ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED?
INSR ADDL SUBR
LTR INSD WVD
DATE (MM/DD/YYYY)
PRODUCER CONTACT NAME: PHONE FAX
(A/C, No, Ext): (A/C, No): E-MAIL ADDRESS:
INSURER A :
INSURED INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
POLICY NUMBER
POLICY EFF POLICY EXP TYPE OF INSURANCE (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
AUTOMOBILE LIABILITY
UMBRELLA LIAB
EXCESS LIAB WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
AUTHORIZED REPRESENTATIVE
EACH OCCURRENCE $ DAMAGE TO RENTED
CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $
MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS - COMP/OP AGG $ OTHER: $ COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE $ CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $
If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ INSURER(S) AFFORDING COVERAGE NAIC #
COMMERCIAL GENERAL LIABILITY
Y / N
N / A
(Mandatory in NH)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
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.
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).
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
CERTIFICATE HOLDER CANCELLATION
© 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
CERTIFICATE OF LIABILITY INSURANCE
Lockton Companies
444 W. 47th Street, Suite 900
Kansas City MO 64112-1906
(816) 960-9000
[email protected]
DUDEK
605 THIRD STREET
ENCINITAS CA 92024
The Continental Casualty Company 20443
Zurich American Insurance Company 16535
X
X
2,000,000
100,000
10,000
2,000,000
4,000,000
4,000,000
X
X X
1,000,000
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
N
X
1,000,000
1,000,000
1,000,000
PROFESSIONAL
LIABILITY
PER CLAIM $1,000,000
AGGREGATE $1,000,000
A BAP0146329 8/28/2023 8/28/2024
A GLO0146311 8/28/2023 8/28/2024
B EEH591932835 INCL POLL 8/28/2023 8/28/2024
A WC0146330 8/28/2023 8/28/2024
NOT APPLICABLE
8/28/2024
1530007
Y N
Y N
N
5/2/2024
N N
20548221
20548221 XXXXXXX
CITY OF REDONDO BEACH
415 DIAMOND ST
REDONDO BEACH CA 90277
RE: THE CITY, ITS OFFICERS, ELECTED AND APPOINTED OFFICIALS, EMPLOYEES, AND VOLUNTEERS ARE ADDITIONAL INSURED ON THE ¬¬¬GENERAL LIABILITY AND AUTO LIABILITY AS REQUIRED BY WRITTEN CONTRACT. GENERAL LIABILITY AND AUTO LIABILITY IS/ARE PRIMARY
INSURANCE AND ANY OTHER INSURANCE MAINTAINED BY THE ADDITIONAL INSURED SHALL BE EXCESS ONLY AND NON-CONTRIBUTING WITH THIS INSURANCE. 30 DAY WRITTEN NOTICE OF CANCELLATION APPLIES, 10 DAYS FOR NON-PAYMENT OF PREMIUM.
See Attachments
Additional Insured – Owners, Lessees Or
Contractors – Scheduled Person Or Organization
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Policy No. GLO0146311 Effective Date: 8/28/2023 This endorsement modifies insurance provided under the:
Commercial General Liability Coverage Part
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s):
Location(s) Of Covered Operations
ANY PERSON OR ORGANIZATION ARE REQUIRED
TO PROVIDE ADDITIONAL INSURED STATUS IN
A WRITTEN CONTRACT, AGREEMENT OR PERMIT. ALL
LOCATIONS
U-GL-2169-A CW (02/19)
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
Attachment Code: D574649 Certificate ID: 20548221
A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule of this endorsement, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated in such Schedule.
B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after:
1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or
2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project.
All other terms, conditions, provisions and exclusions of this policy remain the same.
U-GL-2169-A CW
(02/19)
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
Attachment Code: D574649 Certificate ID: 20548221
Additional Insured – Owners, Lessees Or Contractors – Completed Operations THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Policy No. GLO0146311 Effective Date: 8/28/2023 This endorsement modifies insurance provided under the:
Commercial General Liability Coverage Part
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s):
Location And Description Of Completed Operations
ANY PERSON OR ORGANIZATION ARE REQUIRED
TO PROVIDE ADDITIONAL INSURED STATUS IN
A WRITTEN CONTRACT, AGREEMENT OR PERMIT. ALL
LOCATIONS
U-GL-2168-A CW (02/19)
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
Attachment Code: D580830 Certificate ID: 20548221
Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule of this endorsement, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in such Schedule, performed for that additional insured and included in the "products-completed operations hazard".
All other terms, conditions, provisions and exclusions of this policy remain the same.
U-GL-2168-A CW
(02/19)
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
Attachment Code: D580830 Certificate ID: 20548221
Other Insurance Amendment – Primary And
Non-Contributory
Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer No. Add’l. Prem Return Prem.
GLO 0146311 08/28/2023 08/28/2024 37385000 INCL
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Named Insured:
Address (including ZIP Code):
This endorsement modifies insurance provided under the:
Commercial General Liability Coverage Part
1. The following paragraph is added to the Other Insurance Condition of Section IV – Commercial General Liability Conditions:
This insurance is primary insurance to and will not seek contribution from any other insurance available to an additional insured under this policy provided that:
a. The additional insured is a Named Insured under such other insurance; and b. You are required by a written contract or written agreement that this insurance would be primary and would not seek contribution from any any other insurance available to the additional insured. 2. The following paragraph is added to Paragraph 4.b. of the Other Insurance Condition of Section IV – Commercial General Liability Conditions:
This insurance is excess over:
Any of the other insurance, whether primary, excess, contingent or on any other basis, available to an additional insured, in which the additional insured on our policy is also covered as an additional insured on another policy providing coverage for the same occurrence , offense, claim or suit . This provision does not apply to any policy in which the additional insured is a Named Insured on such other policy and where our policy is required by written contract or written agreement to provide coverage to the additional insured on a primary and non-contributory basis. All other terms and conditions of this policy remain unchanged. U-GL-1327-B CW (04/13)
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
Attachment Code: D632272 Certificate ID: 20548221
POLICY NUMBER: BAP0146329 COMMERCIAL AUTO
CA 20 48 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED INSURED FOR
COVERED AUTOS LIABILITY COVERAGE
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are “insureds” for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.
Named Insured: DUDEK
Endorsement Effective Date: 8/28/2023
SCHEDULE
Name Of Person(s) Or Organization(s):
ANY PERSON OR ORGANIZATION TO WHOM OR WHICH YOU ARE REQUIRED TO
PROVIDE ADDITIONAL INSURED STATUS OR ADDITIONAL INSURED STATUS ON
A PRIMARY, NON-CONTRIBUTORY BASIS, IN A WRITTEN CONTRACT OR
WRITTEN AGREEMENT EXECUTED PRIOR TO LOSS, EXCEPT WHERE SUCH CONTRACT OR AGREEMENT IS PROHIBITED BY LAW.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 2 Attachment Code: D574651 Certificate ID: 20548221
Each person or organization shown in the Schedule is
an “insured” for Covered Autos Liability Coverage, but
only to the extent that person or organization qualifies as an “insured” under the Who Is An Insured provision
contained in Paragraph A.1. of Section II – Covered
Autos Liability Coverage in the Business Auto and
Motor Carrier Coverage Forms and Paragraph D.2. of
Section I – Covered Autos Coverages of the Auto
Dealers Coverage Form.
CA 20 48 10 13 © Insurance Services Office, Inc., 2011 Page 2 of 2 Attachment Code: D574651 Certificate ID: 20548221
POLICY NUMBER: BAP0146329 COMMERCIAL AUTO
CA 04 44 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US (WAIVER OF SUBROGATION)
This endorsement modifies insurance provided under the following:
AUTO DEALERS COVERAGE FORM
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.
Named Insured: DUDEK
Endorsement Effective Date: 8/28/2023
SCHEDULE
Name(s) Of Person(s) Or Organization(s):
ANY PERSON OR ORGANIZATION YOU ARE REQUIRED TO WAIVE YOUR RIGHTS
OF RECOVERY IN A WRITTEN CONTRACT, AGREEMENT OR PERMIT WITH THE NAMED INSURED.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the
person(s) or organization(s) shown in the Schedule,
but only to the extent that subrogation is waived prior to the “accident” or the “loss” under a contract with that person or organization.
CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1 Attachment Code: D574651 Certificate ID: 20548221
Coverage Extension Endorsment
Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer No. Add’l. Prem Return Prem.
BAP 0146329 08/28/2023 08/28/2024 37385000 INCL
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the:
Business Auto Coverage Form
Motor Carrier Coverage Form
A. Amended Who Is An Insured
1. The following is added to the Who Is An Insured Provision in Section II – Covered Autos Liability Coverage: The following are also "insureds":
a. Any "employee" of yours is an "insured" while using a covered "auto" you don't own, hire or borrow for acts performed within the scope of employment by you. Any “employee” of yours is also an “insured” while operating an “auto” hired or rented under a contract or agreement in an “employee’s” name, with your permission, while performing duties related to the conduct of your business. b. Anyone volunteering services to you is an "insured" while using a covered "auto" you don’t own, hire or borrow to transport your clients or other persons in activities necessary to your business. c. Anyone else who furnishes an "auto" referenced in Paragraphs A.1.a. and A.1.b. in this endorsement. d. Where and to the extent permitted by law, any person(s) or organization(s) where required by written contract or written agreement with you executed prior to any "accident", including those person(s) or organization(s) directing your work pursuant to such written contract or written agreement with you, provided the "accident" arises out of operations governed by such contract or agreement and only u p to the limits required in the written contract or written agreement, or the Limits of Insurance shown in the Declarations, whichever is less. 2. The following is added to the Other Insurance Condition in the Business Auto Coverage Form and the Other
Insurance – Primary and Excess Insurance Provisions Condition in the Motor Carrier Coverage Form:
Coverage for any person(s) or organization(s), where required by written contract or written agreement with you executed prior to any "accident", will apply on a primary and non-contributory basis and any insurance maintained by the additional "insured" will apply on an excess basis. However, in no event will this coverage extend beyond the terms and conditions of the Coverage Form.
Includes copyrighted material of Insurance Services Office, Inc., with its permission. U-CA-424-F CW(04-14) Attachment Code: D633798 Certificate ID: 20548221