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PROOF OF INSURANCE (2019 - 2020) CLOSED
" 01, DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 03/05120'19 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 CONTACP Rebekah Maurice NAME Prodigy Insurance Services,Inc PHONE -7870 (818)641-7875 3701 Ocean View Blvd,Suite D E.MA)L 7870 ql ............._.._._..._.._... .....,...digylns.com Montrose,CA 91020 Rob iNsuRRls)AFFORDING COVERAGENAI OD64793 A #(��wa ny_ 5�$C# License#: INSURER Iter In$yranoe Com INSURED INSURER,B,: Capitol.$peclalty Carol Beck INSURER C DBA:CDB Golf Properties INsuRER D. 3114 Alma Ave Manhattan Beach, CA 90266-3933 INSURER F: INSURER E COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 1 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. (LTR TYPE OF INSURANCE I.INSQ POLICY NUMBER (ADL SUSA MMIDD/YYYY) fMM/OD/YYYY)LICY EFF POLICY EXP I LIMITS CLAIMS-MADE �OCCUR Pio - s $ 1 OO�o00 A )( COMMERCIAL GENERAL LIABILITY Y BP8000317 02/12/2019 02/12/2020 i�dH O T RkN% E EACH OCCURRENCE $ , EM)11 ,Q'Eu t7csna rsrncml... . ,1000. MED EXP(Any one person) $ 10,000 --- ..................................... „ PERSONAL&ADV INJURY $ Included,.... GEN'L,AGCREGATELIMITAPPLIESPER: GENERAL AGGREGATE $ 2X0,00,000PRO _ X, POLICY .... Ji Cr' 2000,000 LOC PRODUCTS-COMPIOPA OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE.UNII1 $ (F4 acr,1&?^N).. ............................ ..I ANY AUTO BODILY INJURY(Per person) ($ OWNED SCHEDULEDO Per accident) $ _ AUTOS ONLY AUTOS HIRED NON-OWNED AUTOS ONLY AUTOS ONLY (Per.cdd, OP-RTy DAMAGE $ d?t at trnlp UMBRELLA L OCCUR MADE EACH OCT � .........� ........... EXCESSLiBAB ............. EA..................-E.R.ENCE,,,.., I$ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- ANY OFFICER/MEMBER EXCLUDED PROPRIETOR/PARTNER/EXECUTIVE Y I❑N NIA EL EACH ACCIDENT ER $ AND EMPLOYERS'LIABILITY (Mandatory in NH) EL DISEASE-EA EMPLOYE;$ If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ B Errors 8r Omissions SGC0764101 102/12/2019 02/12/2020 Each Erroneou 1,000,000 B Errors &Omissions SGC0764101 02/12/2019 02/12/2020 Aggregate 1,000,000 I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE:Covered CA Operations Performed by or on behalf of the named insured. The City of EI Segundo,its officers,officials,employees,agents and volunteers are named as additional insured as respects general liability and this insurance is primary and noncontributory with any other insurance of the additional insured.Thirty (30)day notice of cancellation applies. m CERTIFICATE HOLDER CANCEL'LAT'ION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St. EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE (RAM) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by RAM on March 05,2019 at 10:41AM POLICY NUMBER: BUSINESSOWNERS BP 04 48 0713 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Name Of Additional Insured Person(s)Or Organization(s): City of EI Segundo, its officers, officials, employees, agents and volunteers Information required to complete this Schedule, if not shown above, will be shown in the Declarations. .._........................... Section II—Liability is amended as follows: B. With respect to the insurance afforded to these A. The following is added to Paragraph C.Who Is An additional insureds, the following is added to Insured: Paragraph D. Liability And Medical Expenses Limits Of Insurance: 3. Any person(s) or organization(s) shown in the If coverage provided to the additional insured is Schedule is also an additional insured, but only with respect to liability for "bodily injury", required by a contract or agreement, the most we "property damage"or"personal and advertising will pay on behalf of the additional insured is the injury" caused, in whole or in part, by your acts amount of insurance: or omissions or the acts or omissions of those 1. Required by the contract or agreement; or acting on your behalf in the performance of 2. Available under the applicable Limits Of your ongoing operations or in connection with Insurance shown in the Declarations; your premises owned by or rented to you. whichever is less. However: This endorsement shall not increase the a. The insurance afforded to such additional applicable Limits Of Insurance shown in the insured only applies to the extent permitted Declarations. by law; and b. If coverage provided to the additional insured is 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. BP 04 48 0713 0 Insurance Services Office, Inc., 2012 Page 1 of 1 Prepared onJanuary 31,2019 ® Allied Insurance Your Revised Policy lationwide 1100 Locust St.,Dept.1100 is on your side Des Moines, IA 50391-1100 This is not a bill.Your bill is sent separately, Personal Auto Policy Policy Period:Dec 7,2018-Jun 7,2019 Policy Number: PPA 0067135484-3 Account Number: 7269622949 On Your Side Rewards,like New Car Replacement,are available in your state; Carol Beck please see back for more 3114 Alma Ave details. Manhattan Beach CA 90266-3933 0 o M 0 0 r co N M ✓ Declarations-These pages show your coverages under this policy. Carefully review these details and call PRODIGY INSURANCE SERVICES INC at 1.800.282.1446 if you have questions or want to make changes. • General Information • Coverage Details • Your Total Policy Premium ✓ Policy Contract-Keep this contract for future reference. Your Policy Courtesy of: PRODIGY INSURANCE SERVICES INC How to Contact Us Customer Service 1.800.282.1446 Your Allied Agent PRODIGY INSURANCE SERVICES INC 818.541.7870 5283984 Prepared on January 31,2019 Nationwide® On Your Side Rewards is on your side Features Available for Purchase Deductible Savings Rewards: Total Loss Deductible Waiver: Eliminates your entire comprehensive and/or collision deductible in the event of a total loss. Good-As-New: Gap Coverage: Covers the difference of what you owe on your car and its market value. New Car Replacement/Gap: After a total loss,we replace your car with a new car of the same make and model;also includes Gap coverage. Roadside Assistance: Basic: Towing up to 15 miles,fuel delivery,lockout,jump starts,flat tires,and membership discounts. These services apply while driving a vehicle insured by us or while an insured driver or resident relative is an occupant of someone else's vehicle. Plus: Basic package plus towing up to 100 miles,trip interruption,turn-by-turn directions, pre-trip map routing,and emergency message. Thank You for being a valuable Allied customer. If you have questions about any of the On Your Side Rewards,please contact your agent. ks. Additional Contact Information Internet www.alliedinsurance.com 24-Hour Claims Reporting 1.800.282.1446 Prepared onJanuary 31,2019 Page 1 of 4 Nationwide® Your Policy Declarations is on your side Personal Auto Policy Policy Period:Dec 7,2018-Jun 7,2019 Policy Number: PPA 0067135484-3 Policyholder(Named Insured): Account Number: 7269622949 Carol Beck 3114 Alma Ave Manhattan Beach,CA 90266-3933 Keep these Declarations for your records. General Policy Information Issued:January 31,2019 These Declarations are a part of the policy named above and identified by the policy number above.They supersede any Declarations issued earlier.Your policy provides the coverages and limits shown in the schedule of coverages.They apply o to each insured vehicle as indicated.Your policy complies with the motorist's financial responsibility laws of your state a only for vehicles for which Property Damage and Bodily Injury Liability coverages are provided. M C) Policy Period:December 7,2018-June 7,2019 but only if the required premium for this period has been paid and only for six month renewal periods if renewal premiums have been paid as required.This policy is initially effective at(1)the time the application for insurance is completed,or(2)12:01 a.m.on the first day of the policy period,whichever is later. 00 rii Each renewal period begins and ends at 12:01 a.m.Standard time at the address of the named insured stated herein.This '^ policy term expires at 12:01 a.m.at the address of the named insured stated herein. Your carrier is Amco Insurance Company,NAIC#19100, How You Saved on this Policy with Allied • Multi-Policy Air Bag Discount • Anti-Theft Device • Good Driver Discount Group/Occupational Discount • Elite Driver Discount Insured Drivers Name Date of Birth Marital Status License Number Carol Beck 05/01/63 Single C4690605 Changes Made to Your Policy • Miscellaneous Policy Change Effective date for all changes January 30,2019 16243(12-08) Continued on the next page Prepared onJanuary 31,2019 Page 2 44 Nationwide® Your Policy Declarations is on your side Personal Auto Policy Policy Period:Dec 7,2018-Jun 7,2019 For coverage definitions and descriptions, Policy Number: PPA0067135484-3 Number: 7269622949 visit www.alliedinsurance.com Insured Vehicles and Schedule of Coverages 2013 Jeep Grand Cher VIN 1C4RJEBGODC539217 Coverages Limits of Liability Premium Bodily Injury Liability $250,000 Per Person $172.29 $500,000 Per Occurrence Property Damage Liability $100,000 Per Occurrence $158.20 Uninsured Motorist Bodily Injury $15,000 Per Person $41.13 $30,000 Per Accident Comprehensive Actual Cash Value Less A$1,000 $19.54 Deductible Collision Actual Cash Value Less A$1,000 $178.58 Deductible Waiver Of Collision Deductible $6.53 Rental Reimbursement $30 Per Day/$900 Maximum $15.11 Total for this Vehicle $591.38 Policy Level Schedule of Coverages Allied Extra Coverages See Endorsement Total for Policy Coverages $0.00 Continued on the next page 16243(12-08) Prepared onJanuary 31,2019 Page 3 of4 Nationwide® Your Policy Declarations is on your side Personal Auto Policy Policy Period:Dec 7,2018-Jun 7,2019 Policy Number: PPA 0067135484-3 Account Number: 7269622949 Premium Summary 2013 Jeep Grand Cher $591.38 State Fraud Surcharge*No Refund $0.88 Total For Policy Coverages $0.00 Total Policy Premium $592.26 Policy Form and Endorsements AA0001 (0986) Personal Auto Policy co AA0001A(1111) Signature Page M C) AA0007(1192) Changes Provision 01 AA0008A(1109) Allied Extra Coverages M C) AA0073(0697) Waiver of Collision Deductible C) AAO 169(1014) Amendment of Policy Provisions-California a0o AA0487(1109) Uninsured Motorists Coverage-California ` ri AA1429(0711) Rental Reimbursement/Transportation Expenses-Rental Days Plus r For Office Use Only: 06/07/17 Terr:998 31.33CR Issued By:Amco Insurance Company,Des Moines, IA Countersigned at:Des Moines, IA By:Prodigy Insurance Services Inc How to Contact Us Customer Service 1.800.282.1446 Your Allied Agent PRODIGY INSURANCE SERVICES INC 818.541.7870 Internet www.alliedinsurance.com 24-Hour Claims Reporting 1.800.282.1446 16243(12-08) Prepared on January 31,2019 Page 4of4 Nation wridd' This page intentionally blank is on your side 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: L_)I have and will maintain a certificate of consent of self-insure for workers'compensation, 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 EI Segundo. Policy No. U t 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 EI Segundo is executed.My workerV compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone# „. XI certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, i will not employ 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 lho rovr 'ons r the reement will automatically become void. Signature of A�ppl' nt ° � . a Date Print Name '" f� Agreement for: Dated: Reviewed