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PROOF OF INSURANCE (2021) CLOSEDAC�"R" CERTIFICATE OF LIABILITY INSURANCE I DAT7i2s/zozo 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. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) 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 NAME: Marsh & McLennan Agency LLC PHONE FAX 9850 N.W. 41 st Street I (A/C. No. Exn: 305-591-0090 I (A/c, Ne): Suite 100 I ADDRESS: certsmiami(o7mma-fl.com Miami FL 33178 I INSURER(S) AFFORDING COVERAGE NAIC# INSURERA: Berkshire Hathaway Homestate Ins Co 20044 INSURED WESTE1 Western State Design, Inc INSURER B: Liberty Mutual Fire Insurance Company 23035 dba Western State Design Construction Company I INSURER C: 2331 Tripaldi Way I INSURER D: Hayward CA 94545 I INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 485291235 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 rypE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSD WVD POLICYNUMBER (MM/DDNYYYI (MM/DD/YYYYILIMITS B X COMMERCIAL GENERAL LIABILITY Y TB2Z61065325100 7/1/2020 7/1/2021 EACH OCCURRENCE $ 1 000 000 = CLAIMS -MADE Fx] OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- ECT EO � LOC OTHER: B AUTOMOBILE LIABILITY X ANY AUTO OWNEDSCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY B X UMBRELLALIAB OCCUR EXCESS LIAB CLAIMS -MADE DED I X I RETENTION $ n A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTN ER/EXECUTIV E OFFICER/MEMBEREXCLUDED? N / A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below AS2Z61065325020 TH7Z61065325060 Y WEWC113628 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OPAGG $2,000,000 7/1/2020 7/1/2021 COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Per accident) 7/1/2020 7/1/2021 EACH OCCURRENCE $5,000,000 AGGREGATE $ 5,000,000 $ 7/1/2020 7/1/2021 X I PER ERH I E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE- EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) RE: Fire Station #1 - 314 Main Street, EI Segundo CA 90245; Fire Station #2 - 2261 E. Mariposa Ave., EI Segundo, CA 90245 City of EI Segundo, its officials, and employees, as Owner/Lessee/Contractor, are Additional Insured as respects General Liability (including Ongoing and Completed Operations) when required by written contract subject to the term, conditions and exclusions of the policy. General Liability is primary and non-contributory when required by written contract subject to the terms, conditions and exclusions of the policy. 30 Day notice of Cancellation in favor of Additional Insured as respects General Liability as required by written contract subject to the terms, conditions and exclusions of the policy. Waiver of subrogation as respects Workers Compensation in favor of Additional Insured when required by written contract subject to the terms, conditions and exclusions of the policy. CERTIFICATE HOLDER 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. City of EI Segundo 2261 E. Mariposa Avenue AUTHORIZED REPRESENTATIVE EI Segundo CA 90245 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: TB2-Z61-065325-100 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 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: Name Of Additional Insured Person(s) Or Organization(s): 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. 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 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. SCHEDULE The State of California, the Trustees of the California State University, California State University East Bay (CSUEB) and the officers, employees, volunteers and agents of each of them. Location(s) Of Covered Operations 25800 Carlos Bee Blvd. Hayward, CA 94542 Re: Service Agreement Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 20 10 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: TB2-Z61-065325-1 00 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 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 PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART 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" 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". 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 is added to Section III — Limits Of Insurance: SCHEDULE 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 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. Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operations Services Agreement 1 Research Drive Westborough, MA 01581 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. CG 20 37 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 1 Policy Number TB2-Z61-065325-100 Issued by Liberty Mutual Fire Insurance Co. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. OTHER INSURANCE AMENDMENT —SCHEDULED ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART If you are obligated under a written agreement to provide liability insurance on a primary, excess, contingent, or any other basis for any person(s) or organization(s) shown in the Schedule of this endorsement that qualifies as an additional insured on this Policy, this Policy will apply solely on the basis required by such written agreement and Paragraph 4. Other Insurance of Section IV — Conditions will not apply. Where the applicable written agreement does not specify on what basis the liability insurance will apply, the provisions of Paragraph 4. Other Insurance of Section IV — Conditions will apply. However, this insurance is excess over any other insurance available to the additional insured for which it is also covered as an additional insured for the same "occurrence", claim or "suit". Schedule Name of Porson(s) or Organization(s): All persons or organizations with whom you have entered into a written contract or agreement, prior to an "occurrence" of offense, to provide additional insured status. LC 24 2011 18 © 2018 Liberty Mutual Insurance Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC990410C (Ed. 01-19) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -CALIFORNIA BLANKET BASIS 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.) The additional premium for this endorsement shall be calculated by applying a factor of 2% to the total manual premium, with a minimum initial charge of $350, then applying all other pricing factors for the policy to this calculated charge to derive the final cost of this endorsement. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule Blanket Waiver Person/Organization Blanket Waiver — Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. Job Description Waiver Premium (prior to adjustments) All CA Operations 6921.00 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: 07/01/2020 PolicyNo.: WEWC113628 Endorsement No.: Insured: Premium $ Insurance Company: Berkshire Hathaway Homestate Ins Co Countersigned by WC990410C (Ed. 01-19)