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PROOF OF INSURANCE (2019 - 2019) CLOSED
TIFFHOM-01 �_,,,,,,KG U,RLEY AC'OR CERTIFICATE OF LIABILITY INSURANCE DA_E(MMIDDNYYY) _ 06/13/2018 T IS ISSUED A .A......MATTER ..... .F.....INF RMATI .............................................................................................................................................................................................................______..........................................._ THIS CERTIFICATE S S O O ON 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: ...Ifthec 1.11,111,11111, ............ .�......................................................................................... ..m.. mm....� ................................mm..............................................m..mm...................m....m.. ..-........ certificate'cateholder's an ADDITIONAL INSURED,the policy(Ies)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 ri hts to the certificate holder in lieu of such endorsement(s). _....._ .... ..................................................................................................................................................... .............................. .............................................................................................. PRODUCER License#0757776 CRNTACT Karen Gourley �utOE: HUB International Insurance Services Inc. PHONE Exap;(909 912-6438 FAX 3390 UniversityAvenue,Suite 300 , tAib,ho), E-RyIAlL Karen.GOLj�rley@hubinternational.com Riverside„CA 2501 ADDRESS; Y INSURERS)AFFORDING COVERAGE NAIC# ,INSURER A:Philadelphia Indemnity Insurance Company 18058 INSURED INSURER B Tiffany Home Care INSURER C: DBA:Always Right Home Care 9700 Reseda Blvd.,Ste 105 INSURER D: Northridge,CA 91324-5516 INSURER E INSURER F: ........................� COVERAGE'S CERTIFICATE NUMBER: REVISION NUMBER: mmTHIS IS TO CERTIFYTHATTHE 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 INSR TYPE OF INSURANCE 'ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS . .TR,-.................-..,.,.,.,.,.,.,.,.......,.,.,.,.,.,.,.,...............,.�... INSD WVD fMMIDDIYVWI IMMIDDM'YYl A X COMMERCIAL C l AIMS MADE 7 OCCUR PHPK1834639 06/1512018 06/15/2019 p REW I y&p�, ggrlr;e, S 100 000 GENERAL LIABILITYOCCU1 000 00 X Retro Date 6/15/03 IOED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY S 1,000,000 C:EEIJ'L AGGREGATE.LIMIT APPLIES PER GENERAL AGGREGATE S 31000,000 i X POLICY l7 .... LOC PRODUCTS C.OMPtOP AGG . S 31000,000 .. �r OAC 1 OTHER a A AUTOMOBILE LIABILITY .. .... .. .... .0�Ih°tCEir�4pn ED SPNGLL LW11 ..��$ 1„0005000 ANY AUTO PHPK1834639 06/15/2018 06/15/2019 BODILY INJURY(Perperson) S OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Par apoident) S Al qPROPERTY DAMAGE, X H�R�}Ai X A0F0,' 0I, P[,a .idea S A.J G:1„,�ONL.Y A4.V10,5d,)P�",'n' ti, -,q ...,. ..,,,. E .........,........w._......... ......................._.............................................................. UMBRELLA LIABOCCUR ....................................... ., EACH OC.)RPF.NCF $ EXCESS LIAR CLAIMS-MADE AGGREGATE DED RETENTIONS S ...............' ................ WORKERS COMPENSATION ATION PER OTH- AND EMPLOYERS'LIABILITY Y i N STATUTE F..RANY , OFFICER/MEMBER!PARTNER/EEXCLUDED?ECUTIVE NIA E L EACH ACCIDENT S (Mandatoryin NH) E L DISEASE•EA EMPLOYEE 1 If yes,describe under DESCRIPTION OF OPERATIONS below ................................................�..,.,....................................,.,.,.,.,.,.,.,.__E,.L: DISEASE...;:,.POLICY L,IMI7 S A Prof Liab RD 6115/03 PHPK1834639 06/15/2018 06/15/2019 Ea Incidnt 1,000,000 A Prof Liab RD 6115103 PHPK1834639 06/15/2018 06/15/2019 Aggregate 35000,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES IACORD 101,Additional Re marMs Schedool ule,may ba attached if more space is required) Coverage includes Sexual/Physical Abuse or Molestation$1,000,000153,000,000,Retro Date:6/15103, Certificate Holder is included as Additional Insured as respects to the General Liability when required by written contract per policy terms and conditions as respects Senior In Home Care Project for the City CERTIFICATE HOLDER.............m CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cit of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Y 9 ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street EI Segundo,CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25 2016/03 ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PHPK1834639 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 Organization(s): City of E1 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" 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. In the performance of your ongoing operations; 1• Required by the contract or agreement; or 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 04 13 C Insurance Services Office, Inc., 2012 Page 2 of 6 AC"R"e, CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY( 03/01/2018 PRODUCER THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION Douglas J Carlson ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1820 S Elena Avenue,Suite H HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Redondo Beach,CA 90277 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER Cypress Insurance Company Tiffany Homecare Inc. IN•1O1?I w,I dba Always Right Home Care NNr;V IRFR C: 9700 Reseda Blvd,Ste 105 INS[Frau u?D. Northridge,CA 91324 INSURER F:' COVERAGES 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 AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR ADD'L POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION' LIMITS LTRINSRD TYPE OF INSURANCE DATE(MM/DDIYY) DATE(MMIDDIYY) GENERAL LIABILITY EACI-I OCCURRENCE 8 COMMERCIAL GENERAL.LIABILITY (EA eccur'eril,,O $ CLAIMS MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGA'T'E $ GEN'I_AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ POLICY PRO. .., „JEC LOC .... ..,.,, AUTOMOBILE LIABILITY COMBINED SINGLE I..IINIT ANY AUTO (E a accident) ALL OWNED AUTOS BODILY INJURY SCHErrLlI..FL7 AUTOS (Per person) HI RED AUTOS BODILY INJURY NON OWNED AUTOS � (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT' $ ANY AUTOEA ACC $ OTHER THAN AUTO ONLY: AGO S EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE S OCCUR CLAIMS MADE AGGREGATE i 5 $ DEDUCTIBLE S RETENTION' S S '0 ttt �Suf\T11- OT'H- A WORKERS COMPENSATION AND TIWC913045 03/01/2018 03/01/2019 ('y'RP L.21IoS ER EMPLOYERS'LIABILITY F L EACH ACCIDENT $ 1,0 ANY PROPRIETOR/PARTNER/EXECUTIVE " OFFICER/MEMBER EXCLUDED? EL DISEASE:-EA EMPLOYEE $ 1,000,000 If yes,describe under SPECIAL PROVISIONS below E L DISEASE POLICY LIMIT S 1,000,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS City of EI Segundo 350 Main Street EI Segundo,CA 90245 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of EI Segundo DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN 350 Main Street EI Segundo,CA 90245 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORN 2'5(2001108) ORATION 1988 Important ,I,., . IB rIl<, Il,,� I� � ! fat[) � � Information M IE S P T' E C 0M P P, I1q I P Insured Agency Tiffany HomeCare,Inc. R-T SPECIALTY INSURANCE SERVICES,LLC 9700 Reseda Blvd 500 S Grand Avenue Suite 2100 Ste 105 Los Angeles,CA 90071 Northridge,CA 91324-5516 Changes to Your Workers' Compensation Policy with Cypress Insurance Company Policy Number TIWC913045 . ......... Policy Period From March 1,2018 to March 1,2019, 12:01 AM,standard time at the insured's mailing address. Type of Endorsement Added Forms effective 03/01/2018 WC990402C- CA Waiver Of Right To Recover-Specific Added Waiver of Subrogation effective 03/01/2018 Name:City of EI Segundo;Job Description:Per written contract Added Waiver of Subrogation Class Code effective 03/01/2018 State:CA;Code:8827 Home Care Services Premium change: $ 27000 ............. ................. . .... This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective See Above Policy No TIWC913045 Endorsement No 1 Insured Tiffany HomeCare,Inc. Premium Insurance Company Countersigned by Cypress Insurance Company WC 99 00 13 (Ed. 11-14) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 04 02 C (Ed. 9-14) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy.We will not enforce our right against the 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) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule The additional premium for this endorsement shall be 5%of the applicable manual premium otherwise due on such remuneration subject to a policy maximum charge for all such waivers of 5%of total manual premium The minimum premium for this endorsement is$350. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule Schedule Specific Waiver Person/Organization: City of EI Segundo Job Description: Per written contract Waiver Premium: 350.00 Payroll Subject Class State to Waiver 8827 CA 100 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: 03/01/2018 Policy No.:TIWC913045 Endorsement No.° Insured: Premium$ Insurance Company:Cypress Insurance Company WC 99 04 02C Countersigned by (Ed.. 9-14)