LIMIT $ L FCRIPTION OFpOP AT1 NS I LOCATIONS I V HI 'L S (A h ACORD 147,Addltlrana Rernar'a Schaduls,If more space Is required) Nis red, add ord'a sure W ra�spm r Ewa r peal forrtTni G byytt(e named na red. oTon eitf el �undo.org nvestinga n, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EI Segundo Police Department ACCORDANCE WITH THE POLICY PROVISIONS. Assistant to the Captains Amanda O'Donnell AUTHORIZED REPRESENTATIVE 3Main Street 0 fU ISIl Segundo,CA 90245 Imuz ®1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: CP00960505 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURE - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART " SCHEDULE mPersosOtn )Or Organization !�l Automatic Status Included Where Required b ' q y Written Contract.All Where Required by Written Contract. Section II - Who Is An Insured is amended to in- clude as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 202607 04 0 ISO Properties, Inc., 2004 Page 1 of 1 ❑ Calif ' of Auto Insurance Allstate Nort11 h1.brook Indemni11 ty C11 ompany in good hands. PO Box 660598, Dallas, TX 75266-0598 NAIL# 36455 Q l LT.i a Wyefln This policy meets the requirements of the applicable California financial responsibility law(s). - -- POLICY NUMBER YEAR/ MAKE/ MODEL 934 426 951 2016 Hyundai Elan ra EFFECTIVE DATE VEHICLE ID NUMBER 03/20/18 EXPIRATION DATE 091/'20:/118 This card must be carried in the vehicle at all times as evidence of insurance. it Renewal auto policy declarations Page 6 of 7 Policy number: 1934 426 9511 Policy effective date: March 20,2018 Coverage detail for 2016 Hyundai Elantra Coverage Limits Deductible Premium Automobile Liability Insurance Not applicable Co Bodily Injury $500,000 each person $500,000 each occurrence Property Damage $100,000 each occurrence Auto Collision Insurance Actual cash ......._w_w. ....value .... Waiver of deductible applies .... Auto.......... . ...Come.._r..ehen......S...i.V.e Insurance...n..........._._._. .............. ...._.� .... ..............._�...._.�__...W.._.. ..... a Actual cash value $D.. ... . , .. ..... - . ._. Rental Reimbursement up to$30 per day for a maximum of 30 Not applicable .....m days Towing and Labor Costs Not_ ..............................w ...._..... purchased* ..... Injury $500,000 each person _�...N......of applicable �...... _.. Uninsured Motorists Insurance for Bodily $500,000 each p __._._.....-Autor��obile Medical __. _....e._.s....................�.r.._..__. c accident e Payments Not purchased* Coordinated Medical Protection Not purchased* _m. _. m. _..__... .........._...._... ._.W ._ _—_.____ ............m.V.._............................... m._. __...... ....._.. _._..._....._ ......................_. ....... �.. Lease/Loan Gap Not purchased* Repair or Replacement Cost Option Not purchased* ........... Sound aystem4._._... Not purchased*...__ _.�_�...._..��..�........ ...... Tape ..... . -- Not purchased* (Total premium for 2016 Hyundai Elantra 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: C_)I have and will maintain a certificate of of self-insure for workers'compensation, issued by the Director of Industrial Relations as provided for by ode§3700 for the performance of the work set forth the agreement with the City of EI Segundo. Policy No. (�I have and will maintain workers'compen ation insura s required by Labor Code§3700 for the performance of the work for which the agreement with e f egundo is executed. My workers'compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent � Phone# rtify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not ��;e any person in any me er o as to become subject to the workers' compensation laws of California, and agree that, if I should beco e su ject to the workers' mpensation provisions of Labor Code § 3700 1 must immediately comply with tho a pro isions or the meat will automatically become void. Signature of Applicant . Dam 7 6 Agreement for: w h :='wj Dated: , Reviewed b '' 1