No preview available
PROOF OF INSURANCE (2020 - 2020) CLOSEDAC<>RV CERTIFICATE OF LIABILITY INSURANCE I °AT 8/27/2019 OBI27I2019 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 CONTACT Alis Maynard NAME: Insurance Solutions PHONE(949) 348-7400 FAx (949) 348-2373 Extl; I (Ax. No): License #0746539E -NIHIL AlisM@ins-solutions.com ADDRESS: 33302 Valle Rd, Suite 200 INSURER(S) AFFORDING COVERAGE I NAIC $ San Juan Capistrano CA 92675 INSURERA, Hiscox Insurance Company Inc, �i 10200 INSURED INSURER B Emergency Management Consulting Solutions Inc. INSURER C: 21520 Yorba Linda Blvd. Ste. G560 INSURER D: I INSURER E: Yorba Linda CA 92887 INSURER F: COVERAGES CERTIFICATE NUMBER: 19-20 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. 1LTR TYPE OF INSURANCE NSD WVD POLICY NUMBER (PMM.D"IY�YY'�I (MMIDDYIYYYPYI LIMITS `"X" COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 3,000,000 CLAIMS -MADE X OCCUR DAMAGE'rO RENTED PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 A UDC -1487197 -CGL -19 08/26/2019 08/28/2020 PERSONALBADV INJURY $ 3,000,000 GGEENI(''LAGGREGATELIMIT APPLIES PER: GENERALAGGREGATE $ 3,000,000 ''' .01NPOLICY J'ECT PRO- LOC PRODUCTS - COMPIOPAGG s 3,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBI'N'ED SINGLE UMI'T 4Ea aucr dau tl $ ANYAUTO BODILY INJURY (Per person) $ OWNED SCHEDULED I BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON -OWNED PROPERTY DAMAGE. $ AUTOS ONLY AUTOS ONLY _GPer accident) $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION ry p H � STATUTE II II ER ' AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETO"ARTNERIEXECUTIVE I"—'j N /A I E L EACH ACCIDENT $ OFFICEWMEMBE;R EXCLUDED? l�f! (Mandatory in NH) EL DISEASE -EA EMPLOYEE $ H yes, describe under DESCRIPTION' OF OPERATION'S below I EL DISEASE- POLICY LIMIT Is Limit: $1,000,000 Ded: $500 Errors and Omissions I A UDC -1487197 -EO -19 08/28/2019 08/28/2020 Aggregate: $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Management Consulting @ City of EI Segundo Certificate Holder is included as additional insured. CERTIFICATE HOLDER CANCELLATION 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. 314 Main St, EI Segundo AUTHORIZED REPRESENTATIVE EI Segundo CA 90245 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Policy Number: UDC -1487197 -CGL -19 Named Insured: Emergency Management Consulting Solutions Inc. Endorsement Number: 9 Endorsement Effective: August 28, 2019 Hiscox Insurance Company Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any per- son(s) or organization(s) for whom you are performing operations or leasing a premises when you and such person(s) or organiza- tion(s) have agreed in writing in a contract or agreement that such person(s) or organiza- tion(s) be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to lia- bility for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing opera- tions; or 2. In connection with your premises owned by or rented to you. A person's or organization's status as an addi- tional insured under this endorsement ends when your operations or lease agreement for that additional insured are completed. CGL E5421 CW (02114) Includes copyrighted material of Insurance Services Office, Inc., with its Page 1 of 1 permission. Proprietary Information Not for Publication t lnterinsurance Exchange of the Automobile Club Automobile Insurance Policy Coverages and Limits Policy Change Declarations Insurance is in effect only for the vehicles, coverages, and limits of liability shown on this declarations page and as set forth in the insurance policy and endorsements. These declarations, together with the contract and the endorsements in effect, complete your policy. NAMED INSURED (item 1.) "MiLL, JAMES CLOVERD YORBA LINDA CA 92886-1948 SUBJECT OF POLICY CHANGE CANCEL VEHICLE AUTO - CORRECTION ANNUAL MILEAGE CHG AUTO POLICY NUMBER: CAA 087664017 POLICY PERIOD (PACIFIC STANDARD TIME) POLICY EFFECTIVE DATE: 01-25-19 12:01 A.M. POLICY EXPIRATION DATE: 01-25-20 12:01 A.M. POLICY CHANGE EFFECTIVE DATE: 04-02-19 12:01 A.M. THIS IS NOT A BILL This policy change will decrease your premium by $398.00. VEHICLES VEH. %=AM K.- IDENTIFICATION VEHICLE GARAGE ANNUAL VFRIFIFn COVERAGES AND OMITS Coverage Is not in effect unless a premium or the word "included" Is shown. COVERAGES LIMITS OF LIABILITY Liability Bodily Injury $500,000 each person/ $1,000,000 each occurrence Property Damage $1,000,000 each occurrence Medical Physical Damage Value unless oMarkze toted„ lees deductible) Vehicle 8 Vehicle Comprehensive ACV (Less Deductible) $500 Collision ACV (Less Deductible) $500 Car Rental Expense on (Per Darr) No Coverage No Coverage No Coverage No Coverage l ninsu and Motorist Bodily Injury - $500,ODD each person/ $1,000,000 each accident Uninsured & Underinsured Vehicles Uninsured Deductible Waiver Uninsured Collision Total Premium ANNUAL PREMIUMS Vehicle 7 Vehicle 8 Vehicle 9 Vehicle 10 Vehicle 6 No Coverage No Coverage `No Coverage No Coverage: u z a i 8 ,-No Coverage No Coverage; No CoverageNo Cover'ag'e PREMIUM DISCOUNTS Please refer to the enclosed document entitled "Premium Discounts Applied to Your Automobile Policy." t If at any time you choose to Pay less than the full l ba'lan'ce outstanding, finance charges of up to 1.6% per month of the balance outstanding will apply as explained in your billing statements, which are part of these- declarations. Adjusted Total Annual Premium* (Includes all appliicatde discounts.) Less Policyholder Savings Dividend (Previously applied a to your premium balance) Adjusted Net Annual Premium` (Balance atter previous dividend) m p PROCESS DATE 04.03-19 PLEASE ATTACH TO YOUR POLICY (SEE REVERSE) 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 (#700,000), 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 pequry under ft laws of California one of the following declarationw. (_) I have and will maintain a certificate of consent of selfLinsure for workers! with of . •• (_) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance of the work far which the agreement with the City of El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone # (JL/) I certify that, in the performance of the work set forth in the agreement with the City of El 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 I must immediately comply with those provisions or the agreement will automatically become void. // Signature of Applicar� Date 111.0 /(,e 'ak"Agreement for: Dated: 68 • 11 • cv Reviewed by . -"-I r'� �