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PROOF OF INSURANCE (2020) CLOSEDPage 1 of 2 lio DATE (MMIDD/YYYY) .,SCC>RV CERTIFICATE OF LIABILITY INSURANCE �"„r, 09/27/2019 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. k 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 andorsement(s). PRODUCER c/llis ofnMassachustury Blvdetts, inc. 'CT %b1e Y,..-...77-945.-7378 �� X 1-888-467-2378 FYO 8 FAX P.O. Box 305191 okpk EPA! certificatevowillia - com [_1111111111.11.11”;IR A : ACE American AInaurlano OCE company .... N2667 AIC # 2 ACE Fire Underwriters Insurance Co Nashville, I INSURED INSURER B : 20702 Unirirst Corporation and its Subsidiaries Company 68 Jonapin RoadNSU,,,R ER C: Wilmington, MA 018871086 INSURER D: INSURE-9-k:. ............................. ............... INSURER F: COVERAGES CERTIFICATE NUMBER: W13142069 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 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. INSR " AODL.'8U'aR POLICY EFF C POLICY EXP UNBTS LTR TYPE OF INSURANCE imsn wvn POLICY NUMBER fMMdOWYYYYM1 fMWDWYYYY1 X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 ^�' .rT RIENTED ,. 1,000,000 DE „ %�„I OCCUR D EXP (Any onetl1 A X Contractual ME Derson) $ 5,000 Y Y HDOG7145048A 10/01/2019 10/01/2020 PERSONAL& ADV INJURY $ 1,000,000 fN` r APPLIES PER: POLICY JECT Af?PL ^� GENERAL AGGREGATE � $ 4,000; 000 - „ O( IC � ' PRO- X LOC PRODUCTS - COMP/OP AGO $ 000 OTHER: $ AUTOMOBILE LIABILITY OM9BINEDfSINGLIE LIMIT $ 4,000,000 (.,' ( or"), X ANY AUTO BODILY INJURY (Per person) $ A AOWNED UTOS ONLY AUTOS ONLDY Y Y ISAR2528835A 10/01/2019 10/01/2020 (OOPS "Lail $ AUTOS ONLY AUTOS INJURY (Per accident) ) HIRED NON-OWNED PROPERTY DAMAGIE', $ Pur apdaent) $ UMBRELLA LIAB OCCUR ........... EACH OCCURRENCE $„-........ EXCESS LIAR CLAIMS-MADE AGGREGATE $ �. 'DED ......w. RETENTIONS S WORKERS COMPENSATION X PER OTH- U R B iANYPR PRIET EMBER UDE/EXECUTIVE No NIA Y SCFC65889134 (WI) 10/01/2019 10/01/2020' E.L. AND EMPLOYERS' LIABILITY TAT TE F- 1,000,000 (OFFICE ry m NH ) EACH ACCIDENT$ EMPLDYEE $ Mandato E.L. DISEASE - EA 1,000,000 If yes, desc2L under 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A 'Workers Compensation and Y I WLRC65889055 (AZ, CA) 10/01/2019 10/OS/20201�EL Each Accident ($1,000,000 'Employers Liability TEL Disease - Limit 1$1,000,000 I�Per Statute VEL Disease - Each Empl$1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Division/Location: 324 Certificate Holder is an Additional Insured for General Liability and Auto Liability as their interest may appear if required by written contract but only with respect to liability arising out of operations of the Named Insured. SEE ATTACHED CERTIFICATE HOLDER City of E1 Segundo Attn: City Clerk City Clerk's Office, 350 blain Street Room 5 E1 Segundo, CA 90245-3813 ®1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD sa ID: 18595055 BATCH: 1387895 ACORD 25 (2016/03) CANCELLATION 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 quL. 1 / V1'aL(i 2 of 3 1075 AGENCY CUSTOMER ID: LOC #: A ADDITIONAL REMARKS SCHEDULE Page 2 Of 2 AGENCY NAMED INSURED Willis of Massachusetts, Inc„ uniFirst Corporation and its Subsidiaries 68 Jonspin Road POLICY NUMBER CWilmington, MA 018871086 See Page 1 CARRIER NAIC CODE See Page 1 See Page 1 EFFECTIVE DATE: See Page 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance It is understood and agreed that UniFirst Corporation waives its right of subrogation against the Additional Insured which may arise by reason of a payment of claim under General Liability, Auto Liability and Workers Compensation policies, if required by written contract and as permitted by law. Additional Insureds: City of E1 Segundo, its officials, and employees, General Liability policy shall be Primary and Non-contributory with any other insurance in force for or which may be purchased by Additional Insureds. INSURER AFFORDING COVERAGE: ACE American Insurance Company POLICY NUMBER: WCUC65889171 (MA, ME, OH) EFF DATE: 10/01/2019 EXP DATE: 10/01/2020 SUBROGATION WAIVED: Y TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT; 'Workers Compensation and EL Each Accident $1,000,000 Employers Liability EL Disease - Limit $1,000,000 Per Statute EL Disease - Each Emp $1,000,000 INSURER AFFORDING COVERAGE: ACE Fire Underwriters Insurance Company POLICY NUMBER: SCFC65889134 (WI) EFF DATE: 10/01/2019 EXP DATE: 10/01/2020 SUBROGATION WAIVED: Y TYPE OF INSURANCE: Workers Compensation and Employers Liability Per Statute LIMIT DESCRIPTION: EL Each Accident EL Disease - Limit EL Disease - Each Emp LIMIT AMOUNT: $1,000,000 $1,000,000 $1,000,000 NAIC#: 22667 NAIC#: 20702 I ACORD 101 (2008/01) ® 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID: 18595055 BATCH: 1387895 CERT: W13142069 POLICY NUMBER: HDO G7145048A COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organizatlon(s): Any person or organization whom you have agreed to include as an additional insured under a written contract, provided such contract was executed prior to the date of loss. Information required to complete this Schedule, it not shown above, will be shown in the Declarations, A. Section 11 — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property darnage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of these acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However; 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. 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. CG 20 26 0413 B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: It coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the addilional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. 0 Insurance Services Office, Inc., 2012 Page 1 of I 3 of 3 1075 Workers' Compensation and Employers' Liability Policy "Named insured Endorsement Number i LINIFIRST CORPORATION 68 JONSPIN RD Policy Number WILMINGTON MA 01887 Symbol: WLR Number: C65889055 Policy Period Effective Date of Endorsement 10-01-2019 TO 10-01-2020 10-01-2019 lssued By (Nami- UFance Company) I . ...... ,.-ACE AMERICAN IN COMPANY T rt th_e__ —numb-e—r, The femainder of the intorrnat�c!Li is to be compleied onty ��fjjjn tWis esldor�enje6it ii7;iiuedTu6sequent to the pcaliry., CALIFORNIA WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of the Information Page. We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce out, right against the person or organization named in the Schedule, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract to obtain this waiver from us. You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. Schedule 1, Specific Waiver Name of person or organization: X ) Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Operations: ALL OPERATIONS CONDUCTED BY AN INSURED PURSUANT TO SUCH WRITTEN CONTRACT 3. Premium: The premium charge for this endorsement shall be 2.0 percent of the California premium developed on payroll in connection with work performed for the above person(s) or organization(s) arising out of the operations described. 4. Minimum Premium: $0 5:z ................. Authorized Representative WC 90 03 75 (05/18)