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PROOF OF INSURANCE (2019 - 2019) CLOSED
C CERTIFICATE F LIABILITY' I SI NCE DATE(I71tA0DrYYYY) 10/2512018 I PRODUCER THIS CERTIFICATE IS-TSM%D AS A' MArTR OF IN1=t.RMAt'ION! Insurance Plus 800-516-8822 ONLY AND CONFERS NO RIGHTS UPON TIME CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Willis of New York, Inc., Brookfield Place ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, 200 Liberty Street, 6th Floor New York, NY 10281 INSURERS AFFORDING COVERAGE MAIC # INSURED INSURERA, Aspen Specialty Insurance Company 10717 Donald Henry _Report all claims to Insurance Plus Program via e-mail at 217 Camino de las Colinas Protessk'onalLiabti lityC,taims@aspen-insLirance.com Redondo Beach, CA 90277 Ins.#185579 INSURER B: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD .,.,, INDICATED.NOTWITHSTAN DING 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. I-L.T. L Rn TYPE OFMSURANCE POLICY �' NUMBER DPAOTLICY DFECC VE POLICY E'XPIRA'TION LEIprS GENERAL LIABILITY EACH OCCURRENCE S 2,D3:7,000 X COMMERCIAL GENERAL LIABILITY DAPMGE TO RENTED � g 700,000 08120/20113 08/20/2019 PREM�ses(EaoccurrntoJ CLAIMS MADE X occuR #LRAFVTXI7AOM FASO EXP(Any we pereon) S NIA A PERSONAL&ADV INJURY S2.000,000 X GENERAL AGGREGATE +�3,00,000 GENT AGGREGATE LIMIT, _ fES PER: PRODUCTS-COA KOPAGG PRO,, LOCBUS,PZRS.PROP.ACG I DED si,000/$250 POLICY _ r t _. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Es accident) g ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (Pe" r" m) HIRED AUTOS BODILY IN.II,7R'r' g NON-MINED AUTOS (Per,rac».donl) PROPERTY OAAAGE $ I,Pa.ilcoidzral) GARAGE LIABILITY AUTO ONLY-EAACCIDENT S ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AOG 3 EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE 5 OCCUR CLAIMS MADE AGGREGATE $ S , DEDUCTIBLE 5 - RETENTION S S WOPKeRS COMPENSATION VAC$TATU. OTH. AND EMPLOYERS LIABILITY YIN TORY WAITS ER ANY PROPAMTOWPARTN'gttl'EXE'CUTWE EL EACH ACCIDENT ,5 OF'F'ICE'I8IMEMBER EXCLUAEP9 jr.jand'uloryr in NH) E L.DISEASE-EA EMPLOYEE. $ 1V ,da rxilba under A„ ".A'�l P,�',/yi'tiAV.'SUI"9NfiN ., EL,O'VSEASE.-POLICY 1,%AAAI' 3„ OTHER Professional Liability #LRAFVTX77ADM 3$No ow per occurrence l 33,904,000 annual 08/20/2018 08/20/2019 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Holder named below is listed as an Additional Insured for the General liability policy, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of EI Segundo and Its Employees DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 110„ DAYS WRITTEN 350 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL EI Segundo, CA IMPOSE NO OBLIGATION OR LIABILITY OF ANY NIAIO UPON THE INSURER,ITS AGENTS OR R'EPRESENTATIV'ES. 1 AUTHORIZED REPRESENTATIVE ACORD 25(2009101) ©1988-2009 ACORD CORPORATION, All rights reserved. INS025(20000t) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ENDORSEMENT .................. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY POLICY OCCURRENCE HEALTH, WELLNESS& BEAUTY PROVIDERS PROFESSIONAL LIABILITY INSURANCE POLICY In consideration of the premium charged, it is agreed that the dcl-ined term "Insured" is hereby amended to include the foliowing person(s)and/or entity(ics): 1. City of El Segundo and Its Employees ALL OTHER TERMS,CONDITIONS AND EXCLUSIONS REMAIN UNCHANGED. THIS ENDORSEMEN'I'FORMS A PARI'OF POLICY NUMB UR: 185579 Issued by:Aspen Specialty Insurance Company Issued to: Donald Henry Effective date: 10/25/2018 ASPMT01 1 0118 2018©Aspen Insurance U.S. Services Inc.All rights reserved. Page 1 of 1 Policy Number: Date E9 ntered�0/24/207.8 AC40R" CERTIFICATE OF LIABILITY INSURANCE 9 DATE 10/2hV/2018 10/24/2016 I 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 .., CONTAC"'r ., ,...,..., ....,....,. ............. .i. ..) ............ .. Wells Insurance Agency fxA/�c f w lsins.com FAX 0861 elf 0)375-9745 310)37 -0881 I, PHONE 6- Redondo Beach, Ca. 90277j 3@7e$'g el �fc^Ns ( NAlca 149 Palos Verdes blvd. Suite C E-MAIL21687. NSURER A:MID- CENTURY INSURANCE COMPANY I TRU INsuRED DONAi i� HENRY " " INSURER C CK INSURA.1 NC E EXCHANG .. a INSURERS E 21709 217 CAMINO DE COLINASSURERD: _._,__ ......,........,.... .II' _ INI REDONDO BEACH, CA 90277 _..... INSURER F COVERAGES CERTIFICATE,NUMBER; REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN iSSU'CD TO'IHE 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. ., .... .L.-- ._, .... .....,... 17pY TYPE OF INSURANCE aNy�-f1, WVP! .... mPOLICYNUMBE Fi CkLICY Ei" POLOCYi G,xP LIMITS 1 �. . -.... _ -..-....,... ER Mhb100fYfif YT Nr"MNR30PYYYY ___._.�.... 1 1,._.I.._..__..__..,.P - COMMERCIAL GENERAL LIABILITY r• ^.w_mmm ^. � I �EACH OCCURRENCE 5 CLAIMS-MADE 'OCCUR liMED EXP; n sn }t On) _ I l f 'S A?tiNa.:LuRM S GE N-L AGGREGATE LIMIIT POLICr APPLIES PER. ,I RSJN PRO- NC.fveal J.dyCR.;Gfr'fE S ' I u..,.,_N TODIJCT"",.I"O ROP AGG 1 5 f S R Rf 15 KFI, ANY AUTO .. ,.. ^ 1189756090OILY INJURY(Per pirmon). .,S 250,.,Q00 ..,.�A AUTOMO BILE LIABILITY "LI1I A. �. OWNED i SCHEDULED BO tl, 06/02/201 �DILYINJURY-(Pe�acudena) 500,000 AUTOS ONLY _�, AUTOS ! s LL. HIRED NON-OWNED ', $D 6/02/209, ffrtwYP rnDA.,1�AGm .S�.00,000.' a .! AUTOS ONLY AUTOS ONLY k.... _ EACH 10 23 20181Q123/2019 w .*... .. .-.�. _ I5 0 1 B CCcuR / / 1 S 1,000,000 605984505 G 1 000 000 Y EXCESS Llp � S __ r ti DED RETENTION 5 ... .. ...�. ... . UMBRELLA LIAR i CL ........... .,_. ...._.... .......r...__..®............... .nNFL,nTEaw"PE MdG..._—. COMP B CLAIMS-MADE ''CNTNC. .AND EMPLOYERS'LIABI IWORKERS Y III 57 ATLJlrL 1 iiR . ANY YIN NfA „'E.L EAC ueCC:tDF'fti S (Mandatory in ER EXCLUDED?XECUTIVE ^ i� .. CA E..F a O.L S ....._, r ._- I CESCRIPTiON OF OPERATIONS be... 11 . ............ ....... '.-.-,....___..a. .J..-,...,_. C L.DS +LIC UM l L 5 If es describe undo ¢ 1 GIBE. F M Ce,.ld"�LkN�fr'r low N i I DESCRIPTION OF OPERATIONS)LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space i5 required) 0 V CERTIFICATE HOLDER CAN'CE'LLATION THE CITY OF EL SEGUNDO AND ITS EMPLOYEES 350 MAIN STREET SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN j EL SEGUNDO, CA. 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ti c.: (C.� . ..I ...... ,TEFF S. WELLS ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Produced using Forms Boss Plus software.www.FormsBoss.com;Impressive Publishing 8OD-208-1977 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, ARID ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: Pe Y P l ry 9 (_) I have and will maintain a certificate of consent of self-insure for workers' compensation, issued by the Director of)ndustrial 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. Z._.)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 El Segundo is executed. My workers' compensation insurance carrier and policy number are: j Carrier Policy Number Expiration Date Mame of Agent Phone# ( ) 1 certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not m loy 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 the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with thpse provisions" r_�he agreern nt will automatically become void. Signature of Applicant Date Print Name " / . Agreement for: Dated ` Reviewed by: