PROOF OF INSURANCE (2018 - 2019) CLOSED DRMAU-1 OP ID:C6
CERTIFICATE OF LIABILITY INSURANCE V DATE(MLV05114120 8
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: it the certificate holder is an ADDITIONAL INSURED,the pol'ic'y(les) 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 endorsemen't'(s).
TA
License#OK07568 P q.N
Lo, Eadl:310-524-13577 ell a 949-313-3323
00Wilshire Blvd.#ns.BOrokers E....
IL
Santa Monica,CA 90401 AP 'k.
.,carole.mitchell s'ig.us
A
Darla Gray INSURER(S)AFFORDING COVERAGE NAIC 0
INSURER
I INSURED Dr.Maureen Sassoon
INSURERS:Westchester Surplus Lines los 10172
P O Box 2028
Palos Verdes Peninsula,CA 90274 INSURER C:
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 1 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 PAID CLAIMS.
p
iNSR TYPE OF INSURANCE INSO WVD POUCYNUMBER 'i Dt Q
kOD SUOR ....0ObLiCYEFF' -POL
LTR l LIMITS
A X. COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE [X]OCCUR X X G24270427006 07/01/2018 07/01/2019
D'kiMattile IUHt•..NIED. .............
PRE,WSES Ma occurtencol $ 50,00
X Add'I Insured MED EXP(Any one Person) a 5,00
X Prof&Pollut-CLM PERSONAL 8 ADV INJURY $ 1,000,00
GEN'L AGGREGATE LIMIT APPLIES PER. E E 2,000,00
GENERALAGGREGAT
AlOTHER ❑JECT LOC ,PROD,UCT COMP/OP,
POLICY PRO- $..'...... AGG E 2,000,00
E
AUTOMOBILE LIABILITYnt iN D SINGLE LIMIT $
(Le
ANY AUTO BODILY INJURY(Per person) E
ALL OWNED IqI SCHEDULED BODILY INJURY(Peraccident) E
_--, AUTOS ....."NON-OWNED F...�..... .
AUTOS
HIRED AUTOS AUTOS Parweide�t) 'E $
R,OPI„i17"iP'C.tA
S
UMBRELLA LWB OCCUR EACH OCCURRENCE E
EX1.CESS LIAB DE AGGREGATE E
DED RETENTION E E
WORMERS COMPENSATION PER I OY'H
�......_1 STATUTE 1" -
01 ......AND EMPLOYERS'LIABILITY YIN "_.........._- ......................
ANY PROPRIETORIPARTNEWEXECUTWE' p yN/A E,L,EACH ACCIDENT E
E�
OFFICERIMEMSER EXCLUDED?
(Mandatory In NH) E .DISEASE-EA EMPLOYEE, E
E ON OF OPERATIONS'Wow E.............
ea,describe r
D ns,
L.DISEASE-POLICY LIMIT $
A Professional Liab. G24270427005 07/01/2018 07/01/2019 Prof.Liab 1,000,000
A Contractors Poll. G24270427005 07/01/2018 07/01/2019 Pollution 1,000,000
DESCRIP71ON OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required)
Polyyy Provides 30 days notice of cancellation except 10 days for nonpayment
Applicable Endorsements Attached are Applicable Where required by Written
Contract.
CERTIFICATE HOLDER CANCELLATION'
C-ELSEG
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Ci of EI Segundo
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City ACCORDANCE WR}(THE POLICY PROVISIONS.
Attn:City Clerk
350 Main Street
EI Segundo,CA 90245 AU7HORIZFD REPRESENTATIVE
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
Named Insured Endorsement Number
Dr. Maureen Sassoon
Policy aymbor Policy Number Policy Period Effective Date of Endorsement
ECP G24270427 007 07/01/2018 to 07/01/2019 07/01/2018
Issued By(Name of Insurance Company) —
Westchester Surplus Lines Insurance Company
I
Insert the policy number. The remainder ofthe Information is to be completed only when this endorsem ant is issued subsequent to the preparation of the policy.
THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED ENDORSEMENT
OWNERS, LESSEES OR CONTRACTORS—SCHEDULED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE
CONTRACTOR'S POLLUTION LIABILITY COVERAGE
SCHEDULE:
Name ot,,Etrrs;2n or OroanJzation°
Any person or organization that is an owner of real property or personal property on which you are performing
operations, or a contractor on whose behalf you are perforrning operations, and only at the specific written request of
such persort or organization to you,whereon such request is made prior to commencement of operations,
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
A. SECTION II -WHO IS AN INSURED is amended to include as an insured the person or organization shown in
the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured.
B. With respect to the insurance afforded to these additional insureds,the following exclusion is added:
2. Exclusions
This insurance does not apply to bodily injury or property damage occurring after:
(1) All work, including materials, parts or equipment furnished in connection with such work, on the project
(other then service, maintenance or repairs) to be performed by or on behalf of the additional insured(s)
at the site of the covered operations has been completed,of-
(2)
r(2) That portion, of your work out, of which the injury or damage arises has been put to its intended use by
any person or organization other than another` contractor or subcontractor engaged in performing
operations for a principal as a part of the same project,
ENV-3100(08-04) Includes copyrighted material of Insurance Services Office, Inc.with its permission Page 1 of 1
Named Insured Endorsement Number
Dr. Maureen Sassoon
Policy ECP G24270427
6124270427 007 � 07qcy Period/01/2018 07/0Effective Date of Endorsement �
to 07/01/2019 07/01/2018
Issued By(Name of Insurance Ccronropany)
Westchester Surplus Lines Insurance Company
Insert the policy number. The remainder of the Information Is to be completed only when this endorsement Is Issued subsequent to the preparation of the policy.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED ENDORSEMENT-OWNERS,LESSEES OR CONTRACTORS
(PRIMARY AND NON-CONTRIBUTORY)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE
CONTRACTOR'S POLLUTION LIABILITY COVERAGE
SCHEDULE:
Name of(Person or Orcan'izatrom
Any person or organization that is an owner of real property or personal property on which you are performing
operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of
such person or organization to you, wherein such request is made prior to commencement of operations.
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
SECTION II-WHO IS AN INSURED is amended to include:
A. SECTION II -WHO IS AN INSURED is amended to include as an insured the person or organization shown in the
Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured.
B. With respect to the insurance afforded to these additional insureds, the following exclusion is added.-
2.
dded:2. Exclusions
This insurance does not apply to bodily injury or property damage occurring after:
(1) All work, including materials, parts or equipmerd furnished in connection with such work, ori the project (other
than service, maintenance or repairs) to be perform d by or on'behalf of the additional insured(s)at the site of
the covered operations has been completed; or
(2) That portion of your work out of which the injury or damage arises has been put to its intended use by any
person or organization other than another contractor or subcontractor engaged in performing operations for a
principal as a part of the same project.
C. The coverage provided hereunder shall be primary and not contributing with any other insurance available to those
designated above under any other third party liability policy,
ENV-3101 (08-04) Includes copyrighted material of Insurance Services Office, Inc.with its permission Pagel of 1
Named insured End'oisoment Number
Dr. Maureen Sassoon
P;ficy
V
—F–Policy Period Effective nate of Fndofsernent
ECP G24270427
G 112018 to 07/01/2019 07101!2018
242 Policy 0i 427 007 07/0.
wsxue�t t3y'(Name of lniwfanca corn a )
Westchester Surplus Lines Insurance Company
Insert the policy number.The remainder of the information is to be completed only when this endorsement is issued subsequent to the preparation of the policy.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
CONTRACTORS POLLUTION LIABILITY COVERAGE PART
SCHEDULE
te of Person or rr
"
Any esoaoganization
that is an owner of real property or personal property on which you are performing
operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of
such person or organization to you, wherein such request is made prior to commencement of operations.
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this
endorsement.)
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition is amended by the addition of the
following.-
We waive any right of recovery we may have against the,person or organization shown in the SchedUe above because of
payments we make for injury or damage adsMng out of your ongoing operations or your work done under.a contract with.
that person or,organization and included in the paroducts onnipleted operations hazard, This waiver applies only to the
person or organization shown in the Schedule above.
All other terms and conditions remain the same.
ENV-3143(03-05) Includes copyrighted material of Insurance Services Office,Inc.with its permission Page 1 of 1
ADDITIONAL INSURED ENDORSEMENT—PRODUCTS-COMPLETED OPERATIONS HAZARD
Nerne:d Insured Endorsement Number
Dr. Maureen Sassoon
Poky Symbol Policy Number
] Poky Period Effective Date of Endorsement
ECP G24270427 007 07101/2018to 07/01/2019 07/01/2018
Issued Fay(i of Insurance Company)
Westchester Surplus Lines Insurance Company
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
CONTRACTOR'S POLLUTION LIABILITY COVERAGE PART
SCHEDULE
Any person or organization that is an owner of real property or personal property on which you are performing
operations, or a contractor on whose behalf you are performing operations, and only at the specific written request of
such person or organization to you, wherein such request is made prior to commencement of operations.
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement)
Section I]—Who Is Ain Insured is amended to include as an additional insured the person(s) or organization(s) shown in
the Schedule, but only with respect to liability for bodily injury or property darnage caused, in whole or in part, by your
work performed for that additional insured and included in the products-completed operations hazard,
All other terms and conditions remain the same.
ENV-3225(10-08) Page 1 of 1
ADDITIONAL INSURED ENDORSEMENT—PRODUCTS-COMPLETED OPERATIONS HAZARD
PRIMARY&NON-CONTRIBUTORY
Named CaasurwcS Endorsement Number
Dr. Maureen Sassoon
Policy SymW Effective Date of Endorsement
ECP G24270427 007 07/0112018 to 07/01/2019 07/01/2018
T
7sl.i�'.
, ed By(Name of Insurance
Westchester Surplus Lines Insurance Company
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
CONTRACTOR'S POLLUTION LIABILITY COVERAGE PART
SCHEDULE
Any person or organization that is an owner-of real property or personal property on which you are performing operations,
or a contractor on whose behalf YOU are performing operations, and only at the specific written request of such person or
organization to you,wherein Such request is made prior to commencement of operations
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
Section It—Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in
the Schedule, but only with respect to liability for bodily injury or property damage caused, in whole or in part, by your
work performed for that additional insured and included in the prod ticts-completed operations hazard.
Furthermore, the coverage provided hereunder shall be primary and not contributing with any other insurance available to
those designated above under any other third party liability policy.
All other terms and conditions remain the same.
ENV-3226 (10-08) Page 1 of 1
AMERICAN ALTERNATIVE INSURANCE CORPORATION
Administratco r:Xfce:555 College Road F-aot,Pnpcetoii,NJ 0,8543-5241
A e Rvd,54u AOO,Y01rnim;sm DE I DOM
(a stock nsrraroe+x,�rmy'b
Personal and Business Owners' Umbrella Declarations
Named Insured: Broker:
Maureen Sassoon Business Po4ssional Insursno
PO Box 339 seventh street,
Palos Verdes Peninsula CA 9074-8028 Suft L
Mlister CA 95023
Coated:Tiffany ftvmr
Ph":888-99"126
Policy No: UIAZUB1193927-00 Policy Period:9/1/2017 To 9/1/2010:
(12i01 A$4rsn69rdtim*wt the oddre%% the Gnwietl-)
Coverage A: Bodily Injury,Personal injury,Advertising Injury and Property Damage Liability Coverage
Limits of Liability for Each Loss. $1,000,000
* Policy Total Limit: Not applicable
14 PoNcv TOW Umiit shown In this Xdhcy'%(Was;toins for OoNomqt A Ps the rm%t%v%oO pov for od lo%"s wivmg wt of bussneos
Coverage 0: Excess Uninsured and Underinsured Motorists Bodily Injury Coverage
Limits of Liability for Each Loss: $1,000,000
Pei"Total Limit, $1,000,000
Self Insured Retention: None($0)
Charges Policy Premium- $30Z
Policy Expense Fee- $40
Total Policy Premium. $34:
Attached to and forming a part of Form: PUP 100(06/09)
Endorsements Attached to this Policy at Time of Issue. PUS 100 (06/09)
PUNCA01 (0V12)
State and Privacy Notices* VL 03(04/10)
VLCA04(09/10)
CAPRI
PersonalUmbrella.com Insurance Services, Inc. President,Min P.Vasturia
P.0. Box 8586
-
Emeryville, CA 94662 �
(600)564-1799
Secretary, Robin H. Willcox
PoiD too(06/09)Umblefla Dedaration(Page I Oder Wt A200141 IN"M 1133269 fistm Dine;W22J2017 Picclivrar Print Vetv VV2010
of'1)
xiil order de 7/9,'2018
CA INSURANCE IDENTIFICATION CARD
(STATE)
COMPANY NUMBER COMPANY
10914 Kemper Independence Insurance Company
POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE
RB220068 09/01/2017 09/01/2018
YEAR MAKE/MODEL VEHICLE IDENTIFICATION NUMBER
2016 BMW 328 I SU WBA8E9G57GNT84508
AGENCY/COMPANY ISSUING CARD
BUSINESS PROFESSIONAL [PH: 650-341-4484]
339 SEVENTH STREET #L
HOLLISTER CA 95023
INSURED
rMAUREEN SASSOON
PO BOX 2028
ROLLING HILLS CA 902740000
SEE IMPORTANT NOTICE ON REVERSE SIDE
THIS CARD MUST BE KEPT IN THE INSURED
VEHICLE AND PRESENTED UPON DEMAND
IN CASE OF ACCIDENT: Report all accidents to your Agent/Company as
soon as possible. Obtain the following information:
1. Name and address of each driver, passenger and witness.
2. Name of Insurance Company and policy number for each
vehicle involved.
ACORD 50(1/83) 0 ACORD CORPORATION 1983
CA INSURANCE IDENTIFICATION CARD
(STATE)
COMPANY NUMBER COMPANY
10914 Kemper Independence Insurance Company
POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE
RB220068 09/01/2017 09/01/2018
YEAR MAKE/MODEL VEHICLE IDENTIFICATION NUMBER
2014 HOND CR-V EX 2HKRM3H59EH548165
AGENCY/COMPANY ISSUING CARD
BUSINESS PROFESSIONAL [PH: 650-341-4484]
339 SEVENTH STREET #L
HOLLISTER CA 95023
INSURED
rMAUREEN SASSOON
PO BOX 2028
ROLLING HILLS CA 902740000
SEE IMPORTANT NOTICE ON REVERSE SIDE
THIS CARD MUST BE KEPT IN THE INSURED
VEHICLE AND PRESENTED UPON DEMAND
IN CASE OF ACCIDENT: Report all accidents to your Agent/Company as
soon as possible. Obtain the following information:
1. Name and address of each driver, passenger and witness.
2. Name of Insurance Company and policy number for each
vehicle involved.
ACORD 50(1/83) 0 ACORD CORPORATION 1983
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:
U 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 for the 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#
I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not
e ploy 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
comply isnon ore agreement will automatically become void,
Signature ofppNicaR tpt �r ... . K. ..,.
immediatelycom ose r
Date
Print Name ' '.) ��
Agreement for:
Dated: t L .......... .
Reviewed by: I�y, . . .:.: