PROOF OF INSURANCE (2021) CLOSEDCERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDD/YYYY)
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
11 this certificate does not confer riahts to the certificate holder in lieu of such endorsementlsl.
PRODUCER LocktOn Companies
444 W. 47th Street, Suite 900
Kansas City MO 64112-1906
(816)960-9000
INSURED
1474534 605DT THIRD STREET INSURER C :
1
c:
ENCMTAS CA 92024 INSURER 0 :
COVERAGES CERTIFICATE NUMBER: 1671 1485
NAIL #
1653
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.
_.
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TYPE OF INSURANCE UMBER (MMIDOrYYYY11MMIDDIYYYY1 LIMITS
POLICY
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COMMERCIAL GENERAL LIABILITY
o,
Y
Y
GL00146311
8/28/2020
8/28/2021
EACH OCCURRENCE
$ 1 000 000 ._._
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CLAIMS -MADE OCCUR
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MED EXP (An one erson)
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A
AUTOMOBILE
LIABILITY
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BAP0146329
8/28/2020
8/28/2021
COMBINED SINGLE LIMIT $
i9AA ail _ . �,�:.a«000 M.. --
ANY AUTO
BODILY INJURY (Per person) $ xxxxxxx
_
OWNED SCHEDULED
AUTOS ONLY _,.. AUTOS
BODILY INJURY (Per accident) $ XxXXXXX
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
PROPERTY DAMAGE $ xxxxxxx
.......
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afP..!taTp9"i>lfl(,1....e. ._____,..__...._. ._.
$ xxxxxxx
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8l28f2021
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8/28/2020
8/28/2021
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DISEASE EA EMPLOYEE
$ O
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DESCRIPTION un OPERATIONS below
E.L. DISEASE -POLICY LIMIT
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$ 1 00.000
B
PROFESSIONAL
N
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EEH591932835 1NCL POLL
8/28/2020
8/28/2021
PER CLAIM $1,000,000
LIABILITY
AGGREGATE $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Re: CEQA PSA 20190605 The City of El Segundo, its officials, and employees are an Additional Insured on the Commercial General Liability and Auto Liability when required by
writtencontract or agreement regarding activities by or on behalf of the Named Insured, The Commercial General Liability insurance is primary insurance and anyother insurance
maintained by the Additional insured shall be excess only and non-contributing with this insurance. A waiver of subrogation applies to the Commercial General Liability, Auto
Liability, Umbrella / Ewerss Liability and Workers Compensation / Employers Liability in favor of the Additional Insured.
16711485
El Segundo Planning & Building Safety Dept
350 Main St
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
Cc) 1988f, D15 ACORD CORPORATION. All riahts reserved
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
Attachment Code: D574651 Certificate ID: 16711485
Coverage Extension Endorsement ZUR|CH
Policy No.
Eff. Date of Pol,
Exp. Dale of Pol.
Eff, Dale of
Producer No.
Add'l. Prern
Return Prem.
BSegundo Planning & Building Safety Dept
350 Main St
El Segundo CA 90245
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ |TCAREFULLY. This endorsement
modifies insurance provided under the:
Business Auto Coverage Form
Motor Carder Coverage Form
A.Amended Who |sAnInsured
1. The following is added to the Who Is An Insured Provision in Section 11 — Covered Autos Liability
Coverage: The following are also ''inounede'':
a. My "employee" of yours is an "insured" while using a covered "auto" you don't own, hire or borrow for
acts performed within the scope of employment by you. Any "employee" of yours is also an "insured"
while operating an "auto" hired or rented under contract oragreement in an "employee's" nome, with
your permission, while performing duties related to the conduct of your business.
b. Anyone volunteering services to you is an "insured" while using a covered "auto" you don't own, hire or
borrow to transport your clients or other persons in activities necessary to your business.
o. Anyone else who furnishes an^nuto~referenced inParagraphs A.1.o.and A.1.b.inthis endorsement.
d. Where and to the extent permitted by law, any person(s) or organization(s) where required by written
contract or written agreement with you executed prior to any "accident", including those person(s) or
organization(s) directing your work pursuant to such written contract or written agreement with you,
provided the "accident" arises out of operations governed by such contract or agreement and only up to
the limits required in the written contract or written agreement, or the Limits of Insurance shown in the
Declarations, whichever iyless.
2. The following is added to the Other Insurance Condition In the Business Auto Coverage Form and the
Other
Insurance — Primary and Excess Insurance Provisions Condition in the Motor Carrier Coverage Form:
Coverage for any person(s) or organ ization(s), where required by written contract or written agreement
with you executed prior to any "accident", will apply on a primary and non-contributory basis and any
insurance maintained by the additional "insured" will apply on an excess basis. However, in no event will
this coverage extend beyond the terms and conditions ofthe Coverage Form.
B.Amendment--Gupp|ementaryPaymento
Paragraphs a.(2) and a.(4) of the Coverage Extensions Provision in Section 11 — Covered Autos Liability
Coverage are replaced bythe following:
(2) Up to $5,000 for the cost of bail bonds (including bonds for related traffic law violations) required
because ofnn"mnoident"vvecover. VVedonot have tofurnish these bonds.
(4) All reasonable expenses incurred by the'Insured" at our request, including actual loss of earnings up
to$50Oeday because oftime off from work.
C. Fellow Employee Coverage
The Fellow Employee Exclusion contained in Section 11 — Covered Autos Liability Coverage does not
apply-
D. Driver Safety Program Liability and Physical Omnnuge Coverage
1. The following is added to the Racing Exclusion in Section 11 — Covered Autos Liability Coverage:
Attachment Code: D574651 Certificate ID: 16711485
This exclusion does not apply to covered "autos" participating in a driver safetyprogram event, such as,
but not limited to, auto or truck rodeos and other auto or truck agility demonstrations.
2. The following is added to Paragraph 2. in the Exclusions of Section ||| --Physical Damage Coverage
of the Business Auto Coverage Form and Paragraph 2.b. in the Exclusions of Section IV — Physical
Damage Coverage ofthe Motor Carrier Coverage Form:
This exclusion does not apply to covered "autos" participating in a driver safety program event, such as,
but not limited to, auto or truck rodeos and other auto or truck agility demonstrations.
E. Lease orLoan Gap Coverage
The following is added to the Coverage Provision of the Physical Damage Coverage Section:
Lease OrLoan Gap Coverage
In the event of a total "loss" to a covered "auto", we will pay any unpaid amount due on the lease or loan
fora covered "auto", less:
a. Any amount paid under the Physical Damage Coverage Section of the Coverage Form; and
b. Any:
(1)Overdue lease orloan payments otthe time ofthe "|umm";
(2) Financial penalties imposed under a lease for excessive use, abnormal wear and tear or high mileage;
(3)Security deposits not returned bythe lessor;
(4) Costs for extended mmnonUmn. credit life insurance, health, accident ordisability insurance purchased
with the loan orlease; and
(5)Carry-over balances from previous leases orloans.
F.Towing and Labor
Paragraph A.2. of the Physical Damage Coverage Section is replaced by the following:
We will pay up to $75 for towing and labor costs incurred each time a covered "auto" of the private
passenger type is disabled. However, the labor must be performed at the place of disablement.
G.Extended Glass Coverage
The following is added to Paragraph A.3.a. of the Physical Damage Coverage Section:
If glass must be replaced, the deductible shown in the Declarations will apply. However, if glass can be
repaired and is actually repaired rather than replaced, the deductible will be waived. You have the option
ufhaving the glass repaired rather than replaced.
H. Hired Auto Physical Damage-- Increased Loss of Use Expenses
The Coverage Extension for Loss Of Use Expenses in the Physical Damage Coverage Section is
replaced bythe following:
Loss OfUse Expenses
For Hired Auto Physical Damage, we will pay expenses for which an "insured" becomes legally
responsible to pay for loss of use of a vehicle rented or hired without a driver under a written rental
contract or written rental agreement. We will pay for loss of use expenses if caused by:
(1) Other than collision only if the Declarations indicate that Comprehensive Coverage is provided for any
covered "auto";
(2) Specified Causes Of Loss only if the Declarations indicate that Specified Causes Of Loss Coverage is
provided for any covered "auto";or
(3)Collision only ifthe Declarations indicate that Collision Coverage is provided for any covered "auto".
However, the most we will pay for any expenses for loss of use is $100 per day, to a maximum of $3000.
|. Personal Effects Coverage
The following is added to the Coverage Provision of the Physical Damage Coverage Section:
Personal Effects Coverage
a.VVawill pay upin$758for "|000"topersonal effects which are:
(1)Personal property owned byan^ineurad'';and
(2)|noronacovered "euto".
b. Subject to Paragraph a. above, the amount to be paid for "loss" to personal effects will be based on the
lesser of:
(1)The reasonable cost Loreplace; or
(2)The actual cash value.
c. The coverage provided in Paragraphs a. and b. above, only applies in the event of a total theft of
covered "nuto"No deductible applies tothis coverage. Hmwever, we will not pay for "|ooe"to pnnoono|
effects ofany ofthe following:
(1) Accounts, bills, currency, deeds, evidence of debt, money, notes, securities, or commercial paper or
other documents ofvalue.
Attachment Code: D574651 Certificate ID: 16711485
watches, precious orsemi-precious stones.
( Paintings, statuary and other works ofart.
(4)Contraband orproperty inthe course ofillegal transportation cvtrade.
(5)Tapeo. n000rdo' discs orother similar devices used with oudin, visual or data electronic equipment.
Any coverage provided by this Provision is excess over any other insurance coverage available for the
same "loss".
J.Tapes, Records and Discs Coverage
1. The Exclusion in Paragraph B.4.a. of Section III — Physical Damage Coverage in the Business Auto
Coverage Form and the Exclusion in Paragraph B.2.c. of Section IV — Physical Damage Coverage in the
Motor Carrier Coverage Form does not apply.
2. The following is added to Paragraph 1.a. Comprehensive Coverage under the Coverage Provision of
the Physical Damage Coverage Section:
We will pay for "loss" to tapes, records, discs or other similar devices used with audio, visual or data
electronic equipment. We will pay only if the tapes, records, discs or other similar audio, visual or data
electronic devices:
(a)Are the property nfon"insuned";and
(b)Are inacovered ^mubu"atthe time nf"|oss".
The most we will pay for such "loss" to tapes, records, discs or other similar devices is $500. The Physical
Damage Coverage Deductible Provision does not apply tosuch "|ouo"
K.Airbag Coverage
The Exclusion in Paragraph B.3.a. of Section ||| -- Physical Damage Coverage in the Business Auto
Coverage Form and the Exclusion inParagraph B.4.a.of Section|V--Phyeioa|OamogeCoverogointhe
Motor Carrier Coverage Form does not apply to the accidental discharge of an airbag.
LTwo orMore Deductibles
The following isadded Uathe Deductible Provision nfthe Physical Damage Coverage Section:
If an accident is covered both by this policy or Coverage Form and by another policy or Coverage Form
issued to you by us, the following applies for each covered "auto" on a per vehicle basis:
1. If the deductible on this policy or Coverage Form Is the smaller (or smallest) deductible, it will be
waived; or
2. If the deductible on this policy or Coverage Form is not the smaller (or smallest) deductible, it will be
reduced bythe amount cf the smaller (or smallest) deductible.
yN.Physical Damage -- Comprehensive Coverage --Deductible
The following isadded tothe Deductible Provision ofthe Physical Damage Coverage Section:
Regardless of the number of covered "autos" damaged or stolen, the maximum deductible that will be
applied to Comprehensive Coverage for all "loss" from any one cause is $5,000 or the deductible shown
)nthe Declarations, whichever iegreater.
N. TampunarySubsUtuteAutos--Phyoioa| Damage
1.The following imadded toSection |-- Covered Autos:
Temporary SubatituteAutos-- Physical Damage
If Physical Damage Coverage is provided by this Coverage Form on your owned covered "autos", the
following types of vehicles are also covered "autos" for Physical Damage Coverage:
My "auto" you do not own when used with the permission of its owner as a temporary substitute for a
covered "auho"you doown but imout ofservice because ofits:
1. Breakdown;
2. Repair;
3. Servicing;
4.~Loan";cv
5. Destruction.
2.The following iaadded bothe Paragraph A. Coverage Provision ofthe Physical Damage Coverage
Section: Temporary Substitute Autos — Physical Damage
We will pay the owner for "loss" to the temporary substitute "auto" unless the "loss" results from
fraudulent acts or omissions on your part. If we make any payment to the owner, we will obtain the
owner's rights against any other party.
The deductible for the temporary substitute "auto" will be the same as the deductible for the covered
"auto"itreplaces.
O.Amended Duties |nThe Event CfAccident, Claim, Suit OrLoss
Paragraph a. of the Duties In The Event Of Accident, Claim, Suit Or Loss Condition is replaced by the
Attachment Code: D574651 Certificate ID: 16711485
a. In the event of "accident", claim, "suit" or "loss", you must give us or our authorized representative
prompt notice ofthe "aoodent".claim, ^nud"or"loao" However, these duties only apply when the
"accident", claim, "suit" or "loss" is known to you (if you are an individual), a partner (if you are a
partnership), a member (if you are a limited liability company) or an executive officer or insurance
manager (if you are a corporation). The failure of any agent, servant or employee of the "insured" to notify
us of any "accident", claim, "suit" or "loss" shall not invalidate the Insurance afforded by this policy.
Include, oasoon aupracticable:
(1) How, when and where the "accident" or "loss" occurred and if a claim is made or "suit" is brought,
written notice of the claim or "suit" including, but not limited to, the date and details of such claim or "suit";
(2)The ''inaunyd'o"name and address; and
(3) To the extent possible, the names and addresses of any injured persons and witnesses.
If you report an "accident", claim, "suit" or "loss" to another insurer when you should have reported to us,
your failure toreport to us will not be seen as a violation of these amended duties provided you give us
notice aosoon oapracticable after the fact ofthe delay becomes known toyou.
P.Waiver o[Transfer OfRights (3fRecovery Against Others TuUe
The following is added to the Transfer Of Rights Of Recovery Against Others To Us Condition:
This Condition does not apply to the extent required of you by a written contract, executed prior to any
"accident" or "loss", provided that the "accident" or "loss" arises out of operations contemplated by such
contract. This waiver only applies to the person or organization designated in the contract.
Q. Emp|oyeeHinadAuboo--phymioo|Oamage
PanaQnmphb. of the Other Insurance Condition in the Business Auto Coverage Form and Paragraph f. of
the Other Insurance — Primary and Excess Insurance Provisions Condition in the Motor Carrier
Coverage Form amreplaced bythe following:
For Hired Auto Physical Damage Coverage, the following are deemed to be covered "autos" you own:
(1)Any covered "mubo^you lease, hire, rent orborrow; and
(2)Any covered "auto"hired orrented under awritten contract orwritten agreement entered into byan
"employee" or elected or appointed official with your permission while being operated within the course
and scope of that "employee's" employment by you or that elected or appointed official's duties as respect
their obligations toyou.
However, any "auto" that is leased, hired, rented or borrowed with a driver is not a covered "auto".
R. Unintentional Failure to Disclose Hazards
The following is added to the Concealment, Misrepresentation Or Fraud Condition:
However, we will not deny coverage under this Coverage Form if you unintentionally:
(1) Fail to disclose any hazards existing at the inception date of this Coverage Form; or
(2) Make on error, omieeion, improper description of "autos" or other misstatement nfinformation.
You must notify us as soon as possible after the discovery of any hazards or any other information that
was not provided toueprior (othe acceptance ofthis policy.
S.HinadAuto--VVoddVVideCovenyge
Paragraph 7a.(5) of the Policy Period, Coverage Territory Condition is replaced by the following:
(5) Anywhere in the world if a covered "auto" is leased, hired, rented or borrowed for a period of 60 days
or less,
T.Bodily Injury Redefined
The definition of "bodily injury" in the Definitions Section is nap|aood bythe following:
'Bodily injury" means bodily injury, sickness or disease, sustained by a person including death or mental
anguioh,
resulting from any of these at any time. Mental anguish means any type of mental or emotional illness or
disease.
U.Expected OrIntended Injury
The Expected OrIntended Injury Exclusion ihParagraph B. Exc|uoionaunderGeuionU--CoveredAuto
Liability Coverage imreplaced bythe following:
Expected OrIntended Injury
"Bodily injury" or "property damage" expected or intended from the standpoint of the "insured". This
exclusion does not apply to "bodily injury" or "property damage" resulting from the use of reasonable force
to protect persons nrproperty.
V. Physical Damage — Additional Temporary Transportation Expense Coverage
Paragraph AA.a. of Section III — Physical Damage Coverage Is replaced by the following: 4. Coverage
Extensions
a.Transportation Expenses
Attachment Code: D574651 Certificate ID: 16711485
We will pay up to $50 per day toomaximum of $1,00|or temporary transportation expense incurred by
you because ofthe total theft ofacovered ^eubf ofthe private passenger type. VVewill pay only for those
covered "autos" for which you carry either Comprehensive or Specified Causes of Loss Coverage. We will
pay for temporary transportation expenses incurred during the period beginning 48 hours after the theft
and ending, regardless of the policy's expiration, when the covered "auto" is returned to use or we pay for
its ''|ouo"
W. Replacement of Private Passenger Auto with a Hybrid or Alternative Fuel Source Auto The following
ieadded hoParagraph A. Coverage ofthe Physical Damage Coverage Section:
In the event of a total "loss" to a covered "auto" of the private passenger type that is replaced with a
hybrid "auto" or "auto" powered by an alternative fuel source of the private passenger type, we will pay an
additional 10% of the cost of the replacement "auto", excluding tax, title, license, other fees and any
oftarmorkedvehicle upgrades, uphunmaximum cf $250U.The covered "auhn"must bereplaced byo
hybrid "auto" or an "auto" powered by an alternative fuel source within 60 calendar days of the payment of
the "|oau^and evidenced byobill ofsale ornew vehicle lease agreement.
To qualify as a hybrid "auto", the "auto" must be powered by a conventional gasoline engine and another
source of propulsion power. The other source of propulsion power must be electric, hydrogen, propane,
solar or natural gas, either compressed or liquefied. To qualify as an "auto" powered by an alternative fuel
source, the "auto" must be powered by a source of propulsion power other than a conventional gasoline
engine. An ''outo" solely propelled by biofbe|, gasoline or diesel fuel or any blend thereof is not an ''auto"
powered byenalternative fuel source.
X. Return of Stolen Automobile
The following is added to the Coverage Extension Provision of the Physical Damage Coverage Section:
If a covered "auto" is stolen and recovered, we will pay the cost of transport to return the "auto" to you.
We will pay only for those covered "autos" for which you carry either Comprehensive or Specified Causes
cfLoss Coverage.
All other terms, conditions, provisions and exclusions of this policy remain the same.
U-CA'424-FCVV(0>4/14)
Attachment Code: D574649 Certificate ID: 16711485
Additional Insured -- Automatic -- Owners, Lessees OrZUR|CH@
Contractors
Policy No,
Eff. Date of Pol,
I Exp, Date of Pol.
Eff. Date of End,
Producer No,
AddT Prern
Return Prem.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ [TCAREFULLY,
Named Insured:
Per attached certificate
This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part
A. SectionU—Who|oAo|nsuredioamendedtoindudeas an additional insured any person or
organization whom you are required to add as an additional insured on this policy under a written contract
or written agreement. Such person or organization is an additional insured only with respect to liability for
"bodily injury", "property damage" or "personal and advertising injury" caused, in whole orinpart, by:
1.Your acts oromissions; or
2.The acts oromissions ofthose acting nnyour behalf,
in the performance of your ongoing operations or "your work" as included in the "products -completed
operations hazard", which is the subject of the written contract or written agreement.
However, the insurance afforded bzsuch additional insured:
1.Only applies tothe extent permitted bylaw; and
2. Will not be broader than that which you are required by the written contract or written agreement to
provide for such additional insured.
B. With respect to the insurance afforded to these additional insureds, the following additional exclusion
applies: This insurance does not apply to:
"Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or
failure to render, any professional architectural, engineering or surveying services including:
a. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, reports,
surveys, field orders, change orders ordrawings and specifications; or
b. Supervisory, inopeotion, 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 orsurveying services.
C. The following is added to Paragraph 2. Duties In The Event Of Occurrence, Offense, Claim Or Suit of
Section IV —Commercial General Liability Conditions:
The additional insured must see iuit that:
1. We are notified as soon as practicable of an "occurrence" or offense that may result in a claim;
2.VVoreceive written notice ofaclaim nr"suit"mnsoon aepracticable; and
3. A request for defense and indemnity of the claim or "suit" will promptly be brought against any policy
issued by another insurer under which the additional insured may be an insured in any capacity. This
provision does not apply to insurance on which the additional insured is a Named Insured if the written
contract or written agreement requires that this coverage be primary and non-contributory.
[}. For the purposes cfthe coverage provided bythis endorsement:
1. The following is added to the Other Insurance Condition of Section IV — Commercial General Liability
Conditions:
Primary and Noncontributory insurance
This insurance is primary to and will not seek contribution from any other insurance available to an
additional insured provided that:
a. The additional insured is a Named Insured under such other insurance; and
Attachment Code: D574649 Certificate ID: 16711485
b.You are required bywritten contract nrwritten agreement that this insurance beprimary and not seek
contribution from any other insurance available tothe additional insured.
2. The following paragraph is added to Paragraph 4.b. of the Other Insurance Condition of Section IV
Commercial
Ganmns| Liability Conditions:
This insurance ieexcess over:
Any of the other insurance, whether primary, excess, contingent or on any other basis, available to an
additional insured, in which the additional insured on our policy is also covered as an additional insured
on another policy providing coverage for the same "occurrence", offense, claim or "suit". This provision
does not apply to any policy in which the additional insured is a Named Insured on such other policy and
where our policy is required by a written contract or written agreement to provide coverage to the
additional insured onaprimary and non-contributory basis.
E. This endorsement does not apply to an additional insured which has been added to this policy by an
endorsement showing the additional insured ina Schedule ofadditional insureds, and which endorsement
applies specifically tothat identified additional insured.
F. With respect to the insurance afforded to the additional insureds under this endorsement, the following
ieadded toSection III -- Limits OfInsurance:
The most we will pay on behalf of the additional insured is the amount of insurance:
1. Required by the written contract or written agreement referenced in Paragraph A. of this endorsement;
or
2.Available under the applicable Limits ofInsurance shown inthe Declarations,
whichever is less.
This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.
All other terms and conditions ofthis policy remain unchanged.
Attachment Code: D574650 Certificate ID: 16711485
Policy Number, VVCO14833U
VVORKERS'COK4PENSAT|DNAND EMPLOYERS'LIAB|L|TYINSURANCE POLICY
VVCU403O6
SEci.4'O41
WAIVER. OFOUR RIGHT TDRECOVER 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 inthe work described inthe Schedule,
The additional premium for this endorsement shall be 0 % of the California workers' compensation pre,
miumotherwise due mnsuch remuneration.
Person orOrganization Schedule
Per attached certificate
Job Description
ALL PERSONS AND/OR ORGANIZATIONS THAT
ARE REQUIRED BYWRITTEN CONTRACT C>R
AGREEMENT WITH THE INSURED, EXECUTED
PRIOR TOTHE ACCIDENT ORLOSS, THAT
WAIVER OFSUBROGATION BEPROVIDED
UNDER THIS POLICY FOR. wow( PERFORMED
BYYOU FOR THAT PERSON AND/OR ORGANIZATION
WC 252(4841
Attachment Code: D574648 Certificate ID: 16711485
Waiver Of Subrogation (Blanket) Endorsement
Policy No.
Eff. Date of Pol.L8,12812021
Date of Pol.
Eff. Date of End. Producer
AWL
Return Prem.
Prem
GLOO146311
8/28/2020
8/28/2020 N/A
$ N/A
N/A
El Segundo Planning & Building Safety Dept
350 Main St
El Segundo CA 90245
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the:
Commercial General Liability Coverage Part
The following is added to the Transfer Of Rights Of Recovery Against Others To Us Condition:
If you are required by a written contract or agreement, which is executed before a loss, to waive your
rights of recovery from others, we agree to waive our rights of recovery. This waiver of rights shall not be
construed to be a waiver with respect to any other operations in which the insured has no contractual
interest.
U-GL-925-B CW (12/00