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PROOF OF INSURANCE (2019 - 2019) CLOSED OP ID:MN CERTIFICATE OF LIABILITY INSURANCE46/01120� DATE(M1/20 8 18 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 pollcy(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 ondorsement(s), Alliance Sery INO �T Michelle760-471-7116 Nowell..__ F.A�..No 760.471-9378 ...... .. PRODUCER CON A Nance Mgt.6 Insurance a Fxil I I: Via Vera Crux#7 CAA ent/Broker LNC#0737966 ADot(E �: TTn ME IlarnNscorp.colTa San Aarcos CA 920'70 PR(DU ER SSI-1 -- Michelle A.koWell CUSTOMER ID#: ., IiN;SU,RER(Sa AFFORDNC'COVERAGE NAIC W INSURED Messina&Associates Inc INSURER A:Acceptance Casualty Ins Comp 10349 814 Forbes Drive INSURER B: Brea,CA 92821 I'N'SURER C I INSURER D: _ 1 INSURER E: ...........••. ES CATE C THIS ISS GO CERTIFY THAT THE POL C ES OF INSURANCER � BREVISION L SITED BELOW HAVE BEEN ISSUED TO THE INSUR DNAM D A13OVER^EBFORTHE T LI �•._•_ _... OLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPEC O 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. NSR i LIMITS Lt R GENEtOAL LIABNENOF INSURANCE U POLICY NUMBER I(MIOUDtY y't ) .EPOLICY WP M{EYP) ..I���+O'L��GRRENI�E $ 1^1QQrQQ() I MgD rY CH A X COMMERCIAL GENERAL LIABILITY X CPQ'Q96tQ45 0610112018 Q6/Q7l2Q19 PREMISES+Eeeo fenool $ 'QQQ CLAIMS-MADE V OCCUR MED FRCP(Any one person) S wrQQQ X Errors&r Omission PERSONAL&ADV INJURY $ 1,QQQ,000 GENERAL AGGREGATE 5 5,000,000 GEN'LAGGREGATE LIMIT APP LIES PER, PRODUCTS-COMPIOPAGG S 1,'EQQrIlQQ Is X POLICY T _ LOC w» AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea acchdenq ANY AUTO B'OMLYINUURY(Per person) $ - ALL OWNED AUTOS BODILY INJURY(Pot atOldvn'tp $ SCHEDULED AUTOS PROPERTY DAMAGE, $ HIRED AUTOS (PER ACCIDENT) NON-OWNED AUTOS EXCESS UAB CLAIMS-MADE AGGREGATE ...•5 ...•.• .W UMBRELLA LIAB EACH OCCURRENt"C " DEDUCTIBLE _-' RETENTION 5. .._...T... ...._. ., WORKERSCOMPEN�SATCON I Vit SI Al U- COMPENSATION TCAb°VIAT*TN, AND EMPLOYERS'LIABILITY YIN ANY PROPM TORIPARTNMEXECUATiVEEl EACH ACCIDENT ,$ OFFICERUFMBEREXCN.UDED9 iNIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE If .L.es,daecribe ander EDISEASE^POI ICY UMI"r SDESCRIP'T'ION OF OPERATIONS txakw ---�' ESCRIPTI N F OPERATIONS I L ATIONS i`V HIC�LES tAttach ACORD 181,AeesIdd'Iilonaf Remarks Sohodule,If mare space is required) tr1ttNe� s�etldtynnat10iNs�CerTSNVItttru''ntei" yrortrd Icyieanarrere ittsurod with,and''30 Days Notice o lance atlon. Investigation,CA-- canderson@eisegundo.org CERTIFICATE H'OLDE'R 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 WITH THE POLICY PROVISIONS. Attn Christopher Donovan 314 Main Street 'AUTHORIZED REPRESENTATIVE EI Segundo,CA - ju OL jj ,.0 ©1980-2009 ACORD CORPORATION. All rights reserved. ACORD 26(2009109) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: CP00961045 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Personj,��rOr anizatIon(�J__,,,_. ....... Automatic Status Included Where Required by Written Contract. All Where Required by Written Contract. "it is agreed, as respects the Policy, thirty (30) days notice of cancellation, except as respects non- payment of premium,for which ton(10)days notice will apply,or other regulatory requirements that may! apply,will be given as respects the indicated certificate holder." Information!�eRaired tq.c�lete_this Schedule, if not shown above,Will be shown in the Declarations. Section 11 — Who Is An Insured is amended to in- clude as an additional insured the person(s)or organ- Ization(s) shown in the Schedule, but only with re- spect 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 20 26 07 04 C ISO Properties, Inc.,2004 Page 1 of 1 13 w lnterinsurance Exchange of the Automobile Club a, Automobile Insurance Policy Coverages and Limits Modified Renewal Declarations We are pleased to offer you a renewal for your automobile insurance policy. To renew your policy, send at least the minimum payment on or before the due date. Insurance is in effect only for the vehicles, coverages, and limits of liability shown on this declarations page and as set forth in the insurance policy and endorsements. These declarations,together with the contract and the endorsements in effect, complete your policy. If any change to your policy or to the information we have on file results in a premium decrease during the policy period, the Interinsurance Exchange reserves the right to apply any refund due to your outstanding balance. 9 ..�. NAMED INSURED(Item 1.) AUTO POLICY NUMBER:CAA 086044011 MESSINA, MICHAEL AND CAROLYNAPOLI��c—� IOD(PACIFIC STAODARD TIME,) 814 FORBES DR POLICY EFFECTIVE DATE: 03-25-18 12:01 A.M. BREA CA 92821-7306 POLICY EXPIRATION DATE: 03-25-19 12:01 A.M. . VEHICLES VEH• IDENTIFICATION VEHICLE GARAGE ANNUAL`" VERIFIED NO YEAR MAKE MODEL NUMBER USE ZIP CODE MILES MILEAGE SALVAGE 5 2012 KIA SOUL SW/I/SPORT KNDJT2A65C7474113 PLEASURE 92821 10,001 -12,500 VERIFIED NO 7 2009 JEEP WRANGLER UNLIMITED 1J4GA39159L745955 PLEASURE 92821 7,501 -10,000 VERIFIED NO 8 2016 MBNZ E CLASS 550 WDDKJ7DBOGF314383 PLEASURE 92821 5,501 - 7,500 VERIFIED NO 9 2016 CHEV SLVRDO 1500 CR NEW 3GCUKSEC3GG285230 PLEASURE 92821 10,001 -12,500 VERIFIED NO 10 2017 HYUN ELANTRA SE KMHD84LFOHU299328 COMMUTE 92821 5,501 - 7,500 VERIFIED NO COVERAGES AND LIMITS Coverage Is not In effect unless a premium or the word'Included"Is shown. ANNUAL PREMIUMS COVERAGES LIMITS OF LIABILITY Vehicle 5 Vehicle 7 Vehicle 8 Vehicle 9 Vehicle 10 Liability i i I Bodily Injury $100,000 each person/ $300,000 each occurrence $352 f $408 A $184 $275 i $182 Property Damage $50,000 each occurrence $243 4294 $136 1 $232 $125 Medical No Coverage No Coverage No Coverage No Coverage']No Coverage Physical Damage (Actual cash Value unless otherwise stated,less deductible) Vehicle 5 Vehicle 7 Vehicle 8 Vehicle 9 Vehicle 10 Comprehensive ACV ACV ACV ACV ACV i $62 $43 $83 $53 $53 (Less Deductible) $1000 $1000 $1000 $1000 $1000 Collision ACV ACV ACV ACV ACV $484 $263 $706 $483 $394 (Less Deductible) $1000 $1000 $1000 $1000 $1000 Car Rental Expense a (Per Day) S35 $35 $35 $35 $35 $62 $62 $30 i $26 $30 Uninsured Motorist Bodily Injury- $30,000 each person/ $60,000 each accident $88 $58 $56 $34 $43 Uninsured&Underinsured Vehicles Uninsured Deductible Waiver Included Included Included a Included ?, Included Uninsured Collision No Coverage?No Coverage No Coverage No Coveragei No Coverage Total Premium $1279 $1108 $1196 ? $1103 $827 PREMIUM DISCOUNTS "No Coverage"indicates coverage not purchased. Please refer to the enclosed document entitled"Premium Discounts Applied to Your Automobile Policy." Total Annual Premium" * If at any time you choose to pay less than thefull balance outstanding, (Includes all applicable discounts.) $5512 finance charges of up to 1.5% per month of the balance outstanding will apply Less Policyholder Savings Dividend $791 aBToexplained ee thenyour annualillmi sage for yourwhich expiringpart policy�hplease rdeclarations. to the I Net Premium" $4721 Is Notice of Annual Mileagtr page contained In your,renewal package. E2010401 PROCESS DATE 02-20-18 PLEASE ATTACH TO YOUR POLICY (SEE REVERSE) 022118 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: (_) I 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. (_)I have and will maintain workers'compensation insurance as required by Labor Code§3700 forthe 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# (_2� 1 certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not employ any person in any manner 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 § 3700 1 must immediately comply with those provisions or the agreement will automatically become void. Signature ofApplicant — Lf., f�,.. Date 7/12/2016 Agreement for: o Dated: In Reviewed by: w. 1