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PROOF OF INSURANCE (2021) CLOSEDPage 1 of 2
AC L> 06/
CERTIFICATE OF LIABILITY INSURANCE I DATE(MM/DD/YY
�,,.. 16/20200
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 (CONTACT Willis Towers Watson Certificate Center
NAME:
Willis Towers Watson Northeast, Inc. PHE
c/o 26 Century Blvd I (A/CNNo. Extl: 1-877-945-7378 (AJC, No): 1-888-467-2378
E-MAIL certificates@willis.com
P.O. Box 305191 ADDRESS:
Nashville, TN 372305191 USA I INSURER(S) AFFORDING COVERAGE NAIC#
IINSURERA: Great Northern Insurance Company 20303
INSURED
CivicPlus
302 S 4th Street, Suite 500
Manhattan, RS 66502
INSURERB: Federal Insurance Company 20281
INSURERC: Westchester Surplus Lines Insurance Compan 10172
I INSURER D:
I INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: W16830974 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR INSD WVD POLICY NUMBER IMM/DD/YYYYI (MM/DD/YYYYI
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 2,000,000
DAMAGESf RENTED
2,000,000
CLAIMS -MADE OCCUR
PREMISES (Ea occurrence)
$
A
MED EXP (Any one person)
$ 10,000
3602-53-12
05/17/2020 05/17/2021 PERSONAL & ADV INJURY
$ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,000
POLICY ❑ PRO ❑ LOC
JECT
PRODUCTS -COMP/OP AGG
$ 2,000,000
OTHER:
$
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
fEa accident)
$ 1,000,000
X ANY AUTO
BODILY INJURY (Per person)
$
B OWNED SCHEDULED
7358-87-92
05/17/2020 05/17/2021 BODILY INJURY (Per accident)
$
AUTOS ONLY AUTOS
HIRED NON -OWNED
PROPERTYDAMAGE
$
AUTOS ONLY AUTOS ONLY
fPer accident)
B UMBRELLALIAB X OCCUR
EACH OCCURRENCE
$ 5,000,000
X EXCESS LIAB CLAIMS -MADE
7989-49-14
05/17/2020 05/17/2021 AGGREGATE
$ 5,000,000
DED I X I RETENTION $ 0
$
WORKERS COMPENSATION
X I
AND EMPLOYERS' LIABILITY Y / N
B ANYPROPRIETOR/PARTNER/EXECUTIVE
SPER TATUTE EORH
E.L. EACH ACCIDENT
$ 1,000,000
OFFICER/MEMBER EXCLUDED? � N/A
(21) 7174-92-49
05/17/2020 05/17/2021
(Mandatory in NH)
E.L. DISEASE - EA EMPLOYEE
$ 1,000,000
If yes, describe under
1,000,000
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$
C Cyber Liability
F15611984 001
05/17/2020 04/30/2021 Each Claim/Aggregate
$5,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
This Voids and Replaces Previously Issued Certificate Dated 06/03/2020 WITH ID: W16737755.
Job Project Location: El Segundo, CA
For Division Branch: CivicRec
El Segundo, its officials, and employees are included as Additional Insureds as respects to General Liability and
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 El Segundo CA AUTHORIZED REPRESENTATIVE
350 Main Street
E1 Segundo, CA 90245
© 1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
SR ID: 19701555 BATCH: 1713462
AGENCY CUSTOMER ID:
LOC #:
ACORNADDITIONAL REMARKS SCHEDULE Page 2 Of 2
AGENCY NAMED INSURED
Willis Towers Watson Northeast, Inc. CivicPlus
302 S 4th Street, Suite 500
POLICY NUMBER I Manhattan, RS 66502
See Page 1
CARRIER NAIC CODE
See Page 1 See Page 1 I EFFECTIVE DATE: See Page 1
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance
Auto Liability.
General Liability and Auto Liability Policies shall be Primary to any other insurance in force for or which may be
purchased by Additional Insureds.
Waiver of Subrogation applies in favor of Additional Insureds with respects to Worker's Compensation, as permitted by
law.
ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
SR ID: 19701555 BATCH: 1713462 CERT: W16830974
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
Additional Insured -
Scheduled Person
Or Organization
MAY 17, 2020 TO MAY 17, 2021
MAY 17, 2020
3602-53-12 TPA
CIVICPLUS, LLC
GREAT NORTHERN INSURANCE COMPANY
MAY 15, 2020
Under Who Is An Insured, the following provision is added.
Persons or organizations shown in the Schedule are insureds; but they are insureds only if you are
obligated pursuant to a contract or agreement to provide them with such insurance as is afforded by
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 80-02-2367 (Rev. 5-07) Endorsement Page 1
CHUBB"
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 Insurance Additional Insured - Scheduled Person Or Organization last page
Form 80-02-2367 (Rev. 5-07) Endorsement Page 2
COMMERCIAL AUTOMOBILE
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
COMMERCIAL AUTOMOBILE BROAD FORM ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
This endorsement modifies the Business Auto Coverage Form
1. EXTENDED CANCELLATION CONDITION
Paragraph A.2.b. — CANCELLATION - of the
COMMON POLICY CONDITIONS form IL 00 17 is
deleted and replaced with the following:
b. 60 days before the effective date of cancellation if
we cancel for any other reason.
2. BROAD FORM INSURED
A. Subsidiaries and Newly Acquired or Formed
Organizations As Insureds
The Named Insured shown in the Declarations is
amended to include:
1. Any legally incorporated subsidiary in which
you own more than 50% of the voting stock on
the effective date of the Coverage Form.
However, the Named Insured does not include
any subsidiary that is an "insured" under any
other automobile policy or would be an
"insured" under such a policy but for its
termination or the exhaustion of its Limit of
Insurance.
2. Any organization that is acquired or formed by
you and over which you maintain majority
ownership. However, the Named Insured
does not include any newly formed or acquired
organization:
(a) That is an "insured" under any other
automobile policy;
(b) That has exhausted its Limit of Insurance
under any other policy; or
(c) 180 days or more after its acquisition or
formation by you, unless you have given
us written notice of the acquisition or
formation.
Coverage does not apply to "bodily injury" or
"property damage" that results from an "accident"
that occurred before you formed or acquired the
organization.
B. Employees as Insureds
Paragraph A.1. — WHO IS AN INSURED — of
SECTION II — LIABILITY COVERAGE is amended to
add the following:
d. Any "employee" of yours while using a
covered "auto" you don't own, hire or
borrow in your business or your personal
affairs.
C. Lessors as Insureds
Paragraph A.1. — WHO IS AN INSURED — of
SECTION II — LIABILITY COVERAGE is
amended to add the following:
e. The lessor of a covered "auto" while the
"auto" is leased to you under a written
agreement if:
(1) The agreement requires you to
provide direct primary insurance for
the lessor; and
(2) The "auto" is leased without a driver.
Such leased "auto" will be considered a
covered "auto" you own and not a covered
"auto" you hire.
However, the lessor is an "insured" only
for "bodily injury" or "property damage"
resulting from the acts or omissions by:
1. You;
2. Any of your "employees" or agents;
or
3. Any person, except the lessor or
any "employee" or agent of the
lessor, operating an "auto" with the
permission of any of 1. and/or 2.
above.
D. Persons And Organizations As Insureds
Under A Written Insured Contract
Paragraph A.1 —WHO IS AN INSURED — of
SECTION II — LIABILITY COVERAGE is
amended to add the following:
f. Any person or organization with respect to
the operation, maintenance or use of a
covered "auto", provided that you and
such person or organization have agreed
under an express provision in a written
"insured contract", written agreement or a
written permit issued to you by a
governmental or public authority to add
such person or organization to this policy
as an "insured".
However, such person or organization is
an "insured" only:
Form: 16-02-0292 (Rev. 11-16) Page 1 of 3
"Includes copyrighted material of Insurance Services Office, Inc. with its permission"
(1) with respect to the operation,
maintenance or use of a covered
"auto"; and
(2) for "bodily injury" or "property damage"
caused by an "accident' which takes
place after:
(a) You executed the "insured
contract' or written agreement; or
(b) The permit has been issued to
you.
3. FELLOW EMPLOYEE COVERAGE
EXCLUSION B.S. - FELLOW EMPLOYEE — of
SECTION II — LIABILITY COVERAGE does not apply.
4. PHYSICAL DAMAGE — ADDITIONAL TEMPORARY
TRANSPORTATION EXPENSE COVERAGE
Paragraph AA.a. —TRANSPORTATION EXPENSES
— of SECTION III — PHYSICAL DAMAGE
COVERAGE is amended to provide a limit of $50 per
day for temporary transportation expense, subject to a
maximum limit of $1,000.
5. AUTO LOAN/LEASE GAP COVERAGE
Paragraph A. 4. — COVERAGE EXTENSIONS - of
SECTION III — PHYSICAL DAMAGE COVERAGE is
amended to add the following:
c. Unpaid Loan or Lease Amounts
In the event of a total "loss" to a covered "auto", we will
pay any unpaid amount due on the loan or lease for a
covered "auto" minus:
1. The amount paid under the Physical Damage
Coverage Section of the policy; and
2. Any:
a. Overdue loan/lease payments at the time of
the "loss";
b. Financial penalties imposed under a lease for
excessive use, abnormal wear and tear or
high mileage;
c. Security deposits not returned by the lessor:
d. Costs for extended warranties, Credit Life
Insurance, Health, Accident or Disability
Insurance purchased with the loan or lease;
and
e. Carry-over balances from previous loans or
leases.
We will pay for any unpaid amount due on the loan or
lease if caused by:
1. Other than Collision Coverage only if the
Declarations indicate that Comprehensive
Coverage is provided for any covered "auto";
2. Specified Causes of Loss Coverage only if the
Declarations indicate that Specified Causes of
Loss Coverage is provided for any covered "auto";
or
3. Collision Coverage only if the Declarations indicate
that Collision Coverage is provided for any
covered "auto.
6. RENTAL AGENCY EXPENSE
Paragraph A. 4. — COVERAGE EXTENSIONS — of
SECTION III — PHYSICAL DAMAGE COVERAGE
is amended to add the following:
d. Rental Expense
We will pay the following expenses that you or
any of your "employees" are legally obligated
to pay because of a written contract or
agreement entered into for use of a rental
vehicle in the conduct of your business:
MAXIMUM WE WILL PAY FOR ANY ONE
CONTRACT OR AGREEMENT:
1. $2,500 for loss of income incurred by the
rental agency during the period of time that
vehicle is out of use because of actual
damage to, or "loss" of, that vehicle, including
income lost due to absence of that vehicle for
use as a replacement;
2. $2,500 for decrease in trade-in value of the
rental vehicle because of actual damage to
that vehicle arising out of a covered "loss"; and
3. $2,500 for administrative expenses incurred
by the rental agency, as stated in the contract
or agreement.
4. $7,500 maximum total amount for paragraphs
1., 2. and 3. combined.
7. EXTRA EXPENSE — BROADENED COVERAGE
Paragraph A.4. — COVERAGE EXTENSIONS — of
SECTION III — PHYSICAL DAMAGE COVERAGE
is amended to add the following:
e. Recovery Expense
We will pay for the expense of returning a
stolen covered "auto" to you.
8. AIRBAG COVERAGE
Paragraph B.3.a. - EXCLUSIONS — of SECTION
III — PHYSICAL DAMAGE COVERAGE does not
apply to the accidental or unintended discharge of
an airbag. Coverage is excess over any other
collectible insurance or warranty specifically
designed to provide this coverage.
9. AUDIO, VISUAL AND DATA ELECTRONIC
EQUIPMENT - BROADENED COVERAGE
Paragraph C.1.b. — LIMIT OF INSURANCE - of
SECTION III - PHYSICAL DAMAGE is deleted
and replaced with the following:
b. $2,000 is the most we will pay for 'loss" in any
one "accident' to all electronic equipment that
reproduces, receives or transmits audio, visual
or data signals which, at the time of "loss", is:
(1) Permanently installed in or upon the
covered "auto" in a housing, opening or
other location that is not normally used by
the "auto" manufacturer for the installation
of such equipment;
(2) Removable from a permanently installed
housing unit as described in Paragraph
2.a. above or is an integral part of that
equipment; or
(3) An integral part of such equipment.
10. GLASS REPAIR —WAIVER OF DEDUCTIBLE
Form: 16-02-0292 (Rev. 11-16) Page 2 of 3
"Includes copyrighted material of Insurance Services Office, Inc. with its permission"
Under Paragraph D. - DEDUCTIBLE — of
SECTION III — PHYSICAL DAMAGE COVERAGE
the following is added:
No deductible applies to glass damage if the glass
is repaired rather than replaced.
11. TWO OR MORE DEDUCTIBLES
Paragraph D.- DEDUCTIBLE — of SECTION III —
PHYSICAL DAMAGE COVERAGE is amended to
add the following:
If this Coverage Form and any other Coverage
Form or policy issued to you by us that is not an
automobile policy or Coverage Form applies to the
same "accident", the following applies:
1. If the deductible under this Business Auto
Coverage Form is the smaller (or smallest)
deductible, it will be waived; or
2. If the deductible under this Business Auto
Coverage Form is not the smaller (or smallest)
deductible, it will be reduced by the amount of
the smaller (or smallest) deductible.
12. AMENDED DUTIES IN THE EVENT OF
ACCIDENT, CLAIM, SUIT OR LOSS
Paragraph A.2.a. - DUTIES IN THE EVENT OF
AN ACCIDENT, CLAIM, SUIT OR LOSS of
SECTION IV - BUSINESS AUTO CONDITIONS is
deleted and replaced with the following:
a. In the event of "accident", claim, "suit" or
"loss", you must promptly notify us when the
"accident" is known to:
(1) You or your authorized representative, if
you are an individual;
(2) A partner, or any authorized
representative, if you are a partnership;
(3) A member, if you are a limited liability
company; or
(4) An executive officer, insurance manager,
or authorized representative, if you are an
organization other than a partnership or
limited liability company.
Knowledge of an "accident", claim, "suit" or
"loss" by other persons does not imply that the
persons listed above have such knowledge.
Notice to us should include:
(1) How, when and where the "accident" or
"loss" occurred;
(2) The "insured's" name and address; and
(3) To the extent possible, the names and
addresses of any injured persons or
witnesses.
13. WAIVER OF SUBROGATION
Paragraph A.S. - TRANSFER OF RIGHTS OF
RECOVERY AGAINST OTHERS TO US of
SECTION IV — BUSINESS AUTO CONDITIONS is
deleted and replaced with the following:
5. We will waive the right of recovery we would
otherwise have against another person or
organization for "loss" to which this insurance
applies, provided the "insured" has waived
their rights of recovery against such person or
organization under a contract or agreement
that is entered into before such "loss".
To the extent that the "insured's" rights to
recover damages for all or part of any
payment made under this insurance has not
been waived, those rights are transferred to
us. That person or organization must do
everything necessary to secure our rights and
must do nothing after "accident" or "loss" to
impair them. At our request, the insured will
bring suit or transfer those rights to us and
help us enforce them.
14. UNINTENTIONAL FAILURE TO DISCLOSE
HAZARDS
Paragraph B.2. — CONCEALMENT,
MISREPRESENTATION or FRAUD of SECTION
IV — BUSINESS AUTO CONDITIONS - is deleted
and replaced with the following:
If you unintentionally fail to disclose any hazards
existing at the inception date of your policy, we will
not void coverage under this Coverage Form
because of such failure.
15. AUTOS RENTED BY EMPLOYEES
Paragraph B.S. - OTHER INSURANCE of
SECTION IV — BUSINESS AUTO CONDITIONS -
is amended to add the following:
e. Any "auto" hired or rented by your "employee"
on your behalf and at your direction will be
considered an "auto" you hire. If an
"employee's" personal insurance also applies
on an excess basis to a covered "auto" hired
or rented by your "employee" on your behalf
and at your direction, this insurance will be
primary to the "employee's" personal
insurance.
16. HIRED AUTO — COVERAGE TERRITORY
Paragraph B.7.b.(5). - POLICY PERIOD,
COVERAGE TERRITORY of SECTION IV —
BUSINESS AUTO CONDITIONS is deleted and
replaced with the following:
(5) A covered "auto" of the private passenger
type is leased, hired, rented or borrowed
without a driver for a period of 45 days or
less; and
17. RESULTANT MENTAL ANGUISH COVERAGE
Paragraph C. of - SECTION V — DEFINITIONS is
deleted and replaced by the following:
"Bodily injury" means bodily injury, sickness or
disease sustained by any person, including
mental anguish or death as a result of the "bodily
injury" sustained by that person.
Form: 16-02-0292 (Rev. 11-16) Page 3 of 3
"Includes copyrighted material of Insurance Services Office, Inc. with its permission"
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13
(Ed. 4-84)
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
Any person or organization for which the employer has agreed
by written contract, executed prior to loss, may execute a
waiver of subrogation
For policies or exposure in Missouri:
Any person or organization for which the employer has agreed by written contract, executed prior to loss,
may execute a waiver of subrogation. However, for purposes of work performed by the employer in
Missouri, this waiver of subrogation does not apply to any construction group of classifications as
designated by the waiver of right to recover from others (subrogation) rule in our manual.
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 05-17-20 Policy No. (21) 7174-92-49 Endorsement No.
Insured CIVICPLUS , LLC Premium $ Incl.
Insurance Company Federal Insurance Company
WC 00 03 13
(Ed. 4-84)
© 1983 National Council on Compensation Insurance.
Countersigned By
Insured Copy