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PROOF OF INSURANCE (2021) CLOSED0 AC<>RV CERTIFICATE OF LIABILITY INSURANCE I- DATE (MM/DD1YYYY) 03/2612021 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 enclorsement(s). PRODUCER Marsh USA, Inc, Two Alliance Center PHONE FAX , . . ......... . . . 3560 Lenox Road, Suite 2400 E-MAIL Atlanta, GA 30326 EC -------- - Attn: Atianta,CertRequest@marsh.com I Fax: 212-948-4321 -- - ---- - -------- ------- 1 CNI02326389-RI-GAUWX-20-21 . . ......... . . . ........... A INSURER � Evanston- Insurance Co,moepy, 35378 INSURED Robertson Industries, Inc INSURER 8: Travele P a C . . . . ...... _r9p 25674 Attention: Made Townson -.INSURER q,: ACE Properky Arid, Casualty.!ns'C 20699 2414 W, 12th Street INSURER D: The Travelers Inqemnikggmp an of Amerce 25666 Suite 5 Tempe, AZ 85281 INSURER E : National Union Fire Ins fig, ..2!..Pit1sbur0_P&.. ............... . . . ......... 1944.5. INSURERF: TraveleLs Casualty And Surety Company 19038 COVERAGES CERTIFICATE NUMBER: ATL-005231041-00 REVISION NUMBER: 0 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. ...... . . . . . .......... . ............................ . . . . . . ... . ........ . ----------- 'iiisk lxuajwdk� POLICYEFF POUCYEXP T LTR TYPE OF INSURANCE INS11 WVD POLICY NUMBER IMIAIRPMD (MMIOOryYyyJ LIMITS A X COMMERCIAL GENERAL LIABILITY MKLV2PBC000784 08/01/2020 08/0112021 EACH OCCURRENCE 2,000,000 1XI 100,000 CLAIMS -MADE OCCUR -PaEmsf-S . . ...... X SIR$50,00OPerOcc. Eidcly MEDEXP(AntSj�. $ JE6 ........... PERSONAL& ADV INJURY $ 2,000,000 . .... . . . ......... . AGGREGATE LIMIT APPLIES PER: .... ......... -'-- GENERAL AGGREGATE $ 4,000,000 ,.qEN'L PRO - POLICY 1._� JECT FILOC . . ... .................. . . ....... . ..... PRODUCTS - COMP/OP AGG 4,000,000 OTHER. POLICY AGGREGATE $ 10,000,000 B AUTOMOBILE ........... LIABILITY TJ-CAP-9DB97065TIL-20 08/01/2020 08/01/2021 MBtNED INGLFLIMIT $ 1,000,000 ................. .......... X ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ -"ROPERIY HIRED NON -OWNED DAMAGE $ AUTOS ONLY AUTOS ONLY Comp/Coll Ded: $1,000 LALIAS i X JOCCUR XCCG71549501002 08/01/2020 08/01/2021 EACH OCCURRENCE s 10,000,000 X_. EXCESSLIAB AGGREGATE 10,000,000 DED X RETENTION$ 25,000 $ B WORKERS COMPENSATION U1-2N111953-20-51-R 001/2020 0810112021 X PER ETH- LER D AND LIABILITY YIN UB-2N 1 59031-20-51-K 08/01/2020 08/01/2021E_L TE-1- 1,000,000 ANYPROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBEREXCLUE NI NIA EACH CIDENT F (Mandatory in NH) UB-7J602089-20-14-G 08/01/2020 08/01/2021 E.L DISEASE - EA EMPLOYEE� $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below (See Additional Page.) _1­­1­­..­­1'­ E.L. DISEASE - POLICY L $ 1. 1 0 00 000 E Excess Umbrella BE 016159343 1111112120 1111112021 Each Occurrence 15,000,000 SIR $25,000 Per Project Aggregate 15,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) RE: Gordon Clubhouse Park / 21-31868 City of El Segundo is listed as additional insured in regards to services performed by the Insured, on a primary and non-contributory basis on the General Liability (via CG 2010 & CG 2037) and Automobile Liability (via CA T4 37) policies, when required by written contract. A Waiver of Subrogation applies in favor of the additional insureds on the Workers Compensation policy, when required by written contract, P/1 e�;�40 City of El Segundo Public Works Department 350 Main Street El Segundo, CA 90245 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 REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee @ 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN102326389 LOC #: Atlanta ACC?R" ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh USA, Inc. Robertson Industries, Inc. Attention: Maria Townson 2414 W, 12th Street POLICY NUMBER Suite 5 Tempe,AZ 85281 CARRIER 7�— CODE . ........ EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers" Compensation (Continued): UB-2NI 06953-20-51 A (AZ, FL, OR, WI) UB-2NI 59031-20-51-K (AK AL CO CA IA IL IN KS KY MID MI MN MO MT NO ND NE NV NY OH OK PA PR SO TN TX UT VA WA WY) UB-7J602089-20-14-G (AZ CA CO CT FL GA ID IL IN KS MD MI MIN MO MT NC NH NM NV NY OK OR PA SC TN TX WV) Workers Compensation SIR of $150,000 ACORD 101 (20081011 @ 2008 ACORD CORPORATION. All riahts; reserved The ACORD name and logo are registered marks of ACORD INSURED: PLAYCORE GROUP, INC. POLICY NUMBER: TJ-CAP-9D897065TIL-20 EFFECTIVE DATES: 08-01-2020 - 08-01-2021 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM The following is added to Paragraph c. in A.I., Who Is An Insured, of SECTION 11 — COVERED AUTOS LIABILITY COVERAGE in the BUSINESS AUTO COVERAGE FORM and Paragraph e. in A.1., Who Is An Insured, of SECTION 11 — COVERED AUTOS LIABILITY COVERAGE in the MOTOR CARRIER COVERAGE FORM, whichever Coverage Form is part of your policy: This includes any person or organization who you are required under a written contract or agreement between you and that person or organization, that is signed by you before the "bodily injury" or "property damage" occurs and that is in effect during the policy period, to name as an additional insured for Covered Autos Liability Coverage, but only for damages to which this insurance applies and only to the extent of that person's or organization's liability for the conduct of another "insured". CA T4 37 02 16 C 2016 The Travelers Indemnity Company. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc. with its permission, INSURED: PLAYCORE GROUP, INC. EFFECTIVE DATES: 08-01-2020 - 08-01-2021 POLICY NUMBER: MKLV2PBC000784 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES O . CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART .' SCHEDULE Name Of Additional Insured Person(s) Or Or anization s Location And Description Of Completed Operations As required by written contract executed by both All locations parties prior to loss Information required to complete this Schedule, if not shown above, will be shown in the Declarations. 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: 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. © Insurance Services Office, Inc., 2012 Page 1 of 1 CG 20 37 0413 r 0 A klmni ONE TOWER SQUARE HARTFORD CT 06183 INSURED: PLAYCORE GROUP, INC. EFFECTIVE DATES: 08-01-2020 - 08-01-2021 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 00 03 13 (00) - 001 POLICY NUMBER: UB-7J602089-20-14-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.