PROOF OF INSURANCE (2021) CLOSEDDATE (MM/DDNM)
A�Ra CERTIFICATE OF LIABILITY INSURANCE
9/ 1 /2021 8/31 /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 LOCKTON COMPANIES CONTNAMEACT
3657 BRIARPARK DRIVE, SUITE 700 PHONE F
HOUSTON TX 77042 EMA4.i1t1
866-260-3538 APIP _
_ ...........................I.... OVE E .............-__ NAIL #
-......... INSURERISI,A,FFO.F2,U,�,N.G..�.._----RA,G.............................. ........-
INSURER A, Atlantic Specialty Insurance COgTgpy ............. . _ 27154
INSURED CSA Service Solutions, LLC. Percy Casualty Co of America - 25674
1462664 INSURER B . Travelers Pro — .....
9208 Waterford Centre Blvd, #150 iNsuReR c
.... - .. � ....
Austin TX 78758 INSURER D
INSURER E
INSURER F :
COVERAGES CERTIFICATE NUMBER: 16127253 REVISION NUMBER: XXXXXXX
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.
................ __............, .,. ._m.mm.. . e . _.. ...... .---- ------ ..._...
'INSlU """" Kd L GS"i��m_-�- POLICY EFF �� POLItYEXP LIMITS.......
TR o0 TYPE OF INSURANCE P POLICY NUMBER MMIDDIYYYY MMIDD
A
X
COMMERCIAL GENERAL. LIABILITY
y
Y
711012081-0010 9/1/2020
9/1/2021
EACH OCCURRENCE $ 1,000,000
I
1 000,000
CLAIMS -MADE X ,Q OCCUR
, I9(ae $
ggMDEX(n9r!2.RT on) . $ .A900 ..I-----
_
PERSONAL & ADV INJURY 1,000,000
GEN'
T
LAGGREG❑ATEPROI-
GENEX.. f 0
00
°
F_,_1IES ®C.
POLICY JECtt
--$
RODUCTSCCOMP/AOP AGG $ 2 000 00 ..
P., _...........___________.....
OTHER°
AUTOMOBILE
n..,.
LIABILITY
NOT APPLICABLE
COMBINED SINGLE LIMIT $
Es aerddent) XXXXXXX...
ANY AUTO
BODILY INJURY (Per person) $ XXXXXXX
OWNED SCHEDULED
BODILY INJURY (Per accident) ' $XXXXXXX
AUTOS ONLY AUTOS
HIRED NON -OWNED
---- .. .....
-' ROPEktf DAJ ACE:
$XXXXXXX
AUTOS ONLY AUTOS ONLY
{1"!3m tacv.kda�n@I
$ XXXXXXX
A
UMBRELLA LIAR
X X occ
Y
Y
711012081-0010
9/1/2020
9/1/2021
EACH occ $
EACHO C RRENCE 10,,000 000
EXCESS LIAB IpL_J{I Ms -MADE
I'llCLAI
E . $ t9al ,000
DIED RETENTION $
$ XXXXXXX
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
Y
UB-006N98422A
9/1/2020
9/1/2021
PER 1 OTH-
_X sT�ATUTE �RANY _
Y / N
ECUTIVE
E 0
$ 1000 000
OFFICER/MEMBER EXCLUDED N
(Mandatory in NH)
N/A
n„
L DISEASECID1 EM -�O00000
E PLOYEE $ 1 00
0 ...
If yes, describe under
DESCRIPTION OF OPERATIONS below
...
E.L, DISEASE - POLICY LIMIT $ 1, 000 000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
16127253
City of El Segundo
350 Main Street, Room 5
El Segundo CA 90245-3813
ACORD 25 (2016/03)
CANCELLATION See Attachment
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATtlV
01988-2015 ACORD CORP'ORATIOR, All rights reserved.
The ACORD name and logo are registered marks of ACORD
Attachment Code: D565158 Master ID: 1462664, Certificate ID: 16127253
The General Liability and Umbrella Liability policies include a blanket automatic additional insured
[provision] that confers additional insured status to the certificate holder only if there is a written contract
between the named insured and the certificate holder that requires the named insured to name the
certificate holder as an additional insured. In the absence of such a contractual obligation on the part of
the named insured, the certificate holder is not an additional insured under the policy.
The General Liability, Umbrella Liability, and Workers' Compensation/EL policies include a blanket
automatic waiver of subrogation endorsement [provision] that provides this feature only when there is a
written contract between the named insured and the certificate holder that requires it. In the absence of
such a contractual obligation on the part of the named insured, the waiver of subrogation feature does not
apply.
The General Liability policy contains a special endorsement with "primary and noncontributory" wording.
c. The following is added to Section III — Limits Of Insurance:
The most we will pay on behalf of a vendor that qualifies as an additional insured is the amount of
insurance:
a. Required by the contract or agreement; or
b. Available under the applicable Limits of Insurance shown in the Declarations;
whichever is less. This provision does not increase the applicable Limits of Insurance shown in the
Declarations.
3. Additional Insured —Written Contract, Agreement, Permit or Authorization
a. Section II — Who Is An Insured is amended to include as an additional insured any person or
organization with whom you have agreed in a written contract, agreement, permit or authorization to
provide insurance but only with respect to liability for injury or damage caused, in whole or in part,
by your acts or omissions or the acts or omissions of those acting on your behalf for:
(1) 'Bodily injury', "property damage" or "personal and advertising injury" in the performance of your
ongoing operations, and only until your operations are completed, for such person or
organization at the location designated in the contract, agreement, permit or authorization;
(2) 'Bodily injury', "property damage" or "personal and advertising injury' in the maintenance,
operation or use of equipment leased to you by such person or organization; or
(3) `Bodily injury', "property damage" or "personal and advertising injury' in connection with
premises you own, rent, lease or occupy.
b. The insurance afforded to an additional insured under Paragraph a. above does not apply:
(1) Unless:
(a) The contract or agreement is executed, or the permit or authorization is issued, before the
"bodily injury", "property damage" or "personal and advertising injury' occurs; and
(b) The contract, agreement, permit or authorization is in effect or becomes effective during the
policy period.
(2) To any:
(a) Person or organization included as an insured under any other provision of this policy,
including this or any other endorsement;
(b) Lessor of equipment after the equipment lease terminates or expires;
(c) Owner or other interests from whom land has been leased;
(d) Manager or lessor of premises if:
(i) The 'occurrence" takes place after you cease to be a tenant in that premises; or
(ii) The "bodily injury', "property damage" or "personal and advertising injury' arises out of
structural alterations, new construction or demolition operations performed by or on
behalf of the manager or lessor.
(e) Person or organization if the "bodily injury", "property damage" or "personal and advertising
injury' arising out of the rendering of, or the failure to render, any professional architectural,
engineering or surveying services, including:
(i) The preparing, approving, or failing to prepare or approve, maps, shop drawings,
opinions, reports, surveys, field orders, change orders or drawings and specifications;
or
(ii) Supervisory, inspection, architectural or engineering activities.
This exclusion applies even if the claims against any insured allege negligence or other
wrongdoing in the supervision, hiring, employment, training or monitoring of others by that
insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the
offense which caused the "personal and advertising injury', involved the rendering of or the
failure to render any professional architectural, engineering or surveying services; or
VCG 207 06 18 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 6 of 9
Copyright 2017, OneBeacon Insurance Group LLC
AW
TRAVELERSJ' WORKERS COMPENSATION
AND
ONE TOWER SQUARE
HARTFORD CT 06183 EMPLOYERS LIABILITY POLICY
ENDORSEMENT WC 00 03 13 (00) - 001
POLICY NUMBER: UB-6N98422A-19-I2-G
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
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 any one not named in the Schedule.
SCHEDULE
DESIGNATED PERSON:
DESIGNATED ORGANIZATION:
ANY PERSON OR ORGANIZATION FOR 'WHICH THE INSURED HAS AGREED
BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS
WAIVER.
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.
017528 DATE OF ISSUE: 09-10-19 STASSIGN- PnrF i nF1
CONTINUATION DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECWL PROVISIONS (Use only if more space is required)
All policies (except Workers' ers'' Compensation El.) include a blanket automatic additional insured [provision] that
confers additional insured status to the certificate holder Only if there is a written contract between the named
insured and the certificate holder that requires the named insured to name the certificate holder as an additional
insured. In the absence of such a contractual obligation on the part of the named insured, the certificate holder
is not an additional insured under the policy. All policies include a blanket automatic waiver of subrogation
endorsement [provision] that provides this feature only when there is a written contract between the named insured
and the certificate holder that requires it. In the absence of such a contractual obligation on the part of the
named insured, the waiver of subrogation feature does not apply.
ACORD 25 (2016/03) Certificate Holder ID: 16720020