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PROOF OF INSURANCE (2021 - 2021) CLOSED.. a'' � DATE IMMIDDIYYYY)
�-, CERTIFICATE OF LIABILITY INSURANCE 9/16/2020
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(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 CONCT
NAME: Christian Brothers Services
Artex Risk Solutions, Inc. (CB) PHHOA Epp
800-807-0300
2850 Golf Road, 5th Floor E Ftp
CArc plop: 630 378-2508
Rolling Meadows IL 60008-4050ss;,.,.,,,
...............................
INSURER(S) AFFORDING COVERAGE NAIC #
IN.au.B.E.a..Ivanla Manufacturers Assoc Ins Co 12262
.^....Penns.Y .
INSURED CHRIBRO-14 INSURER B c Old Re UbIIC.II1SUrance Compan 24147
Brothers of the Christian Schools & Affiliates P....................................................................y...........................
Loc #1177028 DOC POW ST VINCENT SENIOR CITIZEN NTR las,uR,eR.9.:....................................................................................................................................
1205 Windham Parkway INSURER D:
Romeoville IL 60446-1679 INSURERE:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 2024388489 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 IERTAIN, 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.
.....................LIMITS...................... .. � � � .......... ...I-,
ILTR GtN RSR..........•"' POLICY OF 06UdY�E%P
TYPE OF INSURANCE WVD POLICY NUMBER IMMIDDNYh"Yp IM'MIDDIYYYYY
A X COMMERCIAL GENERALLIABILITYY 8220000998922 6/15/2020 6/15/2021 EACH OCCURRENCE $4,000„000
�I CLAIMS -MADE X..J OCCUR Ph Mb$O ra� uggr,race)......m. m$mmincluded...................................
MED EXP (Any one person)$...15u.0.0........................................
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Only the General Liability Coverage will apply on a Primary and Non -Contributory basis (per attached endorsement) if required by fully executed written
contract. Certificate Holder is added as Additional Insured (per attached endorsement) for General Liability and Automobile liability coverages solely, strictly and
specifically with regards to:
C'onsuitant Services for the Community Development Block Grant Program for Home Delivered Meals.
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 its Official and Employees Office of City ACCORDANCE WITH THE POLICY PROVISIONS.
Clerk
350 Main Street AUTHORIZREPRESENTATIVE
IIEI Segundo CA 90245
©1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
PERSONAL & ADV INJURY $ Included„ ..............
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $ N/A
POLICY D JPECO” 7 LOC
.. ............................
...P..R.OD.T.S.-...CO.M.P..P.AGG�.$.I.n...c....l.u....d....e...d
OT'HEH.
'
$
AUTOMOBILE LIABILITYCOMBINED
Y MWTB 21543
Bk d;SINGLELuMIP 1
I
6/15/2020 6/15/2021 $ 1,000,000
iE....u,,,....
X ANY AUTO
BODILY INJURY (Per person) $
OWNED SCHEDULED
BODILY INJURY ccident) '',, $
a
_ AUTOS ONLY AUTOS
X HIRED NON -OWNED
PROPERTY DAMACE.................m.,......
$
AUTOS ONLY „XAUTOS ONLY
VPer acedeual7
UMBRELLALIAB CCURAGREGATE
RENCE $
............. CLAIMS -MADE
EXCESS LIAR
A...............
..................._......................................................
DED( � RETENTION$.......................................
$
�....
WORKERS COMPENSATION
(PER �I � OTH-
AND EMPLOYERS' LIABILITY YIN
,,,S.T,.A,,,TIJTE,LI,,,__ „F.R
........._..V
ANYPROPRIETOR/PARTN ERIEXECUTIVE
HA $
BE EXCLUDED? NIA
OFFICER///MEM
(Mandatory )
Ej� DISEASE
E - EA EMPLOYEE' $
If yes, descnbe under
DESCRIPTION OF OPERATIONS below
E L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Only the General Liability Coverage will apply on a Primary and Non -Contributory basis (per attached endorsement) if required by fully executed written
contract. Certificate Holder is added as Additional Insured (per attached endorsement) for General Liability and Automobile liability coverages solely, strictly and
specifically with regards to:
C'onsuitant Services for the Community Development Block Grant Program for Home Delivered Meals.
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 its Official and Employees Office of City ACCORDANCE WITH THE POLICY PROVISIONS.
Clerk
350 Main Street AUTHORIZREPRESENTATIVE
IIEI Segundo CA 90245
©1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
PENNSYLVANIA MANUFACTURERS'
ASSOCIATION INSURANCE COMPANY
Attaching to and forming part of Policy No. 822000 0998922
Named Insured: THE RELIGIOUS AND CHARITABLE RISK POOLING TRUST OF THE BROTHERS OF THE
CHRISTIAN SCHOOLS AND AFFILIATES
Effective date of this endorsement is June 15, 2020
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED
SCHEDULED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under SECTION II INSURING AGREEMENT C, GENERAL LIABILITY
COVERAGE defined within the Coverage Agreement
SECTION 1: Schedule
..................................
Name of Additional Insured Persons(s) or Designated Location(s) Of Covered Operations:
Organization(s):
ANY PERSON OR ORGANIZATION WHEN YOU
HAVE AGREED IN A WRITTEN CONTRACT FOR
THAT PERSON OR ORGANIZATION TO BE ADDED
AS AN ADDITIONAL INSURED ON YOUR POLICY.
If Ilii 11 11
v a l II:)CWe IIIIIi( I' I 11@010 II V� (;,I4.,IIV 1) ;xIi 11lll�1 fl 11 Is FilIIdcI IYlie! lll �o VII 11hP C l: 11:�III "r 1116 11, 1 e 11 ;r;:V" 11) ::1 Ile (III V ui a Vyi,,l !Ju!
I I p l i c. a, 111 t1;. V 111 0 rn",'ti;:,o III k l" If
Section II Insuring Agreement C -Name of Insured Amended
Who Is Alyn insured defined In the (.:general Insurance Agreement is amended to include as an AddihonKal Insured [he
person(s) or organi,rabon(s) shown in the ;schedule above but only with respect to liability in the performance of the
Narned Insured's ongoing operations for thle Additional Insured(s) at the I....ocation(s) designated in the Schc:da..rle above
for "bodily injury" or "property damage;", c,.aused In whole or in part, try the Narned insured's acts or ornissions which
takes place after the execution of a written agreement With the Additional Insured(s)
B. For the coverage provided by this endorsement the following paragraph is added to Section IV General
Conditions, Section sill, Insuring Agreement C -General l lability
l his insurance is primary insurance as respects to this coverage to the additional insured person or organization,
where the written contract or written agreement requires that this insurance be primary and noncontributory In that
event, we will not seek contribution from any other insurance policy available to the additional insured can which the
additional insured person or organization is a Narned Insured
C. Who is Aini Insured is also amended to include as an additional insured the person(s) or organization(s) shown In the
Schedule, with respect to liability forr "bodily injury" err "propertydainaage" caused, in whole or in part by the, "Named
Insureds work" at the location designated and described in thin•, schedule of this endor"sement: performed for that
additional insured and Included in the "products completed operations hazard"
the most we will pay is the arnount of insurance recti..lired by the written contract or the amount of applicable limits of
insurance under this policy; whichever is less
This lnsuirance, does not apply to any claims or suits seeking darrrages, Including defense, arising out of, directly or Indirectly,
frorn any actual or alleged participation rn any act of sexual misconduct, ese,xual harassment, sexual molestation, sexual abuse
or any claim sexual in nature., physical or meatal, of any person.
Except as amended in thtis endoarsement this insurance is subject to all coverage terms. clauses and conditions in the
policy to which this endorsernent is attached and only applies to tho extent permitted by law
IL 10 (12/06) OLD REPUBLIC INSURANCE COMPANY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY,
ADDITIONAL INSURED
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
SCHEDULE
Name of Person(s) or Organization (s):
All persons or organizations as required by contract or agreement
With respect to COVERED AUTOS LIABILITY COVERAGE, Who Is An Insured is changed with the
addition of the following:
Each person or organization shown in the Schedule for whom you are doing work is an "insured". But
only for "bodily injury" or "property damage" that results from the ownership, maintenance or use of a
covered "auto" by:
1. You;
2. an "employee" of yours; or ,
3. anyone who drives a covered "auto" with your permission or with the permission of one of your
"employees".
However, the insurance afforded to the person or organization shown in the Schedule shall not exceed
the scope of coverage and/or limits of this policy. Not withstanding the foregoing sentence, in no event
shall the insurance provided by this policy exceed the scope of coverage and/or limits required by the
contract or agreement.
PCA 001 10 13
MWTB 21543 Religious and Charitable Risk Pooling Trust 06/15/2020 - 06/15/2021
a
"= �'�'`�"' CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY)
AR
12/2/2019
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.
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
Ap) ex Risk Solutions, Inc. CB P.-,.dN,,,C 180'an Brothers Services
2850 Golf Road, 5th Floor ( >� ^.... 00.807-0300 ,,NoiI 630.378-2508
Rolling Meadows IL 60008-4050 ADDRESS.
NSURER(3) AFFORDING COVERAGE NAIC #
INSURERA: Old Republic„Insurance ComP.anY... 24147
INSURED CHRIBRO-14 INSURER B:
Brothersof the Christian Schools & Affiliates INSURER c...................................................................................................................................................
1Loc #1177028 205 Windham POI OW ST VINCENT SENIOR CITIZEN NTR arkway INSURER
,o..................................................................................................................
................ .�...........,..,,.............
INSURE
Romeoville IL 60446-1679 II RE:
p INSURER F :
COVERAGES CERTIFICATE NUMBER: 15726475 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.
INSPOLICYRR TYPE OF INSURANCE D )” .... , EFF r PoCfc y- IT
....................NSD �N.YP
POLICY NUMBER � AM'MIIODNYYI(1'a IM'�M/DCd1Y, PA"1 LIM S
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS -MADE III OCCUR PREMISES ( a QWq enre,),,,,,,,,,,,,,,,,,,,,,,$
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO' LOC
JECT
OTHER:
AUTOMOBILE LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AT
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
UMBRELLALIAB Y OCCUR
EXCESS LIAB fl CLAIMS -MADE
�,-DED L..RETENTION.$....-�...................,
A WORKERS COMPENSATION Y MWC 305311 05
AND EMPLOYERS' LIABILITY Y f N
ANYPROPRIETOR/PARTNERIEXECUTIVE P, NJ N/A
OFFICERIMEMBEREXCLUDED? �I
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
1/1/2020
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
PRODUCTS - COMP/OP AGG $
COMBINED SINGLE LIMIT $
BODILY INJURY (Per person) $
BODILaccident)
.. $
046�� 64446E $
ENC. .. ,........
AGGREGATE
GG RE GATE ...........................................
$
1/112021 XI ( STATUTE ERH
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)
Wavier of Subrogation, per the attached endorsement, (where allowed by law) is provided under the Worker's Compensation coverage when required by fully
executed written contract.
Evidence of Coverage
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, its officials and employees ACCORDANCE WITH THE POLICY PROVISIONS.
Office of the City Clerk
............
350 Main St A'UTHORI,BREPRESENTATIVE
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
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06
(Ed. 0484)
POLICY NUMBER: MWC 305311 05
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -
CALIFORNIA
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.)
You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the
work described in the Schedule.
The additional premium for this endorsement shall be 0 % of the California workers' compensation premium
otherwise due on such remuneration.
SCHEDULE
PERSON OR ORGANIZATION
ALL PERSONS OR ORGANIZATIONS WHERE
REQUIRED BY WRITTEN CONTRACT
DATE OF ISSUE: 11-01-19
JOB DESCRIPTION
©1998 by tha Workers' Compensation Insurance Rating Bureau of California. All rights reserved.
From the WCIRB's California Workers' Compensation Insurance Forms Manual © 1999.
INSURED COPY