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PROOF OF INSURANCE (2018 - 2019) CLOSED 0 DATE(MM/DD/YYYY)
AC R" CERTIFICATE OF LIABILITY INSURANCE
07/30/2018
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(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 rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAPA[
American Specialty Insurance&Risk Services, Inc, PHONEEM) 260-969-5203 FAXlA) Nib; 260-969-4729
dba A,S.I,R S,I Insurance Agency E-MAILADDRESS
7609 W.Jefferson Blvd., Suite 100 INSURER(S)AFFORDING COVERAGE NAIC O'
Fort Wayne IN 46804 INSURER Arch Insurance Compa'n'y 11150
INSURED INSURER B:
National Association of Sports Officials(NASO) INSURER c
2017 Lathrop Avenue INSURER D.-
INSURER
:INSURER E:
Racine WI 53405 INSURER F
COVERAGES CERTIFICATE NUMBER: 1001593268 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
INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR INSQD POLICY NUMBER (MMIDD/YYYY) (MMIDDIYYYY)
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
X OCCUR FIREMISES(, , N1vr 1,000,000
DAMAGE 1 RE
CLAIMS-MADE ISIS(c;a a,p4;,r;r}ir4rt��CN,y S
MED EXP(Any one person) l s Excluded
A Y SBCGL0279601 08/01/2018 08/01/2019 PERSONAL&ADV INJURY S 1,000,000
GEN'L AGGREGAT'E LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,000,000
POLI'CYPIdC3 [� LOC PRODUCTS-COMP/OPAGG $ 5,000,000
JE9�:'r I
X O,',j.tE'R, OFFICIAL
AUTOMOBILE LIABILITY Cr1'Iw4BIhJED SINOZy.E%,IMP7 $
ANY AUTO BODILY INJURY(Per person) S
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED P'RrOP'F:KSW'PlAMAGE
AUTOS ONLY AUTOS ONLY dF"'tyrt,Atac'.Ir9entV,,, $
S
UMBRELLA LIAR X OCCUR EACH OCCURRENCE S 5,000,000
A X EXCESS LIAB CLAIMS-MADE SBFXS0044401 08/01/2018 08/01/2019 AGGREGATE S 9,000,000
DED RETENTION S
WORKERS COMPENSATION PER 0TH-
'AND EMPLOYERS'LIABILITY YIN STATUTE ER
ANYPROPRIETORIPARTNERIEXECUTIVE ENIA/A E L EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? '
(Mandatory in NH) E L DISEASE-EA EMPLOYEE S
It yes,describe under
DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Coverage applies to JOHN ZIELLO,704 CAMINO REAL,REDONDO BEACH,CA 90277
The Certificate Holder is only an Additional Insured with respect to liability caused by the negligence of the Named Insured as per Form 00 SGL0026 00
Additional Insured-Certificate Holders,effective August 01,2018.
CERTIFICATE HOLDER CANCELLATION
THE CITY OF EL SEGUNDO, ITS OFFICERS,OFFICIALS, EMPLOYEES,
AGENTS,AND VOLUNTEERS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
350 MAIN STREET
AUTHORIZED REPRESENTATIVE
EL SEGUNDO CA 90245
©1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID:
LOC#:
ADDITIONAL REMARKS SCHEDULE 1 of 1
A�i�`�' Page ..................
AGENCY NAMED INSURED
American Specialty Insurance&Risk Services,Inc. National Association of Sports Officials(NASO)
.......
...................... _ ,...................................
POLICY NUMBER 2017 Lathrop Avenue
SBCGL0279601
CARRIER NAIC CODE Racine,WI 53405
Arch Insurance Comp...................... �............__........
any 11150 EFFECTIVE DATE:
..........................................
............... 08/01/2018
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: FORM TITLE: INSURANCE-Certificate#1001593268
ACORD 25' CERTIFICATE OF LIABILITY I ................____,,,_,_mmm
Unintentional Errors&Omissions,$100,000 each wrongful act/$100,000 Annual Aggregate per official/assignor
-Other Named Insured:National Association of Sports Officials(NASO)&NASO-member officials,including officials enrolled by associations,contracted with
NASO,
-Other Named Insured(cont'd):but only while acting in their capacity as officials during sports events organized by a recognized sanctioning body or organized
by another entity,but the rules of a recognized sanctioning body are followed,such as local Park Department or any formal organized association, and/or while
attending seminars,conferences,and similar meetings designed to improve their officiating knowledge and skills.
-The excess Aggregate Limit applies separately to each"official"insured under this policy. However,in the event of a suit by one or more plaintiffs against
more than eight"officials",the Aggregate Limit will not apply separately to each"official",and a single aggregate limit of$20,000,000 will apply collectively to all
individual"officials"covered under this policy
VI
ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: SBCGL0279601 COMMERCIAL GENERAL LIABILITY
CG 20 10 04 13
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED, 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) Location(s) Of Covered Operations
CITY OF EL SEGUNDO, ITS OFFICERS, ELECTED
AND APPOINTED OFFICIALS, EMPLOYEES AND
MEMBERS OF BOARDS, COMMISSIONS and
volunteers
350 Main Street
EI Segundo, CA 90245
but only with respect to John Ziello
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 additional
organization(s) shown in the Schedule, but only exclusions apply:
with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or
damage" or "personal and advertising injury" "property damage"occurring after:
caused, in whole or in part, by:
1. All work, including materials, parts or
1. Your acts or omissions; or equipment furnished in connection with such
2. The acts or omissions of those acting on your work, on the project (other than service,
behalf; maintenance or repairs) to be performed by or
in the performance of your ongoing operations for on behalf of the additional insured(s) at the
the additional insured(s) at the location(s) location of the covered operations has been
designated above. completed; or
However: 2. That portion of "your work" out of which the
injury or damage arises has been put to its
1. The insurance afforded to such additional intended use by any person or organization
insured only applies to the extent permitted by other than another contractor or subcontractor
law; and engaged in performing operations for a
2. If coverage provided to the additional insured is principal as a part of the same project.
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 10 04 13 ©ISO Properties, Inc., 2004 Pagel of 2 ❑
C. With respect to the insurance afforded to these 2. Available under the applicable Limits of
additional insureds, the following is added to Insurance shown in the Declarations;
Section III—Limits Of Insurance: whichever is less.
If coverage provided to the additional insured is This endorsement shall not increase the
required by a contract or agreement, the most we applicable Limits of Insurance shown in the
will pay on behalf of the additional insured is the Declarations.
amount of insurance:
1. Required by the contract or agreement; or
CG 20 10 04 13 ©ISO Properties, Inc., 2004 Page 2 of 2 ❑
CSE Insurance Bill
nNSURAINCIE GIROUIP Renewal Personal Auto Policy
PO h QLiV6 Civil Service Employees Insurance Company
""M
Notice Date: 04/05/2018
Bill To: Agent BICHLMEIER INSURANCE SRVS INC
caryb(t_i)bisins.coni
Address Code 41644-41644
730 S.PACIFIC COAST HWY 11201
REDONDO BEACH.CA 90277
ZIELLO.MARY P AND JOHN E
704 CAMINO REAL
REDONDO BEACH,CA 90277-4317 Phone: 800-888-7187 Fax: 310-540-2215
Insured: ZIELLO.MARY P AND JOHN E
Policy: CAA8002278 Term: 05/11/2018 to 11/11/2018
For detailed inforination regarding your coverage.please refer to your
declaration pages. Othenvise,for any insurance needs or questions.please
contact your independent agent.
Billing Activity as of 04/05/2018
Balance From N Tolal Policy Installment Fee Amount Current Minimum Premium
Prior Term Y Premium To Date Received Balance I Due by:05/11/2018
$0.00 $1,777.46 $0.00 $0.00 $1,777.46 $599.60
Payment Plan Options
............... ..............
To pay the current balance in full: To pay the premium in installments:
Return the payment coupon with your check for $1,777.46 Due 05/11/2018 $599.60 Due 08/09/2018 $302.01
Or pay by phone or via the internet. See reverse side for details. Due 06/10/2018 $302.01 Due 09/08/2018 $301.83
If you make changes to your policy resulting in premium Due 07/10/2018 $302.01
adjustments,you will receive an updated installment schedule.
Each installment includes a$6.00 service charge.
This is your renewal billing. Your policy renewal,which indicates your coverages and limits, is enclosed. Your coverage will not
continue unless we receive the minimum premium due before 12:00 a.m. Standard Time on 05/11/2018.
See reverse for important information regarding CSE's installment payment plans.
Keep top porfionforyour records
insured Bill Please defach and return ivithyourpayment. Allow fivedad's for delivel).
CSE Insurance Group
Policy Number: CAA8002278 Effective: 05/11/2018 Notice Date: 04/05/2018
Insured's Name: ZIELLO.MARY P AND JOHN E
To Pay In Full Minimum Due Due Date Amount Enclosed
$1,777.46 $599.60 05/11/2018
Make check payable to Civil Service Employees Insurance Company. Send check with policy number to: CSE Insurance Group, P.O. Box 60289, Los Angeles,
CA 90060-0289 Pay by phone:888-645-2586. Pay on-line:MyCSEpolicy.com. Automated payment:see reverse
04680022?800600011805111805110001783460000599609
EVIDENCE OF INSURANCE COVERAGE
Insurance identification cards are provided below. Please retain one card in the referenced vehicle. An
additional card is available as required by some states for vehicle registration. CSE provides insurance
information electronically to the CA, AZ and NV Department of Motor Vehicles.
California Proof of AutomobileM��► California Proof of Automobile
Liability4"W 111111111 Insurance Liability Insurance
INSURANCi GROUP NAIL 10693 INSURANCE GNOUP MAIC 10693
Insured Name and Address Agent: Insured Name and Address Agent:
ZIELLO,MARY P AND JOHN E BICHLMEIER INSURANCE SRVS INC ZIELLO,MARY P AND JOHN E BICHLMEIER INSURANCE SRVS INC
caryb@bisins com caryb@bisins com
704 CAMINO REAL 704 CAMINO REAL
REDONDO BEACH,CA 90277-4317 Address REDONDO BEACH CA 90277-4317 Address
730 S.PACIFIC COAST HWY#201 730 S PACIFIC COAST HWY#201
REDONDO BEACH,CA 90277 REDONDO BEACH,CA 90277
Policy Number: CAA8002278 Policy Number: CAA8002278
Effective Date: 05/11/2018 Effective Date: 05/11/2018
Expiration Date: 11/11/2016 Expiration Date: 11/11/2018
Ph.800-886-7187 Fx 310-540-2215 Ph 800-888-7187 1`0 10-540-2215
Year/Make/Model VIN Year/Make/Model VIN
2012 FORD TRANSIT CONNECT XLT NMOKS9CN9CT113461 2012 FORD TRANSIT CONNECT XLT NMOKS9CN9CT113461
Am��am �'California Proof of Automobile M California Proof of Automobile
Liability Insurance Liability Insurance
INSURANCE GROUP NAIC 10693 INSURANCE GROUP NAIC 10693
Insured Name and Address Agent: Insured Name and Address Agent:
ZIELLO,MARY P AND JOHN E BICHLMEIER INSURANCE SRVS INC ZIELLO,MARY P AND JOHN E BICHLMEIER INSURANCE SRVS INC
caryb@bisins com caryb@bisins,com
704 CAMINO REAL 704 CAMINO REAL
REDONDO BEACH,CA 90277-4317 Address REDONDO BEACH,CA 90277-4317 Address
730 S PACIFIC COAST HWY#201 730 S,PACIFIC COAST HWY#201
REDONDO BEACH,CA 90277 REDONDO BEACH,CA 90277
Policy Number: CAA8002278 Policy Number: CAA8002278
Effective Date: 05/11/2018 Effective Date: 05/11/2018
Expiration Date: 11/11/2016 Expiration Date: 11/11/2018
Ph.600-888-7187 Fx310-540-2215 Ph.800-888-7187 1`010-540-2215
Year/Make/Model VIN Year/Make/Model VIN
2016 FORD EDGE SEL 2FMPK3J91GBB60321 2016 FORD EDGE SEL 2FMPK3J91GBB60321
CITY OF EL SEGUNDO
COMPENSATIONI
WARNING: FAILURE
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,
FOR IN LABOR CODE § , INTEREST, AND ATTORNEYS 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 workerscompensation, 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 El Segundo.
Policy No,
(_)
I have and will maintain workers'compensation insurance as required b Labor Code§3700 for theperformance Y
of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance
mer and policy number are:
Carver Policy Number Expiration Date
Name of Agent Phone# ..._.. —
NI certify that, in the performanceset forth in the agreementwith the City of El Segundo, I will not
moy 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 theworkers' compensation provisions of Labor Code § 3700 1 must
Signature of Applicant _ �� ent willutoatiautomatically become void. �
Date r�
immediately ply with thos ro i bar r ern
Print Name
a
Agreement for:
Dated:
Reviewed by: '