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PROOF OF INSURANCE (2022) CLOSEDS DATE (MM/DD/YYYY) AC<>R " CERTIFICATE OF LIABILITY INSURANCE 05/12/2021 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 ri hts to the certificate holder in lieu of such endorsements). PRODUCER CONTACT Marsh I U.S Operations Marsh USA Inc. NIA�w� _..__....__..�� FAx .�................� B66 966�664 C No): 701 Market Street, Suite 1100 .._..... .............. L. ..•••••_•••••.--• St. Louis, MO 63101 nnii: Att.CertR ues marsh.com annrtF:��• eQ INSURE'R($ AFFORDING COVERAGE _ NAIC# CN103150778-_GAW-CRT-21-22 Y Y SCha Y INSURER A: Old Republic Insurance Company 24147 New Cing .._........... .�..... INSURED INSURER B ular Wireless PCS, LLC.......— -. .. ..._ One AT&T Plaza INSURER C 208 South Akard INSURER D : Room 1820 ...... ......... Dallas, TX 75202 JINSURER E COVERAGES CERTIFICATE NUMBER: CHI-007309896-23 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. TYPE OF INSURANCEPOLICY NUMBER MMlDDlYY _ ....__- _ . ..... INT R A,.6 _ POLICY EIFF POLICY EXP r IMITS Y MMIDDPYyYY A X COMMERCIAL GENERAL LIABILITY MWZY 313636 21 06/01/2021 06/0112022 EACH OCCURRENCE $ 00.,.0...0..0 X $ 1 00000.0CLAIMS-MADE OCCUR o ure.nee _1--,-0 _ MED E)iP (Any one_Rers. m$ NIA PERSONAL & ADV INJURY $ 1,000,000 COWL AGGREGATE L"MIT APPLIES PER: GENERAL AGGREGATE $ 10,000,000 X POLICY1:1 C LOC PRODUCTS COMP/OPAGG .. ___ $ 1,000,000 OTHER; $ A AUTOMOBILE LIABILITY MWTB 313635 21 06/0112021 06/01/2022 COMBINED SINGLE t IMI`G Eaa da aril)_ $ 1,000,000 X ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED _OS BODILY INJURY (Per accident) X$ ..._.....-...... AUTOS ONLY AU HIRED NON -OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Iraeosral ....... ..._...- $ UMBRELLA LIAB OCCUR EACH OCCURRENCt $ EXCESS LIAB CLAIMS -MADE ..... ................. AGGREGATEm ........... $ DED RETENTION$ $ A WORKERS COMPENSATION MWC 313638 21 (A08) 0610V2021 976112622X PER ERN - TAT�ITE AND EMPLOYERS' LIABILITY YIN 1,000,000 ANYPROPRIETOR/PARTNER/EXECUTIVE El N/A E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) EL . DISEASE EA EMPLOYEE. $ 1,000 000 If yes, desailue under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,000 A Excess Workers' Compensation 1 MWXS 313639 21 (OH WA) 06/01/2021 06/0112022 EL Each Accident i EL Disease 1,000,000 Employers' Liability See Second Page EL Disease -Policy Limit 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Re: FA412992945; GSM ID: NL0515; Address: 400 Lomita St., El Segundo, CA 90245; CountyL Los Angeles. City of El Segundo, its officials and employees is/are included as Additional Insured under the General Liability and Automobile Liability policies but only with respect to the requirements of the contract between the Certificate Holder and the Insured. This insurance is primary with respect to the interest of the Additional insured and any other insurance maintained by Additional Insured is excess and non-contributory with this insurance. Waiver of Subrogation is provided for Workers' Compensation, as required by written contract and allowable by law. CERTIFICATE HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Risk Management THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. 9)1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN103150778 LOC #: St. Louis ►" RLP ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh USA Inc. New Cingular Wireless PCS, LLC One AT&T Plaza POLICY NUMBER 208 South Akard Room 1820 Dallas, TX 75202 CARRIER NAIC CODE EFFECTIVE DATE: lTHIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE. Certificate of Liabili Insurance Excess Workers' Compensation -MWXS 313639 21 (OH -WA) Self Insured Retentions OH & WA - $500,000,000 (except Terrorism) OH & WA - $600,000,000 Terrorism ACORD 101 (2008/01) 0186-01-00-0001957-0002-0004527 © 2008 ACORD CORPORATION. All rights i The ACORD name and logo are registered marks of ACORD IL 10 (12/06) OLD REPUBLIC INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO CERTIFICATE HOLDERS This endorsement modifies the notice of cancellation of insurance provided hereunder by adding the following: A. In the event this policy is cancelled for any permissible reason, other than for nonpayment of premium, we shall endeavor to provide advance written notice of cancellation to certificate holders sat out in the schedule on file with the Company; after notifying the first Named Insured of such cancellation. Notice of cancellation to certificate holders may be made by any commercially reasonable means, including mail, electronic mail, facsimile transmission or courier service. B. This advance written notification of a cancellation of coverage is intended as a courtesy only. Our failure to provide such advance written notification will not extend the policy cancellation date; nor negate cancellation of the policy. All other terns and conditions of this policy i-e► ain unchanged. PIL 029 1€1 19 MWT6 313635 21 AT&T Inc, 06,01/2021 - OW0112022 IL 10 (12106) OLD REPUBLIC INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.. ADDITIONAL INSURED WHERE REQUIRED UNDER CONTRACT OR AGREEMENT This endorsement modifies insurance provided under the Following: COMMERCIAL GENERAL LIABILITY COVERAGE PART/FORM Paragraph Z. of SECTION II - WHO IS AN INSURED is amended to include any person or organization for whom you have agreed under contract or agreement to provide insurance. However, the insurance provided shalt not exceed the scope of coverage or limits of this policy. Notwithstanding the foregoing sentence, in no event shall the insurance provided exceed the scope of coverage or limits required by said contract or agreement. Where required by contract, we will consider our policy to be primary under any other insurance maintained by the additional insured for injury or damage covered by this endorsement and that their policy will be noncontributing with this insurance. G L 739 006a 0609 Includes copyrighted material of Insurance Services Office, Inc., with its permission. I�swzY 313636 21 AT&T Inc. 08f0112t?2.1 - O6i01/2022 0166-01-00-0001957-0003-0004528 Page 1 of 1 IL 10 (12106) OLD REPUBLIC INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTICE OF CANCELLATION TO CERTIFICATE HOLDERS This endorsement modifies the notice of cancellation of insurance provided hereunder by adding the following., A. In the event this policy is cancelled for any permissible reason, other than for nonpayment of premium, we shall endeavor to provide advance written notice of cancellation to certificate holders set out in the schedule can file with the Company, after notifying the first Famed Insured of such cancellation. Notice of cancellation to certificate holders may be made by any commercially reasonable means, including mail, electronic mail, facsimile transmission or courier service. B. This advance written notification of a cancellation of coverage is intended as a courtesy only. Our failure to provide such advance written notification will not extend the policy cancellation date, nor negate cancellation of the policy.. All other terms and conditions of this policy remain unchanged. 14iWZY 313636 21 AT&T Inc. 0610112021 - 0610112022 OLD REPUBLIC INSURANCE COMPANY VI ORKERS' COMPENSATi®N AND EMPLOYERS' LIABILITY POLICY NOTICE OF CANCELATION TO CERTIFICATE HOLDERS ENDORSEMENT This endorsement modifies the notice of cancelation of insurance provided hereunder by adding the following; A. In the event this policy is canceled for any permissible reason, other than for nonpayment of premium, we shall endeavor to provide advance written notice of cancelation to certificate holders set out in the schedule on file with the Company, after notifying the Insured first named in item 1 of the Information Page of such cancelation. Notice of cancelation to certificate holders may be made by any commercially reasonable means, including mail, electronic mail, facsimile transmission or courier service. B. This advance written notification of a cancelation of coverage is intended as a courtesy only. Our failure to provide such advance written notification will not extend the policy cancelation date, nor negate cancelation of the policy. All other terms and conditions of this policy remain unchanged. WC 99 03 64 (03/11) Page 1 of 'I 0186-01-00-0001957-0004-0004529 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 4-84) POLICY NUMBER: MWC313638 21 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule Where Required by Written Contract All locations associated with contract. DATE OF ISSUE: 06/01/2021 WC000313 (Ed. 4-84) ,6 1983 National Council on Compensation Insurance. MWC313638 21 AT&T Services, Inc. 06/01/2021 - 06101/2022