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PROOF OF INSURANCE (2019 - 2019) CLOSED DONOGOL-01 MWODM CERTIFICATE OF LIABILITY INSURANCE DATE 08 N 161201 YY) � 08 612018 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(les)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 License'#OD79613 kRAJACT BoWermaster&Associates Insurance Agency,Inc. (PH Ext/:('714)733-6200 , ,,Nap,(71�Y)252-8253 Cypress,CA10806 06301,Suite 350 amiss^ INSURER(S)AFFORDING COVERAGE MAIC N INSURERA:Philadelphia Insurance Companies INSURED INSURER B:Allianz 21873 The Lakes at EI Segundo INSURER C i Lane Donovan Golf Partners,LLC 400 South Sepulveda Boulevard INSURER D: EI Segundo,CA 90245 INSURER E; INSURER F: CO'VERAM CERTIFICATE NUMBER: REVISION N'UM'BER: 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. INSRIADDLS'Uerd' POLICY EFF POLICY EXP � TYPE OF INSURANCE I POLICY NUMBER pryyyyp LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000' CLAIMS-MADE X OCCURPHPK1844312 07/01/2018 07/01/2019 DAMAGE TO RENTED 100,000 X PREMISE'S Me nenCe) $ MED EXP(Ad)y one pem no $ 5,000 PERSONAL&ADV tlNJURY $ 1,000,0001 GEN"L AGG'REGA'TE,LIMIT APPLIES T PER: GENERAL AGGREGATE S 30000,000 Po$POLuOY J LOC 3,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 To e0dent) $ X ANY AUTO PHPK1844312 07/01/2018 07/01/2019 BODILY INJURY(Per,person) „S OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per sccdent),S XNU%J%NrrOPCERIpAMAGEX AOS ONLY $ $ B X UMBRELLALIA13 X OCCUR EACH OCCURRENCE $ 20,000,000 EXCESS LIAB CLAIMS-MADE ,Ili ikpidll''.I."N 5357296 07/01/2016 07/01/2019 AGGREGATE $ 20,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYCCPRRORPRIIET6OERRIPARTNERIEXECUTIVE - NIA EL EACH'ACCIDENT $ Wlandetory In NH)EXCLUDED? E.L.DISEASE-EA EMPLOYEE,$ If as,describe under DESCRIPTIPN QF QegRATIQNS gow E V_C tl�roEA6mE POLICY LIMIT '$ A Liquor Liability ry PHPK1844312 07/01/2018 0710112019 Each Occur/Aggregate 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES1ACORD 101,AddKlonal Remarks Schedule,may be attached H more space Is required) RE:400 S.Sepulveda Blvd.,EI Segundo,CA 90245. (City of EI Segundo is named Additional Insured per attached endorsement form. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CI Of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City 9 ACCORDANCE WITH THE POLICY PROVISIONS. Attn:Recreations and Parks 350 Main Street EI Segundo,CA 90245-3895 AUTHORIZED REPRESENTATIVE Of. —oLe� ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER; PHPK1844312 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 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 Person(s)Or Organlzation(s): City of EI Segundo Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III—Limits Of Insurance: with respect to liability for "bodily injury", "property If coverage provided to the additional insured is damage" or "personal and advertising injury" g required by a contract or agreement, the most we caused, in whole or in part, by your acts or will pay on behalf of the additional insured is the omissions or the acts or omissions of those acting amount of insurance: on your behalf: 1. Required by the contract or agreement; or 1. In the performance of your ongoing operations; or 2. Available under the applicable Limits of 2. In connection with your premises owned by or Insurance shown in the Declarations; rented to you. whichever is less. However: This endorsement shall not increase the 1. The insurance afforded to such additional applicable Limits of Insurance shown in the Insured only applies to the extent permitted by Declarations. law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 26 0413 0 Insurance Services Office, Inc.,2012 Page 1 of 1 DATE IMM/DD/YYYY) AC"RV EVIDENCE OF PROPERTY INSURANCE 8/16/2018 THIS EVIDENCE OF PROPERTY INSURANCE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ADDITIONAL INTEREST NAMED BELOW.THIS EVIDENCE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS EVIDENCE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE ADDITIONAL INTEREST. AGENCY PHONE COMPANY IAIPe No,Ext):714-733-6200 Philadelphia Insurance Companies Bowermaster&Associates 26300 La Alameda Suite 470 10805 Holder St Mission Viejo CA 92691 Ste 350 Cypress,CA 90630 (A/C,No):714-252-8253 t)RESS:mwsordst ho° rr' aster;com CODE., , SUB CODE: AGENCY CUSTOMER 10 M INSURED LOAN NUMBER POLICY NUMBER The Lakes at EI Segundo PHPK1844312 Lane Donovan Golf Partners, LLC EFFECTIVE DATE EXPIRATION DATE 400 South Sepulveda BoulevardCONTINUED UNTIL EI Segundo, CA 90245 07/01/2018 07/01/2019 F-I TERMINATED IF CHECKED THIS REPLACES PRIOR EVIDENCE DATED: PROPERTY INFORMATION LOCATION/DESCRIPTION The Lakes at EI Segundo Golf Course-400 South Sepulveda Blvd,EI Segundo,CA 90245 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 EVIDENCE OF PROPERTY INSURANCE 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, COVERAGE INFORMATION PERILSINSURED I �BASIC I BROAD SPECIAL G COVERAGEIPERILS/FORMS AMOUNT OF INSURANCE DEDUCTIBLE Blanket Building,S ecial(Includin Theft'),Agreed Value 17,962,002 10,000 Blanket Business I�ersonal Property/Special(Including Theft),Agreed Value 4,501,021 2,500 Blanket Inland Marine/Golf Ca sJEquipmer , eplacement Cost 4,419,000 1,000 REMARK'S(Including Special Conditions) Evidence 1 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ADDITIONAL INTEREST NAME AND ADDRESS ADDITIONAL INSURED LENDER'S LOSS PAYABLE u LOSS PAYEE MORTGAGEE LOAN# City of EI Segundo Attn:Recreations and Parks 350 Main Street El Segundo CA 902453895 AUTHORC7ED RI PRESENTATIVE USA ACORD 27(2016/03) ©1993-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD N DATE(MM/DD/YYYY) ACCIR& CERTIFICATE OF LIABILITY INSURANCE 03/19/2018 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 cer0cate holderis an ADDITIONAL INSURED, the policy(les) must be e'ndors'ed, 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 COY/TACT" NAME: PHONSelf Insured Solutions Awe urT (800)592-0047 uv4Nrr,E.a: (800)592-2541 Administrator,California Restaurant Mutual Benefit Corp. UWSSr si5certs@Selfinsured5olutions.tom 430 N Vineyard Ave..#102 INSURERIS)AFFORDING COVERAGE NAIC8 Ontario,CA 91764 L Benefit Corp.* NSURFR w: CaliforniaCal'dornia Restaurant Mutual I INSURED INSURER B: State National Insurance Company 12831 Donovan Golf Courses Management,Inc. INSURER C- Affiliate of California Restaurant Mutual Benefit Corp. INSURER D: c/o Bowermaster&Associates P.O.Box 6026 INSURER E: Cypress,CA 90630 INSURER F. COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS ISTOCERTIFY THATTHE POLICIES OF INSURANCE LISTEDBELOW HAVE BEEN ISSUEDTO THE INSURED NAMEDABOVE FORTHE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY EQUIREMENT,TERM, OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO 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. INSR� 'ADDL SUBIR POLICY ETF POLICY EW LTR TYP'EOFIN'SURANCE IFISR Wwo POU'CY'NUMBER 0MMmg1YYYY,) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE i OCCUR DAMAGE TO RENTED $ PREMISES(E.occurrence) Y MED EXP(Any one person) $ „.........., C.....:_ yI PERSONAL&ADV INJURY $ OTHER AGGREGATE i$$, (POLICY CaATEPROJECT LOC P COMP/OPAGG I tii',N"t AGGI4L RAL LIMITAPPLIESPER: G PRODUCTS ROE, .. $ COMBINED AUTOMOBILE LIABILITY $ ANY AUTO BODILY INJURY Per person) IEC arxiden SING(UMI i$ ANY OWNED AUTOS AUTOS SCHEDULED BODILY INJURY(Per accident) i$ p HIREDAUTOS NON-OWNED AUTO I AUTO I(Per accident) $ I$ UMBRELLA LIAB OCCUR _ I EACH OCCURRENCE $ III EXCESS LIAR CIAIMSMADE AGGREGATE I,$ DED RETENTION$ I I$ WORKERS COMPENSATION V WCSTATU- 0TH ANY PRORIETOR/PARTNBR/LIXECuTIVE fl .° -^ICH AOC1DENnS,,. ER _ 4 7DRYUM A oFFItEJMEMBERFxauDFDT F N/A X 4517-1652 01/01/2018 01/01/2019 E T $1,,D00,000,00 (Mandatory in NH) I ELL DISEASE-EA EMPLOYEE $1,000,000,00 IFyes,describeunder .L DISEASE-POLICY UMIT 1,0D0,000,00 DESCNPTION OF OPERATIONS below E I ', $ B I'EXCESS WORKERS COMPENSATION NDE-0864486-17 01/01/2018 01/01/2019 AND EMPLOYERS LIABILITY Applicable to WC Statutory Limits and Employers Liability Limits. DESCRIPTION OF OPERATIONS/LOCATION/VEHICLES(Attach ACORD 101,Additional Ramerh's'S�Teduie,,if more space I's required) . Re:Goff Course:The Lakes at EI Segundo—400 S.Sepulveda Blvd. 0 Waiver of Subrogation applies-see attached•• "''Compiles with the requirements of the Director of Industrial Relations under the provisions of Sections 3700 to 3705,inclusive,of Me Labor Code of the State of Califomia,holder of Master Certificate of Consent to Setf-Insure No.4517 "Iq CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn:Recreations and Parks ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street, _.._.... EI Segundo,CA 90245-3895 AtJTHORIZEDI2ED ler REPRESENTATIVE A.See " 01988-2010 ACORD CORPORATION. All rights reserved ACORD 25(2014/01) The ACCORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY California Restaurant Mutual Benefit Corp. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS We have the right to recover our payments from anyone liable for a covered injury. We will not enforce our right against th person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule - Name of Person or Organization: City of EI Segundo Attn:Recreations and Parks 350 Main Street El Segundo CA 90245-3895 Insured: Donovan Golf Courses Management,Inc. Policy No.: 4517-1682