PROOF OF INSURANCE (2021 - 2021) CLOSEDTHIS IS TO C'ERTIFI" THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANN' REQUIRENIEN'1','1'ERNI Oil
CONDITION OF ANN' CONTRACTOR OTHER DOC'UN1ENT WITH RESPECT TO WHICH I HIS CERTIFICATE N1A1 BE ISSUED OR N1A1 PERTAIN, THE INSURANCE AFFORDED BI"THE POLICIES DESCRIBED HEREIN IS SUBJECT TO
ALL I HE TERNIS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LINIFFS SHOWN NIAI' HAVE BEEN REDUCED BN' PAID C'LAIN1S.
USSR TYPE OF INSURANCE ADDL SUER POLIC]' NUMBER POLICYEFF POLICYEXP LIMITS
FUR INSD WYD (NIMIDD/I'I'I']') (MM/11DA11 I')
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE yo,yOCCUR
A GENT AGGREGA'T'E LIMIT APPLIES PER:
POLICY PROJECT V LOC
DATE (MM/DD/]']']']')
$300,000.00
CERTIFICATE OF LIABILITY INSURANCE
E.L. EACH ACCIUEN
.AN]' AU'T'O
$10,000.00
A OWNED AU'T'OS
SCHEDULED
ONLY
04/09/2020
THIS C'ER'T'IFIC'ATE IS ISSUED AS A MATTER
OF I.NFORNIATION ONLIAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. I HIS CERTIFICATE DOES NOT AFFIRNIATINVELI OR
NEGATWELN' AMEND, EXTEND OR
ALTER THE CON'ERAGE AFFORDED BN"
1'HE POLICIES BELOW.I HIS C'ER'TIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE'IANTEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE Oil
PRODUCER, AND THE CERTIFICATE HOLDER
02/26/2021
IMPOR'TAN'T: H the certificate holder is an
ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. H 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
I CON'TAC'T' NAME:
FounderShield, LLC
I PHONE (.A/C No. Ext): 646-854-1058
I FAX (.A/C No):
119 W 24th Street, 3rd Floor
I E-MAIL ADDRESS: coilufoundershield.com
New Pork, New Pork, 10011
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURER A: CONTINENTAL CASUALTY CO (CNA)
20443
INSURED
I INSURER B: AXIS INSURANCE COMPANY
37273
INSURER C: UNDERWRITERS A'1' LLOYD'S LONDON (SCALE)
AA -1122000
Sl'lllR'1'ech
1100 Manhattan Ave.
I INSURER D:
Manhattan Beach, California, 90266
I INSURER E :
INSURER F:
COVERAGES
CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO C'ERTIFI" THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANN' REQUIRENIEN'1','1'ERNI Oil
CONDITION OF ANN' CONTRACTOR OTHER DOC'UN1ENT WITH RESPECT TO WHICH I HIS CERTIFICATE N1A1 BE ISSUED OR N1A1 PERTAIN, THE INSURANCE AFFORDED BI"THE POLICIES DESCRIBED HEREIN IS SUBJECT TO
ALL I HE TERNIS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LINIFFS SHOWN NIAI' HAVE BEEN REDUCED BN' PAID C'LAIN1S.
USSR TYPE OF INSURANCE ADDL SUER POLIC]' NUMBER POLICYEFF POLICYEXP LIMITS
FUR INSD WYD (NIMIDD/I'I'I']') (MM/11DA11 I')
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE yo,yOCCUR
A GENT AGGREGA'T'E LIMIT APPLIES PER:
POLICY PROJECT V LOC
OTHER
$300,000.00
AU'T'OMOBILE LIABILITY
E.L. EACH ACCIUEN
.AN]' AU'T'O
$10,000.00
A OWNED AU'T'OS
SCHEDULED
ONLY
$4,000,000.00
�r HIRED .AU'T'OS
,�t
]�r NON -OWNED AU'T'OS
ONLY
ONLY
UMBRELLA LIAB EXCESS LIAR
OCCUR CLAIMS -MADE
WORKERS C'ONIPENSATION AND ENIPLOYERS LIABILITI'
ANAP ROPRIE'1'Oli/1'AII'I :NEREXECU'1'INV YIN
OFFIC'ERMEMBER EXCLUDED? N
(Mandatory in NH) N/ A
If ves, describe under DESC'RIP'TION OF OPERATIONS below
B Cyber Liability,Errors & Omissions
C Directors & Officers
.A Property
B6020975247 02/26/2020 02/26/2021
EACH OCCURRENCE
$2,00000.00
DAMAGE TO RENTED
$300,000.00
PREMISES (Ea occurrence)
E.L. EACH ACCIUEN
MED EXP (Any one person)
$10,000.00
PERSONAL &.ADV [NJ UR]'
$2,000,000.00
GENERAL AGGREGATE
$4,000,000.00
PRODUCTS - COMP/OP AGG
$2,000,000.00
01/05/2021
S
COMBINED SINGLE LIMIT $1,000,000.00
(Ea accident)
BODILY INJURI' (Per person)
B6020975247 02/26/2020 02/26/2021
B011IL]' 1NJURI' (Per
accident)
PROPERTY DAMAGE (Per
accident)
11-001-000067109-02 01/05/2020
B118OD201043/049 01/05/2020
B6020975247 02/26/2020
Each occurence
Aggregate
DESCRIPTION OF OPERATIONS / LOC'A'TIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The Certificate Holder is included as an Additional Insured on the above referenced policy where required by written contract.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANN OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE
City of EI Segundo 'THEREOF, NO'TIC'E WILL BE DELIVERED IN .ACCORD ANCE WITH THE POLICY PROVISIONS.
350 Main Street
EI Segundo, CA 90245
AUTHORIZED REPRESENTATIVE
1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) 'The ACORD name and logo are registered marks of ACORD
PER STATUTE
OTHER
E.L. EACH ACCIUEN
E.L. DISEASE - EA
EMPLOYEE
E.L. DISEASE - POLICI'
LIMIT
01/05/2021
$ 2.000,000 per occ $2.000.000 in agg
01/05/2021
$ 1.000,000 per occ $1.000.000 in agg
02/26/2021
$ 23814.00 BIT $500 deductible
DESCRIPTION OF OPERATIONS / LOC'A'TIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The Certificate Holder is included as an Additional Insured on the above referenced policy where required by written contract.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANN OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE
City of EI Segundo 'THEREOF, NO'TIC'E WILL BE DELIVERED IN .ACCORD ANCE WITH THE POLICY PROVISIONS.
350 Main Street
EI Segundo, CA 90245
AUTHORIZED REPRESENTATIVE
1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) 'The ACORD name and logo are registered marks of ACORD
SB146932F
CNA (Ed. 6-16)
BLANKET ADDITIONAL INSURED
AND
LIABILITY EXTENSION ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS LIABILITY COVERAGE FORM
BUSINESSOWNERS COMMON POLICY CONDITIONS
TABLE OF CONTENTS
1. Blanket Additional Insured Provisions
A. Additional Insured — Blanket Vendors
B. Miscellaneous Additional Insureds,
C. Additional Provisions Pertinent to Additional Insured Coverage,
1. Primary — Noncontributory orovision
2. Definition of "written contract."'
11, Liabilitv Extension Coveraggs,
A. Bodilv Iniury — Expanded Definition
B. Broad Knowledae of Occurrence
...... .......
C. Estates, Leoal Representatives and Spouses
D. Legal Liabllity — Damacae to Premises
E. Personal and Advertisin InJury — Discrimination or Humiliation
V F. Personal and AdvertisinoIWry — Broadened Eviction
G. Waiver of Subrooation - Blanket
I. BLANKET ADDITIONAL INSURED PROVISIONS
A. ADDITIONAL INSURED — BLANKET VENDORS
Who Is An Insured is amended to include as an additional insured any person or organization (referred to below
as vendor) with whom you agreed under a "written contract" to provide insurance, but only with respect to "bodily
injury" or "property damage" arising out of "your products" which are distributed or sold in the regular course of the
vendor's business, subject to the following additional exclusions:
1. The insurance afforded the vendor does not apply to:
a. "Bodily injury" or "property damage" for which the vendor is obligated to pay damages by reason of the
assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages
that the vendor would have in the absence of the contract or agreement;
b. Any express warranty unauthorized by you;
c. Any physical or chemical change in the product made intentionally by the vendor;
d. Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing, or the
substitution of parts under instructions from the manufacturer, and then repackaged in the original
container;
SB146932F (6-16)
Page 1 of 7
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SB146932F
CNA (Ed. 6-16)
e. Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make
or normally undertakes to make in the usual course of business, in connection with the distribution or sale
of the products;
f. Demonstration, installation, servicing or repair operations, except such operations performed at the
vendor's premises in connection with the sale of the product;
g. Products which, after distribution or sale by you, have been labeled or relabeled or used as a container,
part or ingredient of any other thing or substance by or for the vendor; or
h. "Bodily injury" or "property damage" arising out of the sole negligence of the vendor for its own acts or
omissions or those of its employees or anyone else acting on its behalf. However, this exclusion does not
apply to:
(1) The exceptions contained in Subparagraphs d. orf.; or
(2) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally
undertakes to make in the usual course of business, in connection with the distribution or sale of the
products.
2. This insurance does not apply to any insured person or organization, from whom you have acquired such
products, or any ingredient, part or container, entering into, accompanying or containing such products.
3. This provision 2. does not apply to any vendor included as an insured by an endorsement issued by us and
made a part of this Policy.
4. This provision 2. does not apply if "bodily injury" or "property damage" included within the "products -
completed operations hazard" is excluded either by the provisions of the Policy or by endorsement.
B. MISCELLANEOUS ADDITIONAL INSUREDS
1. Who Is An Insured is amended to include as an insured any person or organization (called additional
insured) described in paragraphs 3.a. through 3.j. below whom you are required to add as an additional
insured on this policy under a "written contract.":
2. However, subject always to the terms and conditions of this policy, including the limits of insurance, we will
not provide the additional insured with:
a. A higher limit of insurance than required by such "written contract";
b. Coverage broader than required by such "written contract" and in no event greater than that described by
the applicable paragraph a. through k. below; or
c. Coverage for "bodily injury" or "property damage" included within the "products -completed operations
hazard." But this paragraph c. does not apply to the extent coverage for such liability is provided by
.<a
paragraph 3.j. below.
Any coverage granted by this endorsement shall apply only to the extent permitted by law.
3. Only the following persons or organizations can qualify as additional insureds under this endorsement:
a. Controlling Interest
Any persons or organizations with a controlling interest in you but only with respect to their liability arising
out of:
(1) such person or organization's financial control of you; or
(2) Premises such person or organization owns, maintains or controls while you lease or occupy these
premises;
provided that the coverage granted to such additional insureds does not apply to structural alterations,
new construction or demolition operations performed by or for such additional insured.
SB146932F (6-16)
Page 2 of 7
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CNA
SB146932F
(Ed. 6-16)
b. Co-owner of Insured Premises
A co-owner of a premises co -owned by you and covered under this insurance but only with respect to the
co-owners liability for "bodily injury", "property damage" or "personal and advertising injury" as co-owner
of such premises.
c. Grantor of Franchise
Any person or organization that has granted a franchise to you, but only with respect to such person or
organization's liability for "bodily injury", "property damage", or "personal and advertising injury" as
grantor of a franchise to you.
d. Lessor of Equipment
Any person or organization from whom you lease equipment, but only with respect to liability for "bodily
injury", "property damage" or "personal and advertising injury" caused in whole or in part by your
maintenance; operation or use of such equipment, provided that the "occurrence" giving rise to such
bodily injuryor property damage or the offense giving rise to such personal and advertising injury
takes place prior to the termination of such lease.
e. Lessor of Land
Any person or organization from whom you lease land, but only with respect to liability for "bodily injury",
"property damage" or "personal and advertising injury" arising out of the ownership, maintenance or use
of that specific part of the land leased to you, provided that the "occurrence" giving rise to such "bodily
injury" or "property damage" or the offense giving rise to such "personal and advertising injury", takes
place prior to the termination of such lease. The insurance hereby afforded to the additional insured does
not apply to structural alterations, new construction or demolition operations performed by, on behalf of or
for such additional insured.
f. Lessor of Premises
An owner or lessor of premises leased to you, or such owner or lessor's real estate manager, but only
with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" arising
out of the ownership, maintenance or use of such part of the premises leased to you, and provided that
the "occurrence" giving rise to such "bodily injury" or "property damage" or the offense giving rise to such
personal and advertising injury", takes place prior to the termination of such lease. The insurance hereby
afforded to the additional insured does not apply to structural alterations, new construction or demolition
operations performed by, on behalf of or for such additional insured.
g. Mortgagee, Assignee or Receiver
A mortgagee, assignee or receiver of premises but only with respect to such mortgagee, assignee, or
receiver's liability for "bodily injury", "property damage" or "personal and advertising injury" arising out of
the ownership, maintenance, or use of a premises by you.
This insurance does not apply to structural alterations, new construction or demolition operations
performed by, on behalf of or for such additional insured.
h. State or Political Subdivisions
A state or government agency or subdivision or political subdivision that has issued a permit or
authorization, but only with respect to such government agency or subdivision or political subdivision's
liability for "bodily injury", "property damage" or "personal and advertising injury" arising out of:
(1) The following hazards in connection with premises you own, rent, or control and to which this
insurance applies:
(a) The existence, maintenance, repair, construction, erection, or removal of advertising signs,
awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoistaway
openings, sidewalk vaults, street banners, or decorations and similar exposures; or
SB146932F (6-16)
Page 3 of 7
(b) The construction, erection, or removal of elevators; or
(c) The ownership, maintenance or use of any elevators covered by this insurance; or
Copyright, CNA All Rights Reserved.
SB146932F
CNA (Ed. 6-16)
(2) The permitted or authorized operations performed by you or on your behalf. But the coverage granted
by this paragraph does not apply to:
(a) "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations
performed for the state or government agency or subdivision or political subdivision; or
(b) "Bodily injury" or "property damage" included within the "products -completed operations hazard."
With respect to this provision's requirement that additional insured status must be requested under a
"written contract", we will treat as a "written contract" any governmental permit that requires you to
add the governmental entity as an additional insured.
I. Trade Show Event Lessor
With respect to your participation in a trade show event as an exhibitor, presenter or displayer, any
person or organization .whom you are required to include as an additional insured, but only with respect
to such person or organization's liability for "bodily injury", "property damage", or "personal and
advertising injury" cause by:
a. Your acts or omissions; or
b. Acts or omissions of those acting on your behalf;
in the performance of your ongoing operations at the trade show premises during the trade show event.
j. Other Person or Organization
Any person or organization who is not an additional insured under paragraphs a. through i. above. Such
additional insured is an insured solely for "bodily injury", "property damage" or "personal and advertising
injury" for which such additional insured is liable because of your acts or omissions.
The coverage granted by this paragraph does not apply to any person or organization:
(1) For "bodily injury," "property damage," or "personal and advertising injury" arising out of the rendering
or failure to render any professional services;
(2) For "bodily injury" or "property damage" included in the "products -completed operations hazard." But
this provision (2) does not apply to such "bodily injury" or "property damage" if:
(a) It is entirely due to your negligence and specifically results from your work for the additional
insured which is the subject to the "written contract'; and
(b) The "written contract" requires you to make the person or organization an additional insured for
such "bodily injury" or "property damage"; or
(3) Who is afforded additional insured coverage under another endorsement attached to this policy.
C. ADDITIONAL PROVISIONS PERTINENT TO ADDITIONAL INSURED COVERAGE
With respect only to additional insured coverage provided under paragraphs A. and B. above:
1. The BUSINESSOWNERS COMMON POLICY CONDITIONS are amended to add the following to the
Condition entitled Other Insurance:
This insurance is excess of all other insurance available to an additional insured whether primary, excess,
contingent or on any other basis. However, if a "written contract" requires that this insurance be either primary
or primary and noncontributing, then this insurance will be primary and non-contributory relative solely to
insurance on which the additional insured is a named insured.
2. Under Liability and Medical Expense Definitions, the following definition is added:
"Written contract" means a written contract or agreement that requires you to make a person or organization
an additional insured on this policy, provided the contract or agreement:
a. Is currently in effect or becomes effective during the term of this policy; and
b. Was executed prior to:
SB146932F (6-16)
Page 4 of 7
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l - A_L_A,�
(1) The "bodily injury" or "property damage"; or
(2) The offense that caused the "personal and advertising injury';
for which the additional insured seeks coverage.
II.. LIABILITY EXTENSION COVERAGES
SB146932F
(Ed. 6-16)
It is understood and agreed that this endorsement amends the Businessowners Liability Coverage Form. If any
other endorsement attached to this policy amends any provision also amended by this endorsement, then that other
endorsement controls with respect to such provision, and the changes made by this endorsement to such provision do
not apply.
A. Bodily Injury – Expanded Definition
Under Liability and Medical Expenses Definitions, the definition of "Bodily injury" is deleted and replaced by the
following:
"Bodily injury" means physical injury, sickness or disease sustained by a person, including death, humiliation,
shock, mental anguish or mental injury by that person at any time which results as a consequence of the physical
injury, sickness or disease.
B. Broad Knowledge of Occurrence
Under Businessowners Liability Conditions, the Condition entitled Duties In The Event of Occurrence, Offense,
Claim or Suit is amended to add the following:
Paragraphs a. and b. above apply to you or to any additional insured only when such "occurrence," offense, claim
or "suit" is known to:
(1) You or any additional insured that is an individual;
(2) Any partner, if you or an additional insured is a partnership;
(3) Any manager, if you or an additional insured is a limited liability company;
(4) Any "executive officer" or insurance manager, if you or an additional insured is a corporation;
(5) Any trustee, if you or an additional insured is a trust; or
(6) Any elected or appointed official, if you or an additional insured is a political subdivision or public entity.
This paragraph applies separately to you and any additional insured.
C. Estates, Legal Representatives and Spouses
The estates, heirs, legal representatives and spouses of any natural person insured shall also be insured under
this policy; provided, however, coverage is afforded to such estates, heirs, legal representatives and spouses only
for claims arising solely out of their capacity as such and, in the case of a spouse, where such claim seeks
damages from marital common property, jointly held property, or property transferred from such natural person
insured to such spouse. No coverage is provided for any act, error or omission of an estate, heir, legal
representative or spouse outside the scope of such person's capacity as such, provided however that the spouse
of a natural person Named Insured and the spouses of members or partners of joint venture or partnership
Named Insureds are insureds with respect to such spouses' acts, errors or omissions in the conduct of the Named
Insured's business.
D. Legal Liability – Damage To Premises
Under B. Exclusions, 1. Applicable to Business Liability Coverage, Exclusion k. Damage To Property, is
replaced by the following:
k. Damage To Property
"Property damage" to:
1. Property you own, rent or occupy, including any costs or expenses incurred by you, or any other
person, organization or entity, for repair, replacement, enhancement, restoration or maintenance of
SB146932F (6-16)
Page 5 of 7
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CNA GB146832F
such property for any raoson, including prevention ofinjury bo o person ordamage to another's
2. Premises you ueU. Qkm away or abandon, if the "property damage" ohuum out of any pod of those
premises;
3. Property loaned toyou;
4. Personal property inthe care, custody orcontrol ufthe insured;
§. That particular part ofany real property on which you or any contractors or subcontractors working
directly or indirectly in your behalf are performing operations, if the "property damage" arises out of
those operations; or
6. That particular pad of any property that must be nmmtoved, repaired or replaced because "your work"
was incorrectly performed onit.
Paragraph 2 of this exclusion does not apply if the premises are ''your wnrk" and were never onoupied,
rented orheld for rental by you.
Paragraphs 1, 3, and 4, of this exclusion do not apply to "property damage" (other than damage by fire or
explosion) topremises:
(1) rented to you:
(2) temporarily occupied byyou with the permission ofthe owner, or
(3) to the contents of premises rented to you for a period of 7 or fewer consecutive days.
A separate limit of insurance applies to Damage To Premises Rented To You as described in Section D —
Liability and Medical Expenses Limits of Insurance.
Paragraphs 3, 4, 5, and 6 of this exclusion do not apply to liability assumed under a sidetrack agreement.
Paragraph 6 of this exclusion does not apply to "property damage" included in the "produds'nomp|eted
operations hazard,"
2. Under B. 2xclwsione, 1. Applicable to Business Liability Coverage, the following paragraph added, and
replaces the similar pamaQmsph, if any, beneath paragraph (14) of the exclusion entitled
' Personal and
Advertising injury:
Exclusions c, d e, f, gM ik, 1, and o, donot apply to damage by fire to premises while rented to you
or temporarily occupied by you with permission of the owner or to the contents of premises rented to you for a
period of 7 or fewer consecutive days. A separate limit of insurance applies to this coverage as described in
Section D. Liability And Medical Expenses Limits Of Insurance.
3. The first Paragraph Premises Rented TmYou Limit ofthe section entitled Liability
And Medical Expenses Limits OfInsurance isreplaced bythe following:
� The most we will pay under Business Liability fordamagesbecause cf" ' to any one
pmemimes, while mon1od to yyou;or ��mp�ma/temporarilyoccupied by you with the permission' ~
`� damage"
owner, including
contents of such premises rented to you for period of 7 or fewer consecutive days, is the Damage to
Premises Rented bzYou limit shown inthe Declaration.
E. PmrmonayandAdvedisTng|njury—DiscdmhnatbnmmrHumi|iaton
1. Under Liability and Nled|co| Expenses DmOn|dons, the definition of "personal and advertising injury' is
amended boadd the following:
h. Discrimination or humiliation that results in injury to the feelings or reputation of a natural person, but only
ifsuch discrimination orhumiliation is:
(1) Not done intentionally byoratthe direction of:
(a) The insured; or
8B146932F(6'16)
Page Gcf7
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CNA
SB146932F
(Ed. 6-16)
(b) Any "executive officer," director, stockholder, partner, member or manager (if you are a limited
liability company) of the insured; and
(2) Not directly or indirectly related to the employment, prospective employment, past employment or
termination of employment of any person or person by any insured.
2. Under B. Exclusions, 1. Applicable to Business Liability Coverage, the exclusion entitled Personal and
Advertising injury is amended to add the following additional exclusions:
(15) Discrimination Relating to Room, Dwelling or Premises
Caused by discrimination directly or indirectly related to the sale, rental, lease or sub -lease or prospective
sale, rental, lease or sub -lease of any room, dwelling or premises by or at the direction of any insured.
(16) Employment Related Discrimination
Discrimination or humiliation directly or indirectly related to the employment, prospective employment,
past employment or termination of employment of any person by any insured.
(17) Fines or Penalties
Fines or penalties levied or imposed by a governmental entity because of discrimination.
3. This provision (Personal and Advertising Injury — Discrimination or Humiliation) does not apply if
Personal and Advertising Injury Liability is excluded either by the provisions of the Policy or by
endorsement.
F. Personal and Advertising Injury - Broadened Eviction
Under Liability and Medical Expenses Definitions, the definition of 'Personal and advertising injury" is
amended to delete Paragraph c. and replace it with the following:
c. The wrongful eviction from, wrongful entry into, or invasion of the right of private occupancy of a room
dwelling or premises that a person or organization occupies committed by or on behalf of its owner, landlord
or lessor.
G. Waiver of Subrogation — Blanket
We waive any right of recovery we may have against:
a. Any person or organization with whom you have a written contract that requires such a waiver.
All other terms and conditions of the Policy remain unchanged.
SB146932F (6-16)
Page 7 of 7
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= VM 10 M-."=
Mailing
Address
I
Employer's ID No.:
PIIC CODE: 7372
For other named insured see Extension of Information Page — Schedule of Named Insured, WC 99 99 99 A
For other workplaces see Extension of Information Page — Schedule of Other Workplaces, WC 99 99 99 B
Item 2. Policy period: From 07-01-2020 To 07-01-2021 12:01 A.M., standard time at the named insured's mailing address.
Item 3A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here:
CA
Item 313. 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 $ 2,000,000 each accident
Bodily Injury by Disease $ 2,000,000 policy limit
Bodily Injury by Disease $ 2,000,000 each employee
Item 3C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
ALL STATES EXCEPT
ND,OH,WA,WY,
AND STATES DESIGNATED IN ITEM 3.A
Item 31). This Policy includes these endorsements and schedules:
See schedule of Forms and Endorsements WC999999D
Item 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information
required below is subject to verification and change by audit.
SEE EXTENSION OF INFORMATION PAGE —CLASSIFICATIONS
If indicated here, interim adjustments of premium will be made:
❑ Semi -Annually ❑ Quarterly ❑ Monthly
PRODUCER NAME AND MAILING ADDRESS
USI INSURANCE SERVICES LLC
2601 SOUTH BAYSHORE DRIVE
16TH FLOOR SUITE 1600
COCONUT GROVE FL 33133
PRODUCER CODE: 205455 13-3771734 DAU
MARKETING OFFICE: DALLAS BRANCH
ISSUE DATE: 07/09/2020
Minimum Premium collected in CA $
Total Estimated Premium $
Deposit Premium $
Authorized Representative
WC 00 00 0 1 A (05/88) Copyright 1987 National Council on Compensation Insurance
INSURED COPY
ISSUING COMPANY
Workers' Compensation
ACE AMERICAN INSURANCE COMPANY
and Employers Liability
NCCI CARRIER CODE
12165
Insurance Policy
Information Page
POLICY NUMBER
❑ New
❑X Renewal
ElRewrite
Symbol:
WLR Number: C6 75 89 80 4
PREVIOUS POLICY NO.
❑ Individual
❑Partnership
❑Association
Symbol:
WLR Number: 066186167
❑X Corporation
—]Joint Venture
—]Other Legal Entity
Item 1.
F—TRINET GROUP, INC.
Inter/Intrastate ID No.:
Named
L/C/F SPIDR TECH, INC
Insured
9000 TOWN CENTER PARKWAY
Federal Employer ID No.: 953359658
BRADENTON FL
34202
Mailing
Address
I
Employer's ID No.:
PIIC CODE: 7372
For other named insured see Extension of Information Page — Schedule of Named Insured, WC 99 99 99 A
For other workplaces see Extension of Information Page — Schedule of Other Workplaces, WC 99 99 99 B
Item 2. Policy period: From 07-01-2020 To 07-01-2021 12:01 A.M., standard time at the named insured's mailing address.
Item 3A. Workers' Compensation Insurance: Part One of the policy applies to the Workers' Compensation Law of the states listed here:
CA
Item 313. 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 $ 2,000,000 each accident
Bodily Injury by Disease $ 2,000,000 policy limit
Bodily Injury by Disease $ 2,000,000 each employee
Item 3C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
ALL STATES EXCEPT
ND,OH,WA,WY,
AND STATES DESIGNATED IN ITEM 3.A
Item 31). This Policy includes these endorsements and schedules:
See schedule of Forms and Endorsements WC999999D
Item 4. The premium for this policy will be determined by our Manual of Rules, Classifications, Rates and Rating Plans. All information
required below is subject to verification and change by audit.
SEE EXTENSION OF INFORMATION PAGE —CLASSIFICATIONS
If indicated here, interim adjustments of premium will be made:
❑ Semi -Annually ❑ Quarterly ❑ Monthly
PRODUCER NAME AND MAILING ADDRESS
USI INSURANCE SERVICES LLC
2601 SOUTH BAYSHORE DRIVE
16TH FLOOR SUITE 1600
COCONUT GROVE FL 33133
PRODUCER CODE: 205455 13-3771734 DAU
MARKETING OFFICE: DALLAS BRANCH
ISSUE DATE: 07/09/2020
Minimum Premium collected in CA $
Total Estimated Premium $
Deposit Premium $
Authorized Representative
WC 00 00 0 1 A (05/88) Copyright 1987 National Council on Compensation Insurance
INSURED COPY