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PROOF OF INSURANCE (2021 - 2021) CLOSEDSOUTBAY-03 LENG'LISH CERTIFICATE OF LIABILITY INSURANCE DATE 12/24/2020 Y) 12/24/2020 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 certificatedoes not confer rights to the certificate holder in lieu of such endorsementlSL .............................. _.._........ _._. — PRODUCERIe 41ACT. Arroyo Insurance Services - LA PHONE PA�x 2900 W Broadway I (323,),550-7900 550-7 00 Inc Ne),(323) 256-0800 Los Angeles, CA 90041 tNSS, INSURED South Bay Children's Health Center Association, Inc. 410 S. Camino Real Redondo Beach, CA 90277 INSURE (S) AFFORDING COVERAGE, N'AIC rr j INSURERA� Nonprofits Insurance Alliance oaf California NSuRER8:Hartford Accident -& Indemnity- 22357 INSURER C,: INSURER D NNS .... i� INSURER E'.: INSURER F COVERAGES CERTIFICATE NUMBER: 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 r INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICA1 E MAY BE ISSUED 185 THE PO CRIB ALL THE TERMS INTaEXCLUSIONSTMNDCONDITIONS ��OF SUCH SR ADDL,sUBI� IM TS BROWNNUMBER NUM SAVE BEEN REDUCED BY PAIEFF D CLAIMS SLIMITS R MAY PERTAIN, � T)�Il�htrR ED HEREIN IS SUBJECT TO PE POLIC A X COMMERCIAL GENERAL LIABILITY f E $ 1,000,000 EACHIDCCURIREN CLAIMS -MADE XOCCUR 2020-15361 3/31/2020 3/31/2021 1 DAMAGE TO RENTED 500,000 X ?,iREMISES,(EaLaeeurreme,) S 20 000 GEN't. AGGIRFOA l"E LIMIT APPLIES PER: I X POLICYCT LOC A AUTOMOBILE LIABILITY ANY AUTO 2020-15361 OWNED SCHEDULED AUTOS ONLY ( AUTOS L X A19�(U4 S ONLYX I AGJ7N'CiC��N�N' ....................................... X UMBRELLALIAB X OCCUR AEXCESS .. A AB S -MADE 2020-15361-UMB DED LI CLAIM RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY I'.N 72WECAC4JWJ ANY PROPRIETOR/PARTNERIEXECUTIVE I" i X �naERIMEMBER EXCLUDED9 NIA ackatory In NH) I .�Riiunder IEaAru011 "MedicallllExoense” coverage LOCATIONS is EIXCLUDED for inmates, PATIENT ( Remarks Schedule, may be attached fi ...�.. more space is required) p g TS or prisoners, Improper Sexual Conduct Liability $1,000,000 Each Occurence $3,000,000 Aggregate Liquor Liability SEE ATTACHED ACORD 101 CERTIFICATE HOLDER' City of EI Segundo, CDBG Grant Attn: Tina Gall PLanning and Building Safety Department 350 Main Street EI Segundo, CA 90245 1,000„000 3,000,000 3000,000 1,000„000 1,000,000 1,000,1000 1,000,000; 1,000,000 0,00 u L I I ........... .. 1 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE N THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN a ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ACORD 25(2016/03) ................ ............... 0.1.98........ _. ...... --: .... 8-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD MED .(Any one per;ropro $ P[RSON . AL,& ADV INJURY � S GENERAL AGGREGAIV,' . $1 PRODUCTS - CO'MN•""iOP AGG S ........... _. -_. _ — ............L .... _..... i"OMBNNED SNNGLF LIMIT NEa aC'edf qnI) 3/31/2020 3/31/2021 „ BODILY INJURY (Por-pe,rsen), 3 BODILY INJURY RPer aAGEncN�etnt) :„ $ .. OPERT Y PE .ISIeYUI,) „ S rtY $ EACH OCCURRENCE $' 3/31/2020 3/31/2021 AGGREGATE $ ,............ — — XPER. , ' E�tµl 12/1/2020 12/1/2021 ,TPT F4, EACH ACCIDENT IN E.L: DISEASE -Eh E,MPN.O'MEI:: 6, EL DISEASE....-PO,I ICY � N� MIfI "MedicallllExoense” coverage LOCATIONS is EIXCLUDED for inmates, PATIENT ( Remarks Schedule, may be attached fi ...�.. more space is required) p g TS or prisoners, Improper Sexual Conduct Liability $1,000,000 Each Occurence $3,000,000 Aggregate Liquor Liability SEE ATTACHED ACORD 101 CERTIFICATE HOLDER' City of EI Segundo, CDBG Grant Attn: Tina Gall PLanning and Building Safety Department 350 Main Street EI Segundo, CA 90245 1,000„000 3,000,000 3000,000 1,000„000 1,000,000 1,000,1000 1,000,000; 1,000,000 0,00 u L I I ........... .. 1 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE N THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN a ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ACORD 25(2016/03) ................ ............... 0.1.98........ _. ...... --: .... 8-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: SOUTBAY-03 LENGLISH LOC #: AC40RO" ADDITIONAL REMARKS SCHEDULE Page 1 of 1 - — -------- . ......... AGENCY NAMEDINSUREO Arroyo Insurance Services - LA South Bay Children's Health Center Association, Inc. 410S. Camino Real POLICY NUMBER Redondo Beach, CA 90277 SEE PAGE I CARRIER NAIC CODE SEE PAGE I 'SEE P I EFFECTIVE DATE' ...........m.._ . . ......... . . ........ U-RAGEA ADDITIONAL REMARKS . ......... ........m......—........,...,............._...... THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: A_qORD 2,5 FORM TITLE: Certifica : to of Uab - ifity I ins rr urance Description of Operations/Locations/Vehicles: $1,000,000 Each Occurrence $3,000,000 Aggregate City of El Segundo, CDBG Grant is included as additional insured' as respects General Liability coverage; Waiver of Subrogation is included as respects Workers Compensation Coverage for the City of El Segundo, CDBG Grant, only as per attached endorsements. 'ACORD 101 (2008/01) C 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 2020-15361 COMMERCIAL GENERAL LIABILITY Named Insured.- South Bay Children's Health Center Association, Inc. CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. I 1 9 1 L a I A 1111111 lZM1 L1 -0.1cf,�wUl I NNAAAA 9 De Nk This endorsement modifies insurance provided under the following: X*1A11T,FXa*_W1 ii Name Of Additional Insured Person(s) Or Organization(s): Any person or organization that YOU are required to add as an additional insured on this policy, under a written contract or agreement currently in effect, or becoming effective during the term of this policy. The additional insured status will not be afforded with respect to lialtflity arising out of or related to YOUF activities as a real estate manager for that person or organization. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section 11 — 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 IjaWlty for "bodily injury", "property damage" or "personal, and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or ornissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. 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: 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. CG 20 26 0413 Q Insurance Services Office, Inc., 2012 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -CALIFORNIA Policy Number: 72 WEC AC4JWJ Endorsement Number: Effective Date: 12/01/19 Effective hour is the same as stated on the Information Page of the policy Named Insured and Address: South Bay Children's Health Center Association Inc 410 CAMINO REAL REDONDO BEACH CA 90277 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 Linder 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 2 % of the California workers' compensation premium otherwise due on such remuneration. Person or Organization Job Description Any person or organization from whom you are required by written contract or agreement to obtain this waiver of rights from us Countersigned by Form WC 04 03 06 (1) Printed in U.S.A. Process Date: 10/22119 Authorized Representative Policy Expiration Date: 12/01/20