PROOF OF INSURANCE (2022) CLOSEDDATE (MMIDD/YYYY)
A+I 40RO CERTIFICATE OF LIABILITY INSURANCE
10/19/2021
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 rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT Rebecca Huddle
Becky Huddle Insurance Agency NAME, _
729 Sunrise Ave Ste 504 H NE t), 916 789 7500e " "" NCI 916 789-2545
Roseville CA 95661 %n ,per staff. rhuddle farmersagency.Com
INSURER(S) AFFORDING COVERAGE NAIC #
D CENTURY INSURANCE 21687
INSURED Lotus Communications, LLC INSURERB:
2084-B Central Avenue INsuRER c
Duarte, CA 91010 INSURER D :
INSURER E
INSURER F :
rnvoo Ar_Cc P`CCTICI!`ATC NII ItUIRCR• RFVISInN NIIMRFR-
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 INSURANCE NUMBER � MMIOD/YEYYY � MMlV�"/EX,h
INSR .. _SURANCE......... iel!7i➢L`'al .-Rid ...,,, POLICY POLICY It
Dfif'Y'"YYY
LIMITS
COMMERCIAL GENERAL LIABILITY RID60669-02
..._EACH OCCURRENCE
1,000,0001-11111111111111
,.�
A
CLAIMS -MADE OCCUR -33 10/1/2021 1011/2022
".
Y7AMA6E'Ti ffN°I"Lb
PREMISES„Ea,P,currpnce
$ 100,00
'...
'.. MED EXP (Any one person)
,.......... ...a,..... ..,
$ 5,000 �,.
... ........ ,, ......... .,,,, ,�.
PERSONAL B ADV INJURY
, _
S 1,000,000
GENIC.
"__... ......... ®...,
AGGREGATE LIMIT APPLIES PER.
GENERAL AGGREGATE
S2,000,000
,r
V
LOG P'H��O-
POL4GY El ,JEC.'q'
PRODUCTS COMP/OP AGG
S2,000,0001-11111-1—
OTHEK
` $
q AUTOMOBILE LIABILITY 211
C75MEINED SINGLE LIMIT
$ 1 000 000
A .. ANY AUTO 60680-17-47 ',10/1/2021 10/1/2022
BODILY INJURY (Per person)
-, $
OWNED .r SCHEDULED
BODILY INJURY (Per accident)
S
AUTOS ONLY M AUTOS
7p... HIRED / NON -OWNED
PROPERTY DAMAGE
S
'M AUTOS ONLY Y AUTOS ONLY
.
UMBRELLA LIAB OCCUR M 'V '',
EACH OCCURRENCE
$ 5 000,000
A
EXCESS LIAB CLAIMS -MADE 60669-09-68 10/1/2021 10/1/2022
AGGREGATE
$ 5,000,000
DED RETENTIONS
S
:WORKERS COMPENSATION i
f PER TH
STATUTE ER
AND EMPLOYERS' LIABILITY
A ANYPROPRIETOR/PARTNER/EXECUTIVE _ ,A0949-23-59 10/1/2021 10/1/2022
EXCLUDED? (' NIA
"""`
EL EACH ACCIDENT S 1,000,000
,
OFFICER/MEMBER
E L DISEASE EA EMPLOYEE
S 1,000,000
(Mandatory in NH)"""""'"""
-
If yes, describe under
s DESCRIPTION OF OPERATIONS below
EL DISEASE- POLICY LIMIT
S 1,000,000
I��
I#
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
30-DAY NOTICE OF CANCELLATION, 10-DAY NOTICE OF NON-PAYMENT OF PREMIUM
WAIVER OF SUB: workers' comp
ADDITIONAL INSURED (COMPLETED OPERATIONS): The City of El Segundo
C:tK I It-It.;A I t HULUtK
CITY OF EL SEGUNDO
350 MAIN STREET, ROOM 6
EL SEGUNDO, CA 90245
1\
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 REPRESENTATGV
U 1988-2015 ACURD GUKPUKA I IUN. All ngnts reservea.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: 60669-02-33 COMMERCIAL GENERAL LIABILITY LIABILITY
CG 24 04 05 09
Lotus Communications, LLC
2084-B Central Avenue
Duarte, CA 91010
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY
LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
The City of El Segundo
As required by contract, provided the contract is executed prior to loss.
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMMERCIAL
GENERAL LIABILITY LIABILITY CONDITIONS) is amended by the addition of the following:
We waive any right of recovery we may have against the person or organization shown in the Schedule above
because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under
a contract with that person or organization and included in the "products -completed operations hazard". This waiver
applies only to the person or organization shown in the Schedule above.
CG 24 04 06 09
POLICY NUMBER: 60669-02-33 COMMERCIAL GENERAL LIABILITY
CG 20 37 04 13
Lotus Communications, LLC
2084-B Central Avenue
Duarte, CA 91010
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
ADDITIONAL INSURED --- OWNERS, LESSEES OR CONTRACTORS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY
SCHEDULE
Name of Person or Organization:
The City of El Segundo
WHO IS AN INSURED (section II) 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".
"THE INSURANCE AFFORDED BY THIS POLICY FOR THE ADDITIONAL INSURED (S) IS PRIMARY
INSURANCE AND ANY OTHER INSURANCE MAINTAINED BY OR AVAILABLE TO THE
ADDITIONAL INSURED (s) IS NON-CONTRIBUTING"
CG20370413
POLICY NUMBER: 60669-02-33 COMMERCIAL GENERAL LIABILITY
CG 20 10 07 04
Lotus Communications, LLC
2084-B Central Avenue
Duarte, CA 91010
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person(s) or Organization(s):
The City of El Segundo
CG 20 10 07 04
91-0002 (E 0002) 1., EDITION 3-08
Pnnled in U.S,A..
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", "property
damage" or "personal and advertising injury"
caused, in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your
behalf;
in the performance of your ongoing operations for
the additional insured(s) at the location(s) designated
above.
B. With respect to the insurance afforded to these
additional insureds, the following additional exclusions
apply:
This insurance does not apply to "bodily injury" or
"property damage" occurring after:
1. All work, including materials, parts or equipment
furnished in connection with such work,
on the project (other than service, maintenance
or repairs) to be performed by or on behalf of
the additional insured(s) at the location of the
covered operations has been completed; or
2. That portion of "your work" out of which the
injury or damage arises has been put to its intended
use by any person or organization other
than another contractor or subcontractor engaged
in performing operations for a principal
as a part of the same project.
CG 20 10 07 04
91-0002 (E 0002) 1st EDITION 3-88
Printed in U.S,A.,
POLICY NUMBER: 60680-17-47 COMMERCIAL AUTOMOBILE LIABILITY
CA 35 99 01 07
Lotus Communications, LLC
2084-B Central Avenue
Duarte, CA 91010
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
ADDITIONAL INSURED --- PRIMARY COVERAGE
This endorsement modifies insurance provided under the following:
COMMERCIAL AUTOMOBILE LIABILITY
SCHEDULE
Name of Person or Organization:
The City of El Segundo
Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the
extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision
contained in Section II of the Coverage Form. The inclusion of additional interest or interests will not
operate to increase the limit of our liability
"THE INSURANCE AFFORDED BY THIS POLICY FOR THE ADDITIONAL INSURED (S) IS PRIMARY
INSURANCE AND ANY OTHER INSURANCE MAINTAINED BY OR AVAILABLE TO THE ADDITIONAL
INSURED (s) IS NON-CONTRIBUTING"
POLICY NUMBER: 60680-17-47 COMMERCIAL AUTOMOBILE LIABILITY
CA 04 44 10 13
Lotus Communications, LLC
2084-B Central Avenue
Duarte, CA 91010
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST
OTHERS TO US
This endorsement modifies insurance provided under the following
COMMERCIAL AUTOMOBILE LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
The City of El Segundo
As required by contract, provided the contract is executed prior to loss.
(If no entry appears above, information required to complete this endorsement will be shown in the
Declarations as applicable to this endorsement.)
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV —
COMMERCIAL AUTOMOBILE LIABILITY CONDITIONS) is amended by the addition of the following:
We waive any right of recovery we may have against the person or organization shown in the Schedule
above because of payments we make for injury or damage arising out of your ongoing operations or "your
work" done under a contract with that person or organization and included in the "products -completed
operations hazard". This waiver applies only to the person or organization shown in the Schedule above.
CA04441013
tow" N ,
FARMERS
ANSI„fIII.AN CIII:;
WORKERS' COMPENSATION AND EMPLOYERS'
LIABILITY INSURANCE POLICY
Named Insured
• Lotus Communications, LLC
• 2084-B Central Avenue
• Duarte, CA 91010
WC 99 06 19
Effective Agent A0949-23-59 2021
Date 10/1 2 21 95-39-36A Policy Number Policy
of the Company Year
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -
BLANKET
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 for which you perform work under a written
contract that requires you to obtain this agreement from us.
The additional premium for this endorsement shall be 3.0 % of the Workers' Compensation premium
otherwise due for the state(s) listed below on such remuneration, subject to a minimum charge of 250 .
All written contracts in the state(s) of:
CA
This endorsement is part of your policy. It supersedes and controls anything to the contrary. It is otherwise
subject to all the terms of the policy.
Countersigned
Authorized Representative
93-6369 1ST EDITION 9-07
WC990619A J6369111 PAGE 1 OF 1