Loading...
PROOF OF INSURANCE (2019) CLOSED " i. DATE(MMIDDIYYYY)CERTIFICATE OF LIABILITY INSURANCE 06/04/2018 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(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 I NAM' C'T Ibrahim Peker Insurance Solutions PHONE (949)348-7400 gg FAX 949 348-2373 AIC.No.Ex": fl(A,,,, N'-L ( ) License#0746539 IIbrahimP@ins-solutions.com i 33302 Valle Rd,Suite 200 INSURERS)AFFORDING COVERAGE NAIC f San Juan Capistrano CA 92675 INSURERA: Hiscox Insurance Company Inc. 10200 INSURED INSURER 8: California Automobile Insurance Co. 38342 Counterrisk,Inc.,DBA:Michael T Little INSURER C: 18000 Studerbaker Road,Suite 700 INSURER D: INSURER E: Cerritos CA 90703 p INSURER F: COVERAGES CERTIFICATE NUMBER: 18-19AII 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 Pa POLICY EFF POLICY EXP LTR TYPE OF INSURANCE �INSD Wvn POLICY NUMBER (MMIDD/YYYYI (MMIDD/YYYY) LIMITS - ------------ X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE a OCCUR P�OaREMAISES(EaUE IU tNoccrarrerrcel $ 100,000 MED EXP(Any one person) $ 5,000 A Y UDC-1993098-CGL-18 06/06/2018 06/06/2019 PERSONAL BADV INJURY $ 1,000,000 GEN'LAGGREGATELWITAPPUES'PER, j GENERALAGGREGATE S 2,000,000 POLICYEIJEa LEl OC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER' $ "AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 lee acodenli ANYAUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED Y BA040000034276 06/06/2016 06/06/2019 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY I(Per ac4dentl MLD s UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE S EXCESS LIAB AGGREGATE $ .... DED RETENTION S $ „WORKERS COMPENSATION 'N PER I 0TH- Y/N AND EMPLOYERS'LIABILITY II STATUTE ER ANY PROPRIETORIPARTN'EWCXECUTIVE ❑ NIA E,LEACH ACCIDENT S gOFFIC'ERIMEMBER EXCLUDED IfMands'lory Pur INH) E L DISEASE-EA EMPLOYEE S j If yes,describe under 6 DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S Each Claim: $1,000,000 A Professional Liability Y UDC-1993098-CGL-18 06/06/2018 06/06/2019 (Aggregate: $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may lre attached If more space is required) City of EI Segundo its officials,and employees as'additional insureds'under said insurance coverage and to state that such insurance will be deemed 'primary'such that any other insurance that may be carried the City of El Segundo will be excess thereto. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 314 Main Street AUTHOR®REPRESENTATIVE EI Segundo CA 90245 -Z., ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26(2016103) The ACORD name and logo are registered marks of ACORD Am HIS,COX Hiscox Insurance Company Inc. Policy Number: UDC-1993098-CGL-18 Named Insured: Michael Little Endorsement Number: 8 Endorsement Effective: June 07, 2018 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURE - AUTOMATIC STATUS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II —Who Is An Insured is amended to include as an additional insured any per- son(s) or organization(s) for whom you are performing operations or leasing a premises when you and such person(s) or organiza- tion(s) have agreed in writing in a contract or agreement that such person(s) or organiza- tion(s) be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to lia- bility 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: 1. In the performance of your ongoing opera- tions; or 2. In connection with your premises owned by or rented to you. A person's or organization's status as an addi- tional insured under this endorsement ends when your operations or lease agreement for that additional insured are completed. CGL E5421 CW (02/14) Includes copyrighted material of Insurance Services Office, Inc.,with its Page 1 of 1 permission. MERCURY N Policy Number: BA040000034276 � S U A C E Effective Date: 06/06/2018 N Renewal Declarations BUSINESS AUTO DECLARATIONS For resolving issues or other information you can contact your agent or Mercury using the below phone numbers: Issued By: Agent: California Automobile Insurance Company INSURANCE SOLUTIONS# P.O. Box 10730 33302 VALLE ROAD SUITE 200 C anta Ana,CA 92711-0730 SAN JUAN CAPISTRANO,CA 92675 Billing:(888)637-2176 Agent Number:043319 laims:(800)503-3724 Agent Phone:(949)348-7400 ; I ,I u, I I I,I I• IIII , I , IIIII II II . I I ,. , hII,,,I , I L. y�) I, a vYY Vo I I h J6 .I I Ilolflllllll II II I III JI I Y hlYhull I II I�II Vllol IIII IIS WI SII a ,, , I71 M „Aa IIII ul �1 � 16 11�II41 IIPu Itl I li 1 IIIIVII NIIII I I f VN V mll I I V ul ,V I e l uluull L. , NII ., „IIN�Y I I V, , I,. , III I. lu�l I YII IIII I,IIII I. IIIIIIII. ..I I. Illfllllll I. � I, II I I d I�1 II I Y l 1. IVIII I IIIA I IIIIYI Idllllu Ih y N .u IIIIYI umu II IIIIIIII I„ I)I l II I u I I I I III I I n II III ��J o� Illll,lf I ,I, I �I„ IIII; III lu� ( II m .+�� �'^� dI:IVNN���V,1�6d1Y,IN u�@Ill�l,l o 'Il� �„e„,'III��VI�G.CIII IV�.1I�Ih,,I�hV�Y�I ^I�11 VI,611„�lul,l��r, IVll � .1I � I��v����I�+�II���h�L�J d41Y�Yo,lll 1p All loll.„l �I�l�l,l,,,,u eu,l)h'^�,1�I,I41 ,,I...JI6.IIII „I�III, urIIIIIUIIVIh,,ll� Named Insured: MICHAEL LITTLE Mailing Address: 8504 Firestone Blvd,#400 Downey,CA 90241-4926 Policy Perlod: From 06/06/2018 to 06/06/2019 at 12:01 AM Standard Time at your mailing address Buslness Type: Management Consulting Business Category: Services Form of Business: Individual/Sole Proprietorship Total Policy Premium: $2,278.76 This policy may be subject to final audit. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. ENDORSEMENTS ATTACHED TO THIS POLICY IL 00 17 1198-Common Policy Conditions MCANONFAC0516-Permanently Attached Non-Factory IL 00 2109 08-Nuclear Energy Liability Exclusion CA 2154 10 13-California Uninsured Motorists Coverage- IL 00 03 09 08-Calculation of Premium CA 00 0110 13-Business Auto Coverage Form CA 01 21 10 13-Limited Mexico Coverage CA 0143 05 17-California Changes IL 02 70 09 12-California Changes-Cancellation and CA 23 94 10 13-Silica or Silica Related Dust Exclusion IL N 119 1015-California Auto Body Repair Consumer Bill of CA 20 48 10 13-Designated Insured MCA650CW1215-Transportation Network and Livery CA 04 25 10 13-California Individual Named Insured MCADS030817-CA Page 1 of 4 06/06/2018 12:01 AM PT 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 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# IZ (tj I 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 fir) as to become subject to the workers' compensation laws of California, and agree that, if I should become . 'at ),oO IVo;a, the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those p� siono ,or the agreement will automatically become void. Signature of Applicant Date� .µ. ..-- .' _ ..... _.... ....I Agreement for; Dated: '..`.. .G."...1.... .....w w. Reviewed by 1