Loading...
PROOF OF INSURANCE (2021) CLOSEDa DATE (MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 05/2012020 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. 1 IMP'OR'TANT: 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 US Centralized Services raAtnnne ; .m.m. _ _..........il............. . Marsh USA Inc. PHONE866-966-4664 Y........................ FAX 701 Market Street, Suite 1100 M �.EXtl....m.. 866 966-eg64st@marsll com ter .....N.ol^ . , mm Attn:AIs, MO 63101 TT.CertRequest@marsh.com ADORESS:............^AIL Att.CertR ue......"".......^ .....,....m.RAGE NAIc# INSURER(S)AFFORDING COVERAGE CN103150778-GAW-CRT-20-21 N Y SCha Y i INSURER A; Old Republic Insurance Company 24147 i INSURED INSURER ,B a New Cingular Wireless PCS, LLC --"" ..._""" —' One AT&T Plaza INSURER C 208 South Akard INSURER D Room 1820 .............. Dallas, TX 75202 URER E INS...........__.._._ ...._.._.................. ............................... _......._...._...... .......... INSURER F : COVERAGES CERTIFICATE NUMBER: CHI -007317234-22 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 'OLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, .NSR . _.,. _..— AO L- i,k..m..........._ ............................-_ POLICY'" VF....M. POLICY EXP LIMITS uLITR TYPE OF INSURANCE ra POLI'C'Y NUMBER' IMM/DDIYYYYI IMMIDDIYYVYI A X COMMERCIAL GENERAL LIABILITY MWZY 31363620 06101/2020 0610112021 EACH OCCURRENCE$ 5,000,000 .......................... DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: LAD0951FA#100867651348 E. Main Street, EI Segundo, CA 90245 City of EI Segundo (Landlord), its officials, and employees are included as Additional Insured under the General Liability and Automobile Liability policies but only with respect to the requirements of the contract between the Certificate Holder and the Insured. Waiver of Subrogation is provided for Workers' Compensation, as required by written contract and allowable by law. CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Deputy City Clerk 1; City Clerk's Office – Mona F. Shilling THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD CLAIMS -MADE t� OCCUR .._... 1,000,000 I PR MISES fm,a�..a7c�cuirrencal ..� ... GE_N'LAGGREGATE LIMIT APPLIES PER: NA X PRO* JECT POLICY ❑ PRO* LOC S. 5,000,000 _......................,......._.. uj OTHER $ 10,000,000 A AUTOMOBILE LIABILITY WMB 3136'35 20 A X ANY AUTO MWZX 31363720 (MI) 06,101020 ' OWNED SCHEDULED $ 5,000,000 AUTOS ONLY AUTOS .......... .... 06101/2020 HIRED $ HNON-OWNED AUTOS ONLY AUTOS ONLY $ UMBRELLALIAB OCCUR $ EXCESS LIjA"B p CLAIMS -MADE III ._..m....... DEO V RETENTIONS .................... A WORKERS COMPENSATION MWC 3136'3820 (AOS) AND EMPLOYERS' LIABILITY Y I N t11w 0112020 ANYPROPRI ETOR/PARTNER/EXECUTI VE N N/A ...... OFFICER/MEMBER EXCLUDED? 5,000,000 ..�........................... _ I (Mandatory in NH) 5,000'............ $ _ 000 n css„ describe under $ 5,000,000 _ DESCRIP'T'ION OF OPERATIONS below 1,000.000; A Excess Workers' Compensation I MWXS 31363920 (OH,WA) Employers' Liability See Second Page DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: LAD0951FA#100867651348 E. Main Street, EI Segundo, CA 90245 City of EI Segundo (Landlord), its officials, and employees are included as Additional Insured under the General Liability and Automobile Liability policies but only with respect to the requirements of the contract between the Certificate Holder and the Insured. Waiver of Subrogation is provided for Workers' Compensation, as required by written contract and allowable by law. CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Deputy City Clerk 1; City Clerk's Office – Mona F. Shilling THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD CE"It1"1N'T"EL� tLAEA._:_..._.t .._... 1,000,000 PR MISES fm,a�..a7c�cuirrencal ..� ... MED EXP gAny one person;) NA PERSONAL & ADV INJURY . — S. 5,000,000 _......................,......._.. "........................... GENERAL AGGREGATE $ 10,000,000 PRODUCTS - P_LOP A X ............. .. ,000 .5..,.0.�00 06,101020 ' 0610112021 ,OMBCNE�SINGLEL9M� $ 5,000,000 t r accarOrs ..G....G..........._..S .......... .... 06101/2020 0610112021 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ ..-kb _f 6?AMAGE � $ -PROPERTY Pmr aeaadenN -............... .... . ._..m....... EACHOCCURRENCE .................... AGGREGATE $ t11w 0112020 0610112021X PER li OTI+ .11..... ER ...... ACCIDENT 5,000,000 ..�........................... _ _EA E L DIS.m�B EASE - EA LMPLOYEE 5,000'............ $ _ 000 E L. DISEASE " POt,tld;Y LIMIT $ 5,000,000 0610112020 06/0112021 EL Each Accident/ EL Disease 1,000.000; EL Disease -Policy Limit 1,000.000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: LAD0951FA#100867651348 E. Main Street, EI Segundo, CA 90245 City of EI Segundo (Landlord), its officials, and employees are included as Additional Insured under the General Liability and Automobile Liability policies but only with respect to the requirements of the contract between the Certificate Holder and the Insured. Waiver of Subrogation is provided for Workers' Compensation, as required by written contract and allowable by law. CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Deputy City Clerk 1; City Clerk's Office – Mona F. Shilling THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN103150778 LOC #: St. Louis CC)R" ADDITIONAL REMARKS SCHEDULE Page- 2 of ? AGENCY NAMED INSURED Marsh USA Inc. New Cingular Wireless PCS, LLC One AT&T Plaza POLICY NUMBER 208 South Akard Room 1820 ...__..... Dallas, TX 75202 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Excess Workers' Compensation -MWXS 31363920 (OH -WA) Self Insured Retentions OH & WA - $500,000,000 (except Terrorism) OH & WA - $600,000,000 Terrorism Excess Automobile Liability - MWZX 31363720 (MI) Combined Single Limit -$1,000,000 Self Insured Retention - $1,000,000 ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): All Persons or Organizations as Required by Written Contract or Agreement. In no event shall the insurance provided exceed the scope of coverage or limits as required by said contract or agreement. Location And Description Of Completed Operations The Locations as Specified in the Written Contracts or Agreements. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — 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" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products - completed operations hazard". CG 20 37 07 04 Q ISO Properties, Inc., 2004 Page 1 of 1 MWZY 313636 20 AT&T Inc. 06101/2020 - 06/01/2021 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 10 12 19 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 Organization(s) Location(s) Of Covered Operations All Persons or Organizations as Required by Written Contract or The Locations as Specified in the Written Contracts or Agreement. Agreements. In no event shall the insurance provided exceed the scope of coverage or limits required by said contract or agreement. Information required to complete this Schedule, if not shown above, will b shown in the Declarations. 'ons. 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, 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 above. 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. 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. CG 20 10 12 19 C Insurance Services Office, Inc., 2018 Page 1 of 2 MWZY 313636 20 AT&T Inc. 06/0112020 - 06J0112021 C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contractor agreement; or 2. Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. Page 2 of 2 c' Insurance Services Office, Inc., 2018 CG 20 1012 19 MWZY 313636 20 AT&T Inc. 06/01/2020 - 06/01/2021 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY UNC 00 0313 POLICY NUMBER: MWC 313638 20 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 WHERE REQUIRED BY WRITTEN CONTRACT DATE OF ISSUE: 06-01-20 1983Nat! one I Council on Cart) pen sat 1on Insurance.