PROOF OF INSURANCE (2022) CLOSEDPage 1 of 2
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DATE (MVIDDNYYY)
B"y
CERTIFICATE OF LIABILITY INSURANCE 09/29
09/29/20121
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA71ON 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.
IRP—ORTANT: If the certificate holder is an ADDITIONji—L 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 c ch endorsement(s).
PRODUCER NAMESq�teACCT WillisiTowers Watson Certificate Center
�
Willis Towers Watson Northeast, Inc.
ONE
c/o 26 Century BPH
lvd _L&(;�� N X 1-877-945-7378 1-888-467-2378
P,O, Box 305191 E-AML
Nashville, TN 372305191 USA -ADDRESS: certificates@willis-,-com,
INSURED
UniFixst Corporation and its Subsidiaries
69 Jonspin Road
Wiliftington, WA 01887
AFFORDING COVERAGE NAIC #
INSURERA: ACE Americ!&n Insurance Company 22667
INSURERS: Indemnity Insurance Company of North Aumri 43575
— ----- -----
INSURERC: ACE Fire Underwriters Insurance Company 20702
INSURER D:
INSURER E:
COVERAGES CERTIFICATE NUMBER. W22314984 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 WHIr,H THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY T14E POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ADDL suak� POLICY tO PO-U& UP
TYPE OF WSURANCE
X CoiiERCALC ,EMERAL Ll ,,L,Ty
'0
EACH OC CURF IENCE $ 2,000,00
CLAIMS-MADE X OCCUR
PRE 1,000,000
A X , Contractual
y y i MID EXP Luny one person)
SDOG72495470 10/01/2021 10/01/2022: PERSONAL & ADV INJURY S
1,000,000
GENT AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $ 4,000,000i
FIRO-
POLICY X L01-,
PRODUCTS - ( 0MPz'0PAGS
OTHER:
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(E�M 1, SINGLE 4, 4,000,000
X ANY AU t-0 6 D'L_'NJ'R" (Per Pe's
BODILY INJURY (Per persoaii
A OVVNrD SCHEDULED s y y ISAR25557633 10/01/2021�
AUTOS ONLY - - ----- AUTOS �10/01/2022: PODILY INJURY (Pe; acci&rtt)
HIRED NON OWNED
AU 1 OS ONLY PROPERTY DAMAGE
AUTOS ONLY (Pe; 'Iccidem)
UMBRELLA LIAB OCCUR
EACH OCCURRENCE
EXCESS LIAR
CLAIMS MADE
- -- ---- AGGREGATE
WORKERS COMPENSATION
AND EVIPLOYERS'LIABILITY YIN
li ANYPROPRIETOR/PAii
OFFICERIMEMBEREX6, NO NA Y WLRC678213.5A (AOS)
(Mandatory in NH)
If yes. desube wdes'
El- EACH ACCIDFNT $ 1,000,000
10/01/202110/01/2022'
E.L. DISEASE EA EMPLOYEE, S 1,000,000
EA- DISEASE POLICY LIMIT $ 1,000,000
A WOrkGrs Compensation and y to TARC67821397 (CA, HA} 10/01/2021I10/01/2022:ML Each Accident $1OUP, 000
Employers Liability
EL Disease-Pol Limit $1,000,000
Per Statute
EL Disease -- Each Emp$1,000,000
DESCRIPRON OF OPERATIONS / LOCATIONS! VEHICLES (ACORD 101 AdditionM Remarks Schoduke, may be attached if more space is required)
Division/Location: 324
SEE ATTACHED
M
El Segundo Police Dept.
A
Attu Julissa Solano UTHORIZED REPRESENTATIVE
348 in St.
09 1988-2016 ACORD CORPORATION, All rights reserved.
ACORD 25 (2016,103) The ACORID name and logo are registered marks of ACORD
sy- ID; 21623243 BATcR: 2253233
2 of 3 691
AGENCY CUSTOMER ID:
LOC #:
AC"R" ADDITIONAL REMARKS SCHEDULE
i I
AGENCY NAMED INSURED
UniFir8t Corporation and its Subsidiaries
Willis Towers Watson Northeast, lnc� 68 Jonnpin Road
POLICY NUMBER Wilmington, FA 01887
See Page 1
CARRIER DNAIC CODE
Seg
e
age
See Page I See Page I EFFECTNEDATE: See Page I
Page 2 Of 2
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER. 2 5 FORIVITITLE: Certificate of Liability insurance
Certificate Holder is an Additional insured for General Liability and Auto Liability as their interest may appear if
required by written contract but only with respect to liability arising out of operations of the Named Insured.
It is understood and agreed that UniFirst Corporation waives its right of subrogation against the Additional Insured
which may arise by reason of a payment of claim under General Liability, Auto Liability and Workers Compensation
policies if required by written contract and as permitted by law.
General liability shall be Primary and Non-contributory with any other insurance in force for or which may be purchas
by Additional Insured.
INSURER AFFORDING COVERAGE: ACE American Insurance Company
POLICY NUMBER: WCUC67821476 (ME, OH) EFF DATE: 10/01/2021
SUBROGATION WAIVED: Y
TYPE OF INSURANCE:
Workers Compensation and
Employers Liability
Per Statute
LIMIT DESCRIPTION:
EL Each Accident
EL Disease -Pol Limit
EL Disease - Each EMp
EXP DATE: 10/01/2022
LIMIT AMOUNT:
$1,000,000
$.1,000,000
$1,000,000
INSURER AFFORDING COVERAGE: ACE Fire Underwriters Insurance Company
POLICY NUMBER: SCFC67821439 (WI) EFF DATE: 10/01/2021 EXP DATE: 10/01/2022
SUBROGATION WAIVED: y
TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT:
Workers Compensation and EL Each Accident $1,000,000
Employers Liability EL Disease -Pol Limit $1,000,000
Per Statute EL Disease - Each Emp $1,000,000
NAIC#: 20702
ACORD 101 (2008/01) @ 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
SIR !D: 21623243 BATCH: 2253233 CERT: W22314984
POLICY NUMBERHDO G72495470
This endorsement modifies insurance provided Linder the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
Endorsement Number:
I&VCM17
CG 20 26 12 19
Name Of Additional Insured Person(s) Or Organization (s): Any person or organization whom you have
agreed to include as an additional insured under a written contract, provided such contract was executed prior to
the data of loss.
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 liability 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 omissions 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.
8With respect to the insurance afforded to these
additional insureds, the following is added to
Section III — Limits Of Insurance:
It 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
anIOUnt of insurance:
I. Required by the contractor agreement; or
2. Available under the applicable limits of
insurance;
whichever is less.
This endorsement shall riot
applicable limits of insurance.
increase the
Cc) Insurance Services Office, Inc., 2018
am�
3 of 3 691
ffilm
Nameo insuroo
UNIFIRST CORPORATION
68JONSPIN RD
WILMINGTON MA 01887 Symbol, WLR Number:C67821397
Policy Period Effective Date of Endorsement
10-01 -2021 TO 10-01 -2022 10-01-2021
Issued By (Name of Insurance Company)
ACE AMERICAN INSURANCE COMPANY
I Insert the oolicv number. The remainder o4 the information is to b ration of the policy.
r
This endorsement applies only to the insurance provided by the policy because California is shown in Item 3.A. of
the Information Page.
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, but this waiver applies only with respect
to bodily injury arising out of the operations described in the Schedule, where you are required by a written contract
to obtain this waiver from us.
You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the
work described in the Schedule.
Specific Waiver
Name of person or organization:
X ) Blanket Waiver
Any person or organization for whorn the Named Insured has agreed by written contract to furnish this
waiver.
ALL OPERATIONS CONDUCTED BY AN INSURED PURSUANT TO SUCH
WRITTEN CONTRACT
3, Premium:
The premium charge for this endorsement shall be percent of the California premium developed
on payroll in connection with work performed for the above person(s) or organization(s) arising out of the
operations described.
4. Minimum Premium: $0
Authorized Representative
WC 99 03 75 (05/18)