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CERT5FOCATE OE <br />I <br />�LMY �O��Uff��NC DAosilziio ' <br />s <br />THISCERTIFICATE ISISSUED ASA MATTEROFINFORMATION ONLYAND CONFERS NO <br />AMEND, EXTEND ORALTERTHECOVERAGEAFFORDED BYTHE POLICIES BELOW.THI$:.CER <br />AUTHORIZED REPRESENTADVEORPRODUCER,ANDTHECERTIRCATEHOLDER. <br />RIGH <br />PON THECERTIFICATE HOLDER. THISCERTIRCATEDOES NOTAFRRMATIVELYOR NEGATIVELY <br />CATEOFINSURANCE DOES NOTCONSTTfUTEACONTRACTRETWEEN THE ISSUINGINSURER(S), <br />"^PORTANT.Iftherertitia hoiderison ADDRIONALINSURED,thepolicy(les)must <br />iitionsofthepolicy,certainpoliciesrnayrequtmanendursement.Aslaterimenton <br />ave <br />PI&C <br />I-UONALINSUREDpmvisiomorbeendomed.ifSUBROGATIONiSWA1VED,subjecttotheiamisand <br />i a doesnotconferdghtswthecertiflmwholderin lieu ofsuchendomement(s). <br />PRODUCER <br />CONTACT <br />NAME: <br />GDlsa DDlatabadi(295033N) <br />1451 W7th St SteA <br />PHONE <br />(A/c, NO, EXT): 310-371-3575 <br />FAX <br />(A/C,NOX 855-320-87481 <br />EMAIL <br />San Pedro CA 90732-3524 <br />ADDRESS: gdolatabadi@farmersagent.com <br />j <br />INSURER(S)AFFORDING COVERAGE NAIC# <br />INSURED <br />; <br />INSURERA: Truck Insurance Exchange 21709 <br />INSURERB: Farmers Insurance Exchange ; 21652 <br />JOHN MANTIKAS <br />INSURERC: Mid Century Insurance Company 1 21687 <br />Dulux Painting <br />INSURER°' <br />26 ROCKINGHORSE RD <br />INSURERE: <br />RCH PALOS VRD CA 90275 <br />INSURERF: <br />COVERAGES CERTIFICATENUM8E8: <br />REVISION NUMBER: <br />THIS ISTO CERTIR'THATTHE POLICIESOF INSURANCE OSTED BELOW HAVE BEEN ISSUE5TO <br />REQUIREMENT, TERM ORCONDITION OFANY CONTRACTOR OTHER DOCUMENTWITH <br />POLICIES DESCRIBED HEREIN ISSUBJECTTO ALLTHETERMS, EXCLUSIONS AND COND <br />ESP <br />bNS <br />I INSURED NAMEABOVE FORTHE POLICY PERIOD INDICATED. NOTWITHSTANDINGA,NY - <br />O WHICHTHIS CERTIFICATE MAYBE ISSUED OR MAYPERTAIN, THE INSURANCEAFFORDED BYTHE <br />UCH POLICIES. LIMITS SHOWN MAYHAVEBEEN REDUCED BY PAID CLAIMS.. <br />INSR <br />LTR <br />TYPE OFINSURANCE <br />ADDTL <br />IVSD <br />SUBR <br />WVD <br />PO <br />LYBER <br />POLICY EFF <br />(MM/DO/YYYY) <br />POLICYEKP <br />(MM/DD/YM) <br />LIMNS :.., <br />COMMERCIALGENERALLIABILITY <br />f <br />EACH OCCURRENCE <br />i$ <br />CLAIMS -MADE ❑OCCUR <br />DAMAGETORENTEDPREMISES(Fa Occurrence) <br />:$ <br />MED EXP (Anyone person) <br />$ <br />i <br />PERSOADV INJURY <br />I$ <br />GENT AGGREGATE LIMITAPPUES PER: <br />GENERREGATE <br />1$ <br />POLICY ❑ PROJECT LOC <br />�. <br />PRODUOMP/OPAGGI$ <br />OTHER: <br />1 <br />$ <br />v <br />AUTOMOBILE LIABILITY <br />i <br />COMBINGLE LIMIT <br />(Ea acc <br />.$ <br />ANYAUTO <br />' <br />BODILYY(Per person) <br />'$ '100000OWNED <br />Y(Peraccident)$HIREDAUTOS <br />AUTOS v SCHEDULEDBODILY1300000ONLY /� AUTOS <br />N <br />6058890 <br />k <br />; <br />01/19/2016 <br />01/19/2017 <br />NON -OWNED <br />AUTOS ONLY(Peracc <br />1PROPEMAGEONLY <br />: 50,000$UMBRELLALIAB <br />OCCUR <br />EACH ORENCE <br />$EXCESS <br />AGGRE$ <br />UAB <br />CLAIMS -MADE <br />' <br />OED RETENTION$ <br />$ <br />WORKERS COMPENSATION <br />AND EMPIAYERS'LIA81LriY <br />PERTA <br />STUTE <br />OTHER <br />$ <br />ANYPROPRIETOR/PARTNER/ Y/N <br />EXECUTIVEOFFICER/MEMBER <br />N/A <br />I <br />ELEACHACCIDENT <br />$ <br />E.L. DISEASE- EA EMPLOYEE <br />EXCLUDED? (Mandatory in NH) <br />�1 <br />Ifyes, describe under DESCRIPTION OF <br />OPERATIONS below <br />E.L. DISEASE - POI ICYLIMIT <br />$ <br />II <br />1 <br />I <br />DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101, Addhional Rema <br />, S <br />ule,maybeattachedifmomspaceismquired) ' <br />2008 FORD F250 SUPER; VIN: I FTSW21R08EB70681 <br />l <br />Policy shall not be canceled or reduced in coverage or changed in any other <br />r <br />terial aspect without thirty (30) days prior written notice to the City, <br />CERTIFICATEHOLDER <br />r <br />CANCELLATION <br />�'A— ANK— <br />PURCHASING DIVISION M-16 <br />! <br />SHOULD ANYOFTHEABOVE DESCRIBED POLICIES BECANCELLED BEFORETHEEKPIRAYION <br />DATE THEREOF, NOTICEWiLLBEDIRIVEREDINACCORDANCEWRHTHEPOLfCf <br />PROVISIONS. <br />20 CIVIC CENTER PLAZA RM 429 <br />AUTHORIZEDREPRESENTATIVE GDlsa Dolatabadi 09/12/2016 i <br />SADNrTFA.AN <br />11 <br />�j <br />I <br />