HomeMy WebLinkAboutInsuranceAccORLf CERTIFICATE OF LIABILITY INSURANCE
DATEIMM/bI1tYYYY)
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 CQVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUR,ER(Sj, AUTHORIZED
!REPRESENTATIVE DR. PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: if the certificate holder Is. an ADDITIONAL INSURED, the po(Icy(ies) must be endorsed. If SUBROGATION IS WAIVED, Subject to
the terms and conditlotis of the policy, certain policies may require an endorsement A statement on this certificate does net confer rights to the
certificate holder in lieu of such endorsement(s).
PAOQUCER
Cavignac & Associates
450 B Street, Suite 1800
San Diego, CA 92i01-8005
License NC. OA99520
cmnme
HAM Certificate Department
rest, Exti: 619-2}4-6848 J ,1,101:619-234-86O1
&IpL
AgbI% cextificatesticav gnac.eont
CUST cERER
PROS ID tit KTUt,A-1
INSURER(S)AFFORDING COVERAGE
NAIC II
INSURED ,..
K T U + A, Inc.
3916 Normal Street
San Diego, Ch 92103 United s'^*^a
INSURER A: FTITTTTTTRTITAT, r A g CD
90441
25674
1788
INSURaIB:TRAVELERS PROP CAS CO OP AMER
INSURER c:XL SPECIALTY INS CO
INSURER 0 :
INSURER E':
INSURER F:
COVERAGES
CERTIFICATE NUMBER:'14s163.
: 1E604
THIS IS TO CERTIFY THAT' THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED•TO THE 'INSURED NAMED.ABOVE FOR THE POUCY PER;OD
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 TENTS,
EXCLUSIONS AND CONDITIONS:OP SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSR
L.Th"
,.TYFEOFINSURANCE
ADDLSURR POLiCYEFPF� POLICYEXP
alaR wvn POUCYNRMDER IMM/0DA:YYYI
UNITS
A
GENERAL
X
LIABILITY
COMMERCIAL GENERAL
J
�
{ ry'
ILWf NY
4030967113S
„IMMIDOIYYYY1
9/1/2011
9/1/2012
'EAGI4.00CURRENcE.
S. 1,, BOO, 000.
DAMAGERENTED
PREteseSO le ota litenoa)
3 300/000
CLAIMS -MADE
OC'KUR
.
MED EXP (Any ono pawn I
3 14,000
X
Contractual Liability
PERSONALS ADVINJURY
S 1, 000,000
X
separation of Insureds
GENERAL AGGREGATE
$ 2,000,000
GEM AGGRE�JECT I IGATEUNIITAPP�LIESPER;
7 PoLICY I x AT�l I LOC
PRODUCTS -COMP/OPAGG
S 2.,coo, ono
DBdUdtt311e
S 0
AUTMMOEILELLABILITY
--
—
X
X
x
ANY AUTO
ALLOWNEOAUTl7S
SCHEDULED AUTOS
HIRED AUTOS
HON-OWNED AUTOS
No Company Owned Autos
4036967635
9/1/2011
9/1/2012
COMBINED SINGLE MIT
(Eoauldanit ,
s I,004,0o0
BODILY INJURY IPrron)
S
BODILY INJURY(Pereccldanil
S
PROPERTY DAMAGE
IParaceidenll
S
S
UMBRELLA LAB
EXCESS LAB
—
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
S
AGGREGATE
S
D
DEDUCTIBLE
RETENTION S
S.
S
5
WORKERS COMPENSATION
ANDEMPLDYERS'LIABBJTY Y/H
ANY PROPRIETOR/PAATNERJEXECUTWE
CFFICERiMEMBER 2XCLUttED7 n
(MandabryIn NH)
Wpm; d/0013.a under
DESCR'PTIONOFOPERATIONS heIow
NIA
UB7109Y567
•
9/1/2011
9/1/2012
X I TWDGTM1U5• OTH
ELLEAOH•ACCiDENT
S 1,.000,000
El. DISEASE-EAEMPLOYEE
S 1, 000, 000
E.L DISEASE -POLICY Lear
.& 1,CDC, ec0
C
•Profeustansl Liability
D9R9696166
9/1/2011
9/1/2012
Ea Claim & Aggreg $.,OA0,(100
DESCRIPTION OF OPERATIONS ►LOCATION$: VSNIG..EE (Anaah ACORO 101. Add llonel Rsn 1uks Schedule, Emoro:rpst:o Is required)
Prof. Liab, - Claims made, defense costs indluded within limit. For informational purposes.
CERTIFICATE HOLDER
CANCELLATION
Specimen Certificate
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Dorothy Amundson
ACORD 25 (2009109)
IW 1054009 ACORD CORPORATION, All rights reserved.
The. ACORD narna and logo are reglsterad Markel:1f ACORD
EXIGiS • CAVIGNAC A ASSOCIATES 1ea049
Pagetoti
SB-146968-A
(Ed. 01/06)
Policy No. 4030967835
IMPORTANT: THIS ENDORSEMENT CONTAINS DUTIES THAT APPLY TO THE
ADDITIONAL INSURED IN THE EVENT OF OCCURRENCE, OFFENSE, CLAIM OR SUIT.
SEE PARAGRAPH C., OF THIS ENDORSEMENT FOR THESE DUTIES.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED ENDORSEMENT
WITH PRODUCTS -COMPLETED OPERATIONS COVERAGE
BLANKET WAIVER OF SUBROGATION
Architects, Engineers and Surveyors
This endorsement modifies Insurance provided under the following:
BUSINESSOWNERS LIABILITY COVERAGE FORM
BUS INESSOWNERS COMMON POLICY CONDITIONS
A. WHO IS AN INSURED (Section C.) of the
Businessowners Liability Coverage Form Is
amended to Include as an insured any person or
organiz,ation whom you are required to add as an
additional insured on this policy under a written
contract or written agreement; but the written
contract or written agreement must be:
1. Currently in effect or becoming effective during
the term of this policy; and
2. Executed prior to the "bodily injury," "property
damage," or "personal and advertising Injury."
B. The insurance provided to the additional insured is
limited es follows:
1. That person or organization is an additional
insured solely for liability due to your negligence
specifically resulting from "your work" for the
additional insured which is the subject of the
written contract or written agreement. No
coverage applies to liability resulting from the
sole negligence of the additional Insured.
2. The Limits of Insurance applicable to the
additional insured are those specified In the
written contract or written agreement or in the
Declarations of this policy, whichever is less.
These Limits of Insurance are inclusive of, end
not in addition to, the Limits of insurance shown
in the Declarations.
3. The coverage provided to the additional insured
within this endorsement and section titled
LIABILITY AND MEDICAL EXPENSE
DEFINITIONS — "Insured Contract" (Section
F.9.) within the Businessowners Liabiligr
Coverage Form, does not apply to "bodily
injury" or "property damage" arising out of the
"products -completed operations hazard" unless
SB-146968-A
(Ed, 01106)
C.
required by the written contract or written
agreement.
4. The insurance provided to' the additional
Insured does not apply to "bodily Injury,"
"property damage," "personal and advertising
injury" arising out of an architect's, engineer's,
or surveyor's rendering of or failure to render
any professional services including:
a. The preparing, approving, or failing to
prepare or approve maps, shop drawings,
opinions, reports, surveys, field orders,
change orders or drawings and
specifications by any architect, engineer or
surveyor performing services on a project of
which you serve as construction manager;
or
b. Inspection, supervision, quality control,
engineering or architectural services done
by you on a project of which you serve as
construction manager.
5. This insurance does not apply to "bodily injury,"
"property damage," or "personal and advertising
Injury" arising out of:
a. The construction or demolition work while
you are acting as a construction or
demolition contractor. This exclusion does
not apply to work done for or by you at your
premises.
BUSINESSOWNERS GENERAL LIABILITY
CONDITIONS — Duties In The Event of
Occurrence, Offense, Claim or Suit (Section
E.2.) of the Businessowners Liability Coverage
Form is amended to add the following:
An additional insured under this endorsement will
as soon as practicable:
Page 1 of 2
Page 3 of 5
Policy No. 4030967835
1. Give written notice of an occurrence or an
offense to us which may result in a claim or
"suits' under. this Insurance;
2. Tender the defense and Indemnity of any claim
or "suit" to us for a loss we cover under this
Coverage Part;
,, 3. Tender the defense and indemnity of any claim
or "suit" to any other insurer which also has
Insurance for a loss we cover under this
Coverage. Part; and
4. Agree to make available any other insurance
which the additional insured has for a loss we
cover under this Coverage Part.
We have no duty to defend or Indemnify an
additional insured under this endorsement until we
receive written notice of a claim or "suit" from the
additional insured.
D. OTHER INSURANCE (Section H. 2. & 3.) of the
Businessowners Common Policy Conditions are
deleted and replaced with the following:
2. This insurance is excess over any other
insurance naming the additional insured as art
Insured whether primary, excess, contingent or
on any other basis unless a written contract or
written agreement specifically requires that this
insurance be either primary or primary and
noncontributing to the additional. Insured's own
coverage. This insurance is excess over any
other insurance to which the additional insured
has been added es an additional Insured by
endorsement.
3. When this Insurance is excess, we will have no
duty under Coverages A or B to defend the
SB-1469.613-A
(Ed. 01106)
E.
SB-146968-A
(Ed. 01/06)
additional insured against any "suit" if any other
insurer has a duty to defend the additional
insured against that "suit" If no other Insurer
defends, we will undertake to do so, but we will
be entitled to the additional Insured's rights
against all those other insurers,
When. this Insurance is excsiss over other
insurance, we will pay only our share of the
amount of the foss, If any, that exceeds the sum
of:
(a) The total amount that all. such other
insurance would pay for the loss in the
absence of this insurance; and
(b) The total of all deductible and self -insured
amounts under all that other insurance.
We will share the remaining loss, if any, with
any other insurancethat is not described in this
Excess Insurance provision and Was not bought
specifically to apply in excess of the Limits of
Insurance shown in the Declarations of this
Coverage Part,
TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US (Section K.2.) of the
Businessowners Common Policy Conditions 1s
deleted and replaced with the following:
2. We waive any right of recovery we may have
against any person or organization against whom
you have agreed to waive such right of recovery In
a written contract or agreement because of
payments wemake for Injury or damage arising out
of your ongoing operations or your work" done
under a contract with that person or organization
and included within the "products -completed
operations hazard.'
Page 2 of 2
Pape-4 DI 5
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
ENDORSEMENT WC 99 03 76 (00)
POLICY.NUMBER: UB7109Y567
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS
ENDORSEMENT - CALIFORNIA
(BLANKET WAIVER)
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will
not enforce our right against the person or organization named in the Schedule.
You. must maintain payroll records accurately segregating the remuneration of your employees while
engaged in the work. described in the Schedule.
The additional premium for this endorsement shall be %a of the California. workers' compensation
premium otherwise due on such remuneration,
Schedule
Person or Organization Job Description
ANY PERSON OR ORGANIZATION FOR WHICH THS
NAMED INSURED HAS AGREED BY WRITTEN CONTRACT
EXECUTED 'PRIOR TO LOSS TO FURNISH THIS
WAIVER..
Pose 5et6
CITY OF NATIONAL CITY BUSINESS LICENSE APPLICATION
1243 NATIONAL. CITY. BLVD, NATIONAL CITY, CA 91950
PLEASE TYPE. OR PRINT, LICENSE WILL NOT 8E ISSUED IF REQUIRED INFORMATION IS
INCOMPLETE. ENCLOSE PAYMENT WITH APPLICATION. MAKE CHECKS PAYABLE TO THE CITY
OF NATIONAL CITY.
A. *GENERAL INFORMATION(
BUSINESS NAME (D.B.A. OR INDIVIDUAL NAME)
KTU+A
1,0 I. BUSINESS PHONE
6 / 9294-4477
CORPORATE NAME (IF DIFFERENT FROM D.B A.)
•KTU+A
,
LOCATION IN NATIONAL CITY
NUMBER I DIR ROOM/SUITE NO:
NUMBER I DIR II STREET NAME
30i8 IN ni ISt
p.O. BOX NO;
0
CITY
San DIogO
PHONE NUMBER AT MAILING ADDRESS. INCLUDE AREA CODE
619294-44'77
. TRANSACTION TYPE — CHECK ANp COMPLETE IF AEPLICABLE
STATE. I ZIP CODE
CA 821C3
CASHIER'S COPY
8US# LTC#
ALL LICENSES EXPIRE DECEMBER 31
RENEWALS ARE DUE BY FEB UARY 28
City of
National City
C418TNESS LICENSE DIVISION
(619) 336-4330
TAXES $
MISC $
PENALTY $
TOTAL $
n NEW BUSINESS IN NATIONAL CTrY: BUSINESS W1LLOPEN/OPENED OM
Cl OWNERSHIP. CHANGE: PREVIOUS BUSINESS NAME:
N.
CHECK ONE: A. D WHOLESALE B. D RETAIL C. (i SERVICE D. ❑ RENTAL UNITS,# OF UNITS _ E: D MANUFACTURING F. D CONTRACTOR
STATE IICRNEE #/ HEALTH PERMIT/ ABC #/ DRIVERS LIC #
N/A
STATE RESALE A
N/A
FEDERAL ID #/ SOCIALSEC. #
95=2750597
DESCRIBE BUSINESS FULLY — INCLUDE PRINCIPAL PRODUCT OR SERVICE
Landscape Architecture end Planning Firm (Consultant to Engineering Department)
NUMBER OF BUSINESS VEHICLES OPERATING. IN NATIONAL cm WITH YOUR COMPANY ADVERTISING (LOGO) ON THEM
D. OWNERSHIP INFORM.
MEEK ONE: 1. p SINGLE PROPRIETORSHIP
2. D PARTNERSHIP
C CORPORA11ON
LIST OWNER/PARTNERS/CORPORATE OFFICERS
LAST NAME ' FIRST NAME
Campo •Sandra
MI TITLE
Prcgdan!
HOME PHONE
61019e41
�O ME ADDRESS
enpy One, Swing VW*, GA 91411
CITY
STATE
.4
ZIP 00DE
LAST NAME
',Slngnan Swan
' TITLE
VibeNI Prelidonl.
I HONE PHONE
HOME ADDRESS
42eI WD mib . Street, Snn Dino. CA 92103.
CITY
ME
ZIP CODE
•
LIST IN ORDER OF PRIORITY AND PROXIMITY TO BUSINESS THE PERSON TO BE CONTACTED AT NIGHT IN CASE OF BREAK IN OR FIRE
NAME
L WA
TITLE.
a?1
TELEPHONE A
WA
2. WA
WA
WA
DI)YOU HAVE A BURGLAR ALARM? 1. ❑ NO 2. D YES: IF YES 3. ❑ SILENT 4..0 AUDIBLE
NA.ME.OF ALARM COMPANY PHONE #
N/A
PLEASE INDICATE THE NUMBER OF EMPLOYEES EMPLOYED BY YOUR BUSINESS:
4 will be warktr,p In National City
•
DECALS V
—OFFICE USE ONLY
G.
B/C — I -I/O PEND ON FILE:. B/C — WO NIA. BM — HID PEND .P L A L— A AMP C C-A/P
AUDITED -BY DATE ENTERED BY DATE
DATE WO PD B/L SENT
INT
BUSINESS LICENSE TAX RATE SCHEDULES
SCHEDULE I. BUSIN SSES NOT CHARGED ON GROSS RECEIPTS (ENTER TOTAL ON LINE 1.1 BELOW)
CONSTRUCTION'ONLY
A. Type'C' Sup.ContrdclprOul.CFTams
�B Typo A or'FP migisdar•Out•9RTam
Adtit only Movie Omits/
__- D. Adult only book spas
- E. Amusement arcade
F. Bawling alley
_O. 0aaeat,ali
S 135.00
5 200:00
S 835.00
S 535.00
S 205.00
S 28500
S 605.00
_ H. Fortuna telling
_ I..Bingo
- J. Pawn.txdrer
K Swap meet
- L. Noblesaerc>t tight advaiiising
- M.144bfleAmuromentvahide
_ N. 2nd ioc nn tn:Noltonal City
SCHEOULE 11:-BUSINESSES CHARGED ON- GROSS RECEIPTS
TAXABLE GROSS RECEIPTS
0-19;999
29 -4E.999
50,00049.299
180,000.199,999
200,0024291,999
390:0004B1itM13
400,060499,999
:500,000.599,999
600,000498,999
700;000'799,999
500,0004899,990
900,000-999,999
1,00F],000-1,099, 999
imao.000.1,199,999
1,200,000-1,299,999
1,300,000-1,3es, 999
1,400,000-1,499,e99
1,500,000-1.,999 999
2,000;000.2,499,999
2,500,000-2.999,989
3,000,000-3,499,999
3,5000004.999,989
4,0110,0004,999,899
5,000,090.5,999,999
6,000,000.7,999,999
8,000,000-10,992,989
11,090, 00a13,9S9,998
14,000,000-15,112,899
16,00.0,000-17,099,999
19,190,000-19,919,999
20,000,00041,199,999
22,000,000'--ANP AIDYE
S. 265.00
S 50.00
S +100,90
S 5,0.00.00
S. 135.00
S 65.00
$ 20.00
_ O. Regieteed N0140r-31o51
_P. Feeaaempl
_ Q. Wrtettpuae Inddarmel to business
(Business must be In Nalianal Qty.}
_S. Atelloneer
-_1. DtSc6 awn vendor 565.00 per vehicle
$65,Q4x o -..« veNclos= mm
_'2.RbWlfood 8tin/WO vendtxs.S200 dde
5200.90x 0 vehidearitIste
NIC
MC
NIC
i 135.00
BUSINESS CLASSIFICATION
1 2 ,2 4 L1 6
54 50 50 50 50. 60
50 50 50 50 60 59
50 50 52 .8,0 74 86
60 50 88 70 81 93
54 64 Bo 98 112 128
20 81 101 121. 141 161
78 97 121 145 169 194
84 11,3 141 169 117 225
•96 128 160 192 224 256'
107 143 179 214 25'0 286
116 157 197 236 275 315
129 172 215 257 3D0 343
138 165. 232 278 324 371
149 199 248 293 348 390
159 212 265 3.18 371 423
168 224 280 335 392 449
177 236 286 355 414 473
222 298 370 444 618 592
268 -356 444 633 221 710
310 413 516 6.10 723 826.
352 469 586 703 020 938
392 523 853 764 915 1045
470 627 783 140 1;098 1253
545 727 908 1,090 1;271 1453
CO 915 1,147. 1,376 1,806 1835
894 1,192 1480 1,766 2,086 2304
1,091 1,455 1,849 2,183 2,547 2,910
1;217 1,823 2,029 2,434 2;840 3,248
1,343 1,791 2,232 2,686 . 3,133 3,581
1,469 1,958 2,440 2,937 3,427 3,915
1;594 2,126 2,657 .3,189 3,720 4,262
1;720 2.294 2,067 3.440 4,014 4,587
BUSINESS LICENSE TAX CALCULATION
P. BASIC TAX 4CI�{{ECK ONEI.
1, FOR CLASSIFICATION1'8i FIRST LICENSE $80.00
(e) Prt'ncessing.iee'for Initial "in City- business license application $50 00
2. _ FOR CLASSIFICATION 1-6 ONLY, SECOND YEAR RENEWAL.
3. FOR
GROSS RECEIPTS FROM PREVIOUS YEAR S
4. TAX (FROM RATE SCHEDULE II) $ X 2 =
5; LESS PRIOR YEAR MINIMUM DEPOSIT S ' -5b:00
6. NET TAX
7. FOR. CLASSIFICATION 1-6 ONLY. RENEWALS AFTER SECOND YEAR
8. EXACT GROSS RECEIPTS. FROM PREVIOUS YEAR 5
9. TAX (FROM RATE SCHEDULE 1I)
10. FOR BUSINESSES NOT CHARGED ON GROSS RECEIPTS.
11. FLAT TAX (FROM. RATE SCHEDULE I) . . .
13, OTHER PEE (CHECK IF APPUCABLEi,
12. _ CHANGE OF LOCATION ($80.00)
13, _ CHARGE OE BUSINESS NAME ($11.00)
14.._. VIDEO GAMES,--56.00 PER MACHINE Tt MACHINES-
15. _ MISCELLANEOUS
16. SUBTOTAL .... a
C.PENALTY IF RENEWAL IS PAID AFER FEBRUARY 29th
17. MARCH 1' through MAROH 31 ADD 20%
18. _ APRIL.1st through APR IL 301' ADD.4058
19. _:MAY 1" through MAY.31*IADD B086
20, _JUNE 1 ihraugr J.UNE SDADD:99%
21. _AFTER JUNE 30PADD 10a%.
22. TOTAL TAX DUE
?LEASE ENCLOSE PAYMENT. WITH APPUCA'BON
CHECKS &HOUI.D SEAM( PAYABLE TO THE CITY OF NATIONAL CITY
D. SALES OR USE TAX MAY APPLY TO YOUR BUSINESS ACTIVITIES. YOU MAY SEEK WRITTEN ADVICE REGARDING THE APPLICATION OF TAX TO. YOUR
PARTICULAR. BUSINESS BY -WRITING TO THE NEAREST STATE BOARD OF EQUALIZATION OFFICE.
E.1 DECLARE UNDER PENALTYCF PERJURY THATTtIE STATEMENTS HEREIN ARE TRUE AND CORRECT TO THE BEST OF ►e1Y 3CNOVt1LECGEAND BELIEF.
j� ATUR
9.lySiNi;S5 SLAM as ,3- lt+>ie7' .;e' -betilir . %a"
I TITLE - _
DATE
CITY OF NATIONAL CITY
Finance Department
619 336-4330
National City 39 / 48897
11/26/2012 13:40:16.000 Reg CASH11
Validation Receipt
CHARGES -
001-00000-3040
BL ktu+a $ 65.00
Sub -total $*********66.00
PAYMENT -
Cash $ 105.00
Change $********-40.00
THANK YOU!
Business Hours:
7:00 - 6:00 Monday through Thursday
Closed on Fridays