PROOF OF INSURANCE (2019 - 2019) CLOSED C CERTIFICATE OF LIABILITY INSURANCE °1tiiti2o a'
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 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). CONTACT
PRODUCER Brian Hunt Insurance Agency .PONHE ...
FAX
Hunt, Lic#OE02545 r ,No „ „„,
96
-AtL
5693 Woodruff Ave
Lakewood, CA 90713 INSURER(S)AFFORDINGCOVERAGE NAICN
" INSURER A:State Farm General Insurance Comoanv 25151
.....................................
_.._._.
IN ALLISON _..._..
ROBBY INaURER B.-
DBA
:DBA ALLISON TRAINING INSURER C
PERSPECTIVES &SERVICES 1N§RI FRD:
........ ........_. . ..
4067 HARDWICK ST STE 495 SURER E:
NSURER 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.
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RCkdi'�LTs"lGlt/kT..,. .... POLICY EBF'�. mPOLICY"EXP
TYPE OF INSU'RANCE� Jim 13ia PC7L9C'I!NUMBER IMMYd?D WYYYY...tl�1�N!/'p01YYYY9 .. LIMITS
A 3 0,004
X COMMERCIAL GENERAL LIABI'LI'TY 0�I P1tiG OCCURRENCE............... $ 11.00
CH O
RE
92-EL-B253-8 G P "r�^9 �EI1'
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.0,000
GENERAL LIABILnn/ 10112/2018 01 20 EACH
MED EXP IAAWr one aosonc $
CLAIMS-MADE ��OCCUR sang S 5,000
PERSONAL.&ADV INJURY S 1.000.000
GENERAL
q 2,000.000
GENL A....,......,,,, ..... ., ._. V
GGRE,GATE OMIT APPLIES PER: 2,000,000
GENERALA
I—p PRODUCTS-COMPIOP ....L...._.—.
Business
d AUTOMOBILE LIABILITY rtrt �� jEOi atYINJURY roPer ersmmn S 9,504
X]POLICY JECT V J LOC _ P
ANY AUTO _w� ( p O)
UM
IT
OWNED SCHEDULED BODILY INJURY(Per acddenl) S
AUTOS AUTOS
NON-OVMED � h' 'm0�;"�A
Vier S
HIRED AUTOS ac"Ideral AUTOS -••°-•° -
" ; I
EXCESS LIAB .d,CGT1Ek,+A'T lr S
H OCCURRENCE
... OCCUR
...... $UMBRELLA LIAR � ......................
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V+rORbkER�SIICOM COMPENSATION
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YIN' WC ST�ATU• OT ht.
OFFICEIMEMBERF.XCLUDERI �, NIA I �.._.� H ACCIDENT
1ICYYE 5............w. ............ ...........�
AND EMPLOYERS'LIABILITY TAY
ANY PROPRIETORIPARTNERlEXECUTIVE �1
11 EL
(Mandatory In NH) L L DISEASE-EA� .
IIyc%A.describe under E .DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,M more spats Ia required(
CITY OF EL SEGUNDO ti r
ITS OFFICERS,OFFICIALS,
EMPLOYEES,AGENTS&VOLUNTEERS
Y
CE'RTIFI'CATE'MOLDER CANCELLATION
ANY OF THEBEFOE
Additional Insured: a THEULD EXPIRATIION DATE DESCRIBED
NOTICE IEWILLL CBECDELIVERED ELLED RN
CITY OF EL SEGUNDO ACCORDANCE WITH THE POLICY PROVISIONS.
300 MAIN ST
AUTNORDED REPRESENTATIVE
EL SEGUNDO CA 90245
p 1988-2010 ACORD ORPORATION, All rights reserved.
ACORD 26(2010105) The ACORD name and logo are registered marks of ACORD 1001486 132849.7 03-01-2012
CMP—4626.1
61 w1 ADDITIONAL INSURED—
ESI TE PERSON OR c. If the contract or agreement between you
,ORGANIZATION and the additional insured is governed by
This endorsement modifies insurance California Civil Code Section 2782 or
provided under the following:
PRODUCTS AND COMPLETED
OPERATIONS LIABILITY COVERAGE
FORM 2782,05, the insurance provided to the
additional insured is the lesser of that which:
Policy No: 92-EL-6253-8 G
Named Insure& (1) Is allowed for the satisfaction of
ALLISON,ROBBY a defense or indemnity obligation
DBA ALLISON TRAINING by California Civil Code Section
PERSPECTIVES&SERVICES 2782 or 2782.05 for your sole
4067 HARDWICK ST S 495 liability, or
LAKEWOOD CA 90712-235O (2) You are required by contract or
agreement to provide for such
Name and address of Additional Insured additional insured,
Person or Organization: We have no duty to defend or indemnify the
additional insured under this endorsement
until a claim or"suit" is tendered to us.
2. Any insurance provided to the
1® WHO IS AN INSURED is amended additional insured shall only apply
to include, as an additional insured, with respect to a claim made or a
any person or organization shown in "`slain brought for damages for which
the Schedule above, but only with you are provided coverage,
respect to liability for"bodily injury" 3. With respect to the insurance
or"property damage" caused, in afforded to the additional insured,
whole or in part, by"your work" the following is added to
performed for that additional insured SECTION 11—LIMITS OF
and included in the"products- INSURANCE:
completed operations hazard".
If coverage provided to the additional
However, Paragraph 1. above is subject to insured is required by contract or
the following: agreement, the most we will pay on behalf
of the additional insured will be,the lesser of
a. The insurance afforded to the additional the amount of insurance:
insured only applies to the extent permitted
by law: a. Required by the contract or
agreement; or
b. If coverage provided to the additional
insured is required by a contract or b. Available under the applicable Limits
agreement, the insurance provided to the Of Insurance shown in the
additional insured will not be broader than Declarations.
that which you are required by the contract
or agreement to provide for such additional
insured; and
Page 1 of 2
CMP—4616.1
This endorsement shall not increase the
applicable Limits Of Insurance shown in the b. Regardless of any agreement between
Declarations. you and the additional insured, this
insurance is excess over any other
4. With respect to the insurance insurance whether primary, excess,
afforded to the additional insured, contingent or on any other basis for which
the following is added to Paragraph the additional insured has been added as
3. Duties In The Event Of an additional insured on other policies.
Occurrence, Offense, Claim Or
Suit of SECTION II All other policy provisions apply.
—GENERAL CONDITIONS:
The additional insured must:
a. See to it that we are notified as soon as
practicable of an "occurrence" or an offense
which may result in a claim. To the extent
possible, notice should include:
(1) How, when and where the
"occurrence" or offense took place;
(2)The names and addresses of any
injured persons and witnesses; and
(3) The nature and location of any ,
injury or damage arising out of the
"occurrence" or offense;
b. Tender the defense and indemnity of any
claim or"suit"to us and to all other insurers
who may have insurance potentially vailable
to the additional insured; and
c. Agree to make available any other
insurance the additional insured has
for defense or damages for which
we would provide coverage under
SECTION II—LIABILITY.
5.With respect to the insurance afforded
the additional insured, the following
replaces SECTION II—LIABILITY of
Paragraph 7. Other Insurance of SECTION
I AND SECTION II—
COMMON POLICY CONDITIONS:
a. This insurance is primary to and will not
seek contribution from any other insurance
available to the additional insured, provided
that the additional insured is a named
insured under such other insurance.
Page 2 of 2
GEICO GEICO GENERAL INSURANCE COMPANY
Washington DC VERIFICATION OF COVERAGE
(SEE BELOW UNDER CAUTIONARY NOTE)
MAILING ADDRESS Policy Number: 4438734776
ROBBY JAY ALLISON Effective Date: 11-11-18
4316A N LAKEWOOD BLVD Expiration Date: 05-11-19
LONG BEACH CA 90808-1350 Registered State, CALIFORNIA
To who it may concern:
This letter is to verify that we have issued coverage under the above policy number for the dates indicated in the
effective and expiration date fields for the vehicle listed. This should serve as proof that the below mentioned vehicle
meets or exceeds the financial responsibility requirement for your state.
This verification of coverage does not amend, extend or alter the coverage afforded by this policy.
Vehicle Year. 2004
Make: FORD
Model: EXPXLS/SPT
VIN: 1FMZU62K24ZA34919
COVERAGES LIMITS DEDUCTIBLES
Bodily Injury Liability
Each Person/Each Occurrence
State Minimum$15,000/$30,0000 $25,000/$50,000
Property Damage Liability
State Minimum$5,000 $25,000
Uninsured&Underinsured Motorists
Each Person/Each Occurrence $25,000/$50,000
Uninsured Motorists Property Damage $3,500
Lienholder Additional Insured Interested Party
Additional Informatiow
Issued 12/11/2018
If you have any additional questions, please call 1-800-841-3000.
CAUTIONARY NOTE.,THE CURRENT COVERAGES.LIMITS,AND DEDUCTIBLES MAY DIFFER FROM THE COVERAGES,LIMITS AND DEDUCTIBLES IN EFFECT AT
OTHER TIMES DURING THE POLICY PERIOD.THIS VERIFICATION OF COVERAGE REFLECTS THE COVERAGES,LIMITS,AND DEDUCTIBLES AS OF THE ISSUED
DATE OF THIS DOCUMENT WHICH 15 SHOWN UNDER"ADDITIONAL INFORMATION"OR IF AN ISSUED DATE IS NOT SHOWN,THE DATE OF THIS FACSIMILE.
U-33 10-07
CITY OF' EL SEGUNDO
WORKERSO COMPENSATION DECLARATION
.....................
WARNING: FAILURE TO SECURE WORKERS' COI PENSATION COVERAGE
IS UNLAWFUL AND SUBJECTS AN EMPLOYERTO 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 ATTORNEYS FEES.
affirm under penalty of perjury under the laws of Califomia one of the following dedarations:
L I have and will maintain a certificate of consent of self-insure for workers'compensation, issued by the Director
of Industrial RePations as provided for by Labor Code§, 3700 for the performance of the work set fortf-i the agreement
with the City of B Segundo,
Policy No.
I have and will ma intain workers'compensation insurance as required by i abor Code§3700 for the performance
of then e work, olfor which the agreement with the City of El Segundo is executed, My workers' compensation insurance
cardand picy number are:
Carriier Poiicy Number Explration Date
Name of Agen-L Phone#
f cert;:fy that, in the perforimance of the work set forth in the agreement with the City of B Segundo, I wiY not
employ any person in any manner so as to become subject to the workers' compensation laws of California, and
agren that, if I should become sublect to the workers' compensation provisions of Labor Code § 3700 1 must
in-irnediately comply with those provisions or the agreement will autornatically become void
Signature of Applicant � Date
Q — 01&E—
Agreement fort, A-s-LL- (,4 'TrZlw=�, c-,
Date&
Reviewed by