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PROOF OF INSURANCE (2020) CLOSED
e, I DATE (MM,DDIYYYY) CC CERTIFICATE OF LIABILITY INSURANCE 05/10/2019 THIS CERTIFICATE IS ISSUED ASA 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). PRODUCER CONTACT Brooke Steiner NAME: C&W Insurance PHONE (785) 537-1600 I FAX (785) 537-1657 tA,C, No, ExtL IMC. Nog: 555 Poyntz Avenue, Suite 205 E�MAIu bsteiner@charlsonwilson corn ADDRESS. P.O. BOX 1989 INSURER(S) AFFORDING COVERAGE NAIC # Manhattan KS 66505-1989 wsURER..A..........Great... ............... ....... _............. .....................................P..........y.........................................._..._._....................................................................................................... Northern Insurance Company 20303 . INSURED INSURER B : Chubb Group of Ins Companies ............................................................ ............. d. ..... _._ CivicPlus, LLC INSURER C : Federal Insurance Company 20281 302 S 4th Street, Suite 500 INSURER D: Chubb Indemnity Insurance Company 12777 ___....._ _................................................................... I INSURER E Manhattan KS 66502 INSURER F COVERAGES CERTIFICATE NUMBER: 2019 Master REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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 INSRA8. UI. bu"M POLICY EFF POLICY EXP TYPE OF INSURANCE LTR ( INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDfYYYY) LIMITS X' COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE OCCUR NPREMISES (Ea occurrence) S 2,000,000 MED EXP (Any one person) S 10,000 A Y 3602-53-12 05/17/2019 05/17/2020 PERSONAL & ADV INJURY s 1,000,000 GENT. AG"GREG,+I E LIMIT APPLIES PER. PCfLIC„Y PRS, JEC.p❑LOC OTHER AUTOMOBILE LIABILITY X ANYAUTO B OWNED SCHEDULED Y AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY �. _. ............................... X UMBRELLA L ... CLABB x�' OCCUR EXCESS LIAR QQ CLAIMS -MADE DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN] ANY PROPRIETOR/PARTNER/EXECUTIVE D OFFICER/MEMBER EXCLUDED N N IA (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below A Cyber Liability . .. -. GENERAI_AGGREGATE ............... ... _........................... 2,000,.® ....................................... $ 00 ..$....3,000,000 PRODIology.,E..MPim_...._ PRODUCTS OPAGG $ 2,000,000 Techn &O ............................................................................................................................................................................................................e.._W.e__ ._ ....._.__ _m.. 1,.:OM�811NLO .................................................................... � $ 1,000,000 &rcn:vgenl l BODILY INJURY (Per person) $ 7358-87-92 05/17/2019 05/17/2020 BODILY INJURY(Per accident) $ .....e......_.....,.e...7_................................ P`R .JPERTI• IDI"x14tACaF�, S p Ap' Krrdenli EACH OCCURRENCE s 5,000,000 7989-49-14 05/17/2019 05/17/2020 AGGREGATE $ ryry XI I$ STATUTE II EERH EL EACH ACCIDENT Y 7174-92-49 05/17/2019 05/17/2020 S 1,000,000 E L DISEASE - EA EMPLOYEE li S 1,000,000 E IL DISEASE POLICY LIMIT S 11000,000 General Aggregate $3,000,000 Y 3602-53-12 05/17/2019 05/17/2020 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) 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. 350 Main Street AUTHORIZED REPRESENTATIVE EI Segundo CA 90245 &,bI-Le— n(-,;� I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD C H U B B° Liability Insurance Endorsement Policy Period Effective Date Policy Number Insured Name of Company Date Issued This Endorsement applies to the following forms: GENERAL LIABILITY Who Is An Insured MAY 17, 2019 TO MAY 17, 2020 MAY 17, 2019 3602-53-12 MIN CnWPLUS,LLC GREAT NORTHERN INSURANCE COMPANY JUNE 17, 2019 Under Who Is An Insured, the following provision is added, Additional Insured - Persons or organizations shown in the Schedule are insureds, but they are insureds only if you are Scheduled Person obligated pursuant to a contract or agreement to provide them with such insurance as is afforded by Or Organization this policy. However, the person or organization is an insured only: • if and then only to the extent the person or organization is described in the Schedule; • to the extent such contract or agreement requires the person or organization to be afforded status as an insured; • for activities that did not occur, in whole or in part, before the execution of the contract or agreement; and • with respect to damages, loss, cost or expense for injury or damage to which this insurance applies. No person or organization is an insured under this provision: • that is more specifically identified under any other provision of the Who Is An Insured section (regardless of any limitation applicable thereto). • with respect to any assumption of liability (of another person or organization) by them in a contract or agreement. This limitation does not apply to the liability for damages, loss, cost or expense for injury or damage, to which this insurance applies, that the person or organization would have in the absence of such contract or agreement. Liability Insurance Additional Insured - Scheduled Person Or Organization continued Form 80-02.2387 (Rev. 5-07) Endorsement Page 1 CHUBBO Liability Endorsement (continued) Under Conditions, the following provision is added to the condition titled Other Insurance, Conditions Other Insurance — If you are obligated, pursuant to a contract or agreement, to provide the person or organization Primary, Noncontributory shown in the Schedule with primary insurance such as is afforded by this policy, then in such case Insurance — Scheduled this insurance is primary and we will not seek contribution from insurance available to such person Person Or Organization or organization, Schedule CITY OF EL SEGUNDO 350 MAIN STREET EL SEGUNDO, CA 90245 All other terms and conditions remain unchanged. Authorized Representative Liability Ineuranoe Additional Insured - Soheduled Person Or Organization lost page Form 80-02-2867 (Rev. 6-07) Endoraement Page 2 C H U S S' Chubb Group of Insurance Companies INFORMATION PAGE 202B Hall's Mill Road, Whitehouse Station, NJ 08889 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY Item 1. Name & Mailing Address of the Insured Issued by Federal Insurance Company CIVICPLUS, LLC a stock insurance company 302 SOUTH 4TH STREET STE 500 incorporated in INDIANA MANHATTAN, KS 66502 FEIN 48-1202104 TEL#: (888) 228-2233 # of EMP: U I#: Insured is: Corporation Name & Address of the Producer CHARLSON-WILSON INSURANCE AGENCY 555 POYNTZ AVE STE 205 MANHATTAN KS 66502-0000 Producer Number 0035789 N.C.C.I. Carrier Code 12890 Policy Number (20) 7174-92-49 Previous Policy Number (19) 7174-92-49 OTHER WORK PLACES NOT SHOWN ABOVE - SEE ATTACHED EXTENSION OF INFORMATION PAGE Item 2. POLICY PERIOD 12:01 A.M. standard time at the insured's mailing address FROM 05/17/19 TO 05/17/20 Item 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to°.th.e............ Workers Compensation Law of the states listed here: AL, AR, AZ, CA, CO, DC, FL, GA, IA, ID, IL, IN, KS, LA, MA, MD, MN, MO, MS, NC, NE, NH, NJ, NV, NY, OK, OR, PA, SC, TN, TX, UT, VA, WI B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: All States, Except states designated in Item &A and ND, OH, WA, WY D, Endorsements (Form No.) Refer To Extension of Information Page "List of Endorsements & Schedules" Item 4. The Premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Refer to Extension of Information Page Minimum Premium: $1,000 Total Estimated Premium: Minimum Premium State: NEW YORK Total State Surcharges: Expense Constant: NEW YORK ($450 INCL) Total Estimated Charge: Premium Adjustment Period: AT EXPIRATION Deposit Amount: CHUBB GROUP OF INSURANCE COMPANIES: 1100 WALNUT SUITE 1800 KANSAS CITY, MO 64106 06/06/19 Authorized Representative and Date Signed Issue Date: 06/06/19 Form WC 00 00 01A (Rev. 5-88) Includes copyright material of the National Council on Compensation Insurance,used with its permission. Copyright 1987, National Council on Compensation Insurance Producer Copy WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 0313 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule JEFFERSON COUNTY COLORADO 100 JEFFERSON COUNTY PARKWAY GOLDEN, CO 80419 THE MAYOR AND COUNCIL OF ROCKVILLE 111 MARYLAND AVENUE, ROCKVILLE, MD 20850 CONTACT: CITY FALL CITY OF EL SEGiUNDO 350 MAIN STREET, EL SEGUNDO, CA 90245 CITY OF DES MOINES, PROCUREMENT ADMINISTRATOR 400 ROBERT D. RAY DRIVE, DES MOINES, LA 50309 CONTACT: CITY HALL DES MOINES METROPOLITAN WASTEWATER RECLAMATION, AUTHORITY 3000 VANDALIA ROAD, DES MOINES, LA 50310 CONTACT: EXECUTIVE DIRECTOR ® 1983 National Council on Compensation Insurance. producer Copy