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PROOF OF INSURANCE (2019 - 2019) CLOSED
& I DATE(MMIDD/YYYY) ACRO CERTIFICATE OF LIABILITY INSURANCE 12110/2018 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). CONT PRODUCER PHONE 916-789-7500 NAME: Rebecca Huddle Becky Huddle Insurance Agency PHONE FAX 916-789-2545 IAr No,FXtb' INC.No 729 Sunrise Ave Ste 504 E-MAIL staff.rhuddle,�;1 farmer'sa enc rn ADDRESS„ L"'� g' y.co Roseville CA 95661 MSURER('Sp AFFORDING COVERAGE NAIC0 INSURER A:MID CENTURY INSURANCE 21687 INSURED INSURER B Lotus Communications INSURER C 737 W 31 st St Unit A INSURER D San Pedro,CA 90731 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 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 INSRR TYPE OF INSURANCE ANDI}L.5LI&Y9'k POLICY POLICY NUMBER (MM WYYYYI IMM,DFF CDYE�XP ftn YYI „DF1'lihlkGE.1"OEACH CIVYEU OCCURRENCE CLAIMS-MADE OCCUR 60669-02-33 10/01/2018 10/01/2019 ' S51,000,000 LIMIT AL COMMERCIAL GENE LTR PREMISES(,Ea orc:urrenr.,e) 5100,00 MED EXP(Any one person) S 5,000 PERSONAL 8 ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 5 2,000,000 POLICY❑ PRO•„)prCg0 LOC PRODUCTS-COMP(OPAGG $2,000,000 AUTOMOBILE LIABILITY I I COMBINED SINGLE LIMIT S ISI� „(Ea accidenkl,,,,, ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY ,AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LAB H OCCUR EACH OCCURRENCE $5,000,000 A EXCESS LIAB CLAIMS-MADE 60669-09-68 10/01/2018 10/01/2019 AGGREGATE S5,000,000 DED [7 RETENTIONS S WORKERS COMPENSATIONPER OT - I I AND EMPLOYERS'LIABILITY STATUTE,�,11,ERH A ANYPROPRIETOR/PARTNER/EXECUTIVE YIN Li A0949-23-59 10/01/2018 10/01/2019 EL EACH ACCIDENT S 1,000,000 OFFICER/MEMBER EXCLUDED9 NIA (Mandatory in NH) II E DISEASE-EA EMPLOYEE.S 1,000,000 If yes,describe under 1,000s OOO DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S Li 0 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 30-DAY NOTICE OF CANCELLATION,10-DAY NOTICE OF NON-PAYMENT OF PREMIUM WAIVER OF SUB:workers'comp ADDITIONAL INSURED(COMPLETED OPERATIONS):The City of EI Segundo CERTIFICATE HOLDER CANCELLATION CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 MAIN STREET,ROOM 6 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. EL SEGUNDO,CA 90245 AUTHORIZED REPRESENTATI'V ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Produced using Forms Boss Web Software,www.FormsBoss.com(c)Impressive Publishing 800-208.1977 POLICY NUMBER: 60669-02-33 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 Lotus Communications 737 W 31 st St Unit A San Pedro, CA 90731 THIS ENDO"'RSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY 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 Person or Organization: The City of EI Segundo CG 20 37 07 04 POLICY NUMBER: 60669-02-33 BUSINESS OWNERS POLICY Lotus Communications 737 W 31st St Unit A San Pedro, CA 90731 THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. ADDITIONAL INSURED—OWNERS, LESSEES OR CONTRACTORS This endorsement modifies Insurance provided under the following, BUSINESS OWNERS POLICY SCHEDULE* Name of Person Or Organization: The City of EI Segundo `Information required to complete this Schedule, if not shown on this endorsement, will be shown in the Declarations. The following is added to Paragraph C, Who is An Insured in the Business Owners Liability Coverage Form: 4.Any person or organization for whom you are performing operations is also an insured, if you and such person or organization have agreed in writing in a contract or agreement that such person or organization be included as an additional Insured on your policy. Such person or organization is an additional insured only with respect to liability arising out of your ongoing operations performed for that insured_A person's or organization's status as an insured under this paragraph ends when your operations for that insured are completed or the contractor's agreement is terminated. ,rr �,@�w p 0' � DATE(MM1DDNYYY) — aY„-� CERTIFICATE OF LIABILITY INSURANCE 12110 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 HILI, NAME: PHONE FAX 1 Bristol Bay Insurance Inrome Tax WC,req,,Ext), (3'I a1 833 Fit19F3 tAIID Noe (3'10)5-33-()1981 1 z E MAIL LBAYINSURANCL.COIVf It)7255WG5TERNAVESIAiE .i1:�1 ACaG„ �� CDr�[3RiST0 INSURER(S)AFFORDING COVERAGE NAIC# TORRANCE b 9NSURERA: NATIONAL GENERAL INSURANCE CO 23728 INSURED INSURERS: NAIIONAI_UNION FIRE INSURANCCCOMPANY 19445 JOSE GOME'Z JR INSURER c .... .D.. iM .................................................................................................................................................................................. .,.. . DBA: LOTUS COMMUNICATIONS, INSURER 2u84-13 CEN FRAL.AVE INSURER E: DUA RTE CA 91010 INSURERF: COVERAGES CERTIFICATE NUMBER: 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY 'AID CLAIMS. ILTR ILrr�SLkbb, VD POLICY NUMBER (MMID� TYPE OF INSURANCE Y EF POLICY EXP LIMITS dYVYY) {MMIDD)Y1rYY1 COMMERCIAL GENERAL LIABILITY 1 I 1 11 1I I II'I dPI ::Ill(.�Eo 1 Id 1 !I I IIINIII !' '111' ''1111 1 fl h �d 14 I IIIII;'I'r 1 AUTOMOBILE LIABILITY I. �IFo Y'+I;i� ;Il i,.!fa...i„I9 t,7 $ 1,000,000 1 1 Irl,1 11 1II 11 ... 1 11 1 l 1 1 ' II I I.aO"I'll X t 00 A Y la :, l r t) DCL)UCItIF3(1i_ $ C}ut},Oaa 1000 UMBRE X SLALIAB 4I 11 '... II ,111 rl HI( -J. 5,0010,000 B L1AB 1...:II Y Y EBU 0645275£8£3 04-30-2018 04-30-2019 I ' I 1 � 5,009,000 I EXCES.... 1,:1 L:'I I o Ird r, I S .. 1 , „I1_1.I WORKERS COMPENSATION AND EMPLOYER ..I..i 1 LIABILITY N� Af'dYRP.�!FF'IETORfF'N.RTI'JEFtEY.E_C'�1TiVE: 1 I '11 I III , OFFICERIME.MBEF EXCUJDED N/A N (Mandatary in NH) c ^ FCRI'�'Y'yN OF OPERATION b�aoUv ...L.mL.... If v”s,d•.^ht,'�'�',e under DE „r{ I q"d_n,:,h_ f":!i.I,.'r'L IPril I DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) LICENSE#967691 CERTIFICATE HOLDER ADDED AS ADDITIONAL INSURED. CERTIFICATE HOLDER CANCELLATION CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 MAIN STREET ROOM#6 ACCORDANCE WITH THE POLICY PROVISIONS. EL SEGUNDO, CA 90245 AUTHORIZED REPRESENTATIVE EDWARD L HARAZ_IN ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 4"N WC 99 06 19 FARMERS INSURANCE WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY Named .LOTUS COMMUNICATIONS,LLC Insured 737W31STSTUNITA SAN PEDRO CA907316726 Agent Effective Date 10/01/18 95-39-R6A A0949-23-59 2018 Policy Number Policy of the Company Year WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- BLANKET 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 for which you perform work under a written contract that requires you to obtain this agreement from us. The additional premium for this endorsement shall be 3-0 %of the Workers'Compensation premium otherwise due for the state(s)listed below on such remuneration,subject to a mi nimum charge of .... All written contracts in the state(s)of. CA This endorsement is part of your policy. It supersedes and controls anything to the contrary. It is otherwise subject to all the terms of the policy. Countersigned Authorized Representative WC 99 06 19 9-07 Page 1 of 1 93-6369 J6369101