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PROOF OF INSURANCE (2019 - 2019) CLOSED OP ID: MN A DATE(MMMDMMr) CERTIFICATE OF LIABILITY INSURANCE 0311912018 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 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). ichelle M760-471-7 161 —. . LODUCER ONfia .... ...........__. Aulance MPlgt.8 Insurance 5ery .���I�a,.Sst')�..�....IT�._.._�...._._...... .`-._m..m...•�-°��cq r1a+p;.760-471-9378„ 1355 a Vora mnVlarcos,CAz#792078 CAA, FR DLI E mnoWei ISCOrp.Cortr gpn Bra er L c' C 37 86 1 JD,RC6 pm fel ... ..„ Micho0o A.Nowell u�s.TOtr R ID�_WYENN-1 IN9UR1ERta)AFfOADING CCPNCRAGE I NAIL 0 INSURED Wy®nn 8r AssociatesINA Acceptance Casualty Ins Comp 10349 616 S Central Ave X120 suRER" YM U' Glendale,CA 81204 weuRER C.�!_ ...... . INs�1RER D INSURER E: INSURER F COVERAGES CERTIFICATE N'LIMBER; 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. NOTIMTHSTANDING 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. INR" TYPE OF INSURANCE POLICY NUMBE R'ER1d I ADOL SUSR1 . . - Pou Y rog POLICY CxP ------- d'1,TNMDWYYYYI 10APNDDNYY'YN LIMITS EACH�GENERAL 1,00,. I - � c1ErYcE.... S 06. X � ,nq�walLp A �t GENERAL LIABILITY X ICP00980505 03I08I2018 0310812019 1001000 i,�1�ddCSFl„S X II E...I l..__ --PERSONAL_ ADV_ o ...,' . 00 CLAIMS•MADE X OCCUR MED EXP(AnY OneIIL person) S 8r Dml'ealOn I 9 INJURY u S 1,000 000Y ROra GENERALAGGREGAT E S 5'000'00 01 DEN' azo PLIES PER: [a 1,000,000 X AGGREGATE EC7 PRODUCTS•COMP/OP III . T'E LIMIT AP AOG LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ – (Ea acddenl) ANY AUTO -. BODILY INJURY(Per person) $ ALLOWNEDAUTOS AGE – — BODILY INJURY(Per accldenq $ SCHEDULED AUTOS PROPERTY DAM —. HIRED AUTOS ! (PER ACCIDENT). ..S, .. ........�...... NON-ONMEDAUTOS a...._.... UMBRELLA 1 JOCCUR EACH EXCESS LIABAB CLAIMS-MADE AGGREGATE RENEE w s DEDUCTIBLE S. RETENTION S S WORKERS COMPENSATION VVC 5TATU- TH- ND rdao�rla a s�NH uaBIUTY �EA ACCIDENT � FR ANYry Y❑ NIA RY S tOP'�b:I�Er04J�EhNf1E�Q;A�LUG?IFDYCr.�6J�T%'�»JC E L.DISEASE ., ., ., ....... ......... A E-EA EMPLOYEE $ DIF„SCRwP710N,Or OPEPA7*NS eebN E L DISEASE•POLICY LIMIT S I CRNP''0N OF p1RATff P LOCATFDN131 H%JS S (A.1 b ACORD 101,AddRllonal'Aommraa SOiodula,If more space la required) f�a Lando INce warm ntF 'a''s, caars,agnts nd emyloy,ies are ms as d�t OnSure vardtth res,pec to the vY r pa Orme by t o nIa1TIQd ' efs1aDnves1s Uo.org t go CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EI Segundo Police Department ACCORDANCE WITH THE POLICY PROVISIONS. Assistant to the Captains Amanda O'Donnell AUTHORIZED REPRESENTATIVE 346 Main Street h �� I IEI Segundo,CA 90246 II VL' I 01988.2009 ACORD CORPORATION, All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: CP00960505 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 Insured Person Nam Additional„„,, ' ' sons Or Oranization(s) Automatic Status Included Where Required by Written Contract.All Where Required by Written Contract. Section II - Who Is An Insured is amended to in- clude as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect 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 202607 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ tJ - s ul Ll u Olt c OltU LW t0 +� (N — c3 t...,) c' CU co 0 tv CO Ln ON 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: (J I have and will maintain a certificate of of elf-insure for workers'compensation,issued by the Director of Industrial Relations as provided for by, ode§3700 for the performance of the work set forth the agreement with the City of EI Segundo. Policy No. CJ I have and will maintain workers'cora�per� anon inscnra s required by Labor Code§3700 for the performance of the work for which the agreement with e f egundo is executed. My workers'compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent ,sem Phone# Amplocert if�rthat, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not any person in any ma ier o as to become subject to the workers' compensation laws of Califomia, and agree that, if I should beco e su ject to the workers mpensa'tion provisions of Labor Code § 3700 1 must immediately comply with t'ho a pro isions or the e'nnent will automatically become void. j Signature of Applicant Date Agreement for- Dated: M, Reviewed by: 1