PROOF OF INSURANCE (2021) CLOSEDACCORD® CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYY)
12/1 /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
Crystal IBC LLC
32 Old Slip FI 17
York NY 10005
CONTACT
NAME: Kaitlyn Murphy
PHONE FAX
A/c No Ext : 212-504-1802 A/C, No
E-MNew
ADDRESS: Kaitlyn.Murphy@alliant.com
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURERA: Berkley National Insurance Com
38911
INSURED
Scantron Corporation
1313 Lone Oak Road
INSURERB: Atlantic Specialty Insurance C
27154
INSURERC: Endurance Risk Solutions Assur
43630
INSURERD:
Eagan MN 55121
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: 1349088770 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.
INSR
LTR
TYPE OF INSURANCE
ADDL
INSD
SUBR
WVD
POLICY NUMBER
POLICY EFF
MM/DD
POLICY EXP
MM/DD
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
Y
TCP 7015275
12/3/2020
12/3/2021
EACH OCCURRENCE
$ 1,000,000
CLAIMS -MADE OCCUR
DAMAGE TO RENTED
PREMISES Ea occurrence
$ 1,000,000
MED EXP (Any one person)
$ 15,000
PERSONAL &ADV INJURY
$ 1,000,000
GEN'L
AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,000
POLICY ❑ PRO
JECT LOC
PRODUCTS - COMP/OP AGG
$ 2,000,000
$
OTHER:
A
A
A
AUTOMOBILE
LIABILITY
ANY AUTO
TCA 7015777 - 11
TCA 7015778 - 11
TCA 7015779 - 11
12/3/2020
12/3/2020
12/3/2020
8/25/2021
12/3/2021
12/3/2021
COMBINED SINGLE LIMIT
Ea accident
$ 1,000,000
X
BODILY INJURY (Per person)
$
OWNED SCHEDULED
AUTOS ONLY AUTOS
X
BODILY INJURY (Per accident)
$
X
PROPERTY DAMAGE
Per accident
$
HIRED X NON -OWNED
AUTOS ONLY AUTOS ONLY
A
X
UMBRELLA LIAB
X
OCCUR
TCP 7015275
12/3/2020
12/3/2021
EACH OCCURRENCE
$ 15,000,000
AGGREGATE
$ 15,000,000
EXCESS LAB
CLAIMS -MADE
DED X RETENTION $ n
$
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANYPROPRIETOR/PARTNER/EXECUTIVE
TWC 7015276 Q 3
— —
12/3/2020
12/3/2021
X PER OTH-
STATUTE ER
E.L. EACH ACCIDENT
$ 1,000,000
OFFICE R/M EMBER EXCLUDED? ❑
N/A
E.L. DISEASE - EA EMPLOYEE
$ 1,000,000
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
B
Crime
MML1685320
12/3/2020
12/3/2021
Per Occur./Aggregate
$2,000,000
C
Cyber/Professional Liability
PR030001389801
12/3/2020
12/3/2021
Per Claim/Aggregate
$10,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
Auto Policy Numbers:
TCA 7015777 - 11 (Auto- MA)
TCA 7015778 - 11 (Auto- VA)
TCA 7015779 - 11 (Auto- All Other States)
City of El Segundo, its officials, and employees are included as Additional Insured with regards to the General Liability as required by written contract subject to
the policy terms and conditions. Coverage is Primary and Non -Contributory as required by written contract subject to the policy terms and conditions. 30 days
notice of cancellation applies, except non payment of premium which is 10 days, in accordance with the terms and conditions of the policy.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of El Segundo
AUTHORIZED REPRESENTATIVE
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
COMMERCIAL GENERAL LIABILITY
CG83601216
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
GENERAL LIABILITY EXTENSION FOR TECHNOLOGY
COMPANIES ENDORSEMENT
This Endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
This endorsement broadens coverage. The following schedule of coverage extensions is a general coverage
description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this
endorsement along with your entire policy carefully to determine the extent of coverage afforded.
SCHEDULE OF COVERAGE EXTENSIONS
A.
Additional Insured — Lessors of Leased
Equipment
K.
Duties in the Event of Occurrence, Offense,
Claim or Suit
B.
Additional Insured — Owners, Managers or
Lessors of Premises
L.
Expected or Intended Injury or Damage
(Property Damage)
C.
Additional Insured —Vendors
M.
Medical Payments
D.
Additional Insured — Written Contract or
Agreement
N.
Non -owned Aircraft
E.
Aggregate Limit Per Location
O.
Non -owned Watercraft
F.
Amateur Athletic Participants
P.
Newly Acquired or Formed Organizations
G.
Bodily Injury Definition
Q.
Supplementary Payments
H.
Broadened Named Insured
R.
Unintentional Omission
I.
Damage to Property — Borrowed Equipment,
Customer Goods, Use of Elevators
S.
Waiver of Subrogation - Blanket
J.
Good Samaritan Services
A. ADDITIONAL INSURED - LESSORS OF LEASED EQUIPMENT
Under Section II - Who Is An Insured, the following is added:
Any person or organization that is an equipment lessor is an insured, but only with respect to liability for "bodily
injury", "property damage", "personal and advertising injury" caused, in whole or in part, by your acts or
omissions in the maintenance, operation or use by you of equipment leased to you by such equipment lessor.
The insurance provided to such equipment lessor does not apply to any "bodily injury" or "property damage"
caused by an "occurrence" that takes place, or "personal and advertising injury" caused by an offense that is
committed after the equipment lease expires.
B. ADDITIONAL INSURED - OWNERS, MANAGERS OR LESSORS OF PREMISES
Under Section II - Who Is An Insured, the following is added:
Any person or organization that is a premises owner, manager or lessor is an insured, but only with respect to
liability arising out of the ownership, maintenance or use of that part of any premises leased to you.
The insurance provided to such premises owner, manager or lessor does not apply to:
1. Any "bodily injury" or "property damage" caused by an "occurrence" that takes place, or "personal and
advertising injury" caused by an offense that is committed, after you cease to be a tenant in that premises;
or
2. Structural alterations, new construction or demolition operations performed by or on behalf of such
premises owner, manager or lessor.
CG 83 60 12 16 Includes copyrighted material of Insurance Page 1 of 5
Services Office, Inc., with its permission.
C. ADDITIONAL INSURED - VENDORS
Under Section II - Who Is An Insured, the following is added:
Any person or organization that is a vendor and that you have agreed in a written contract or agreement to
include as an additional insured on this Coverage Part is an insured, but only with respect to liability for "bodily
injury" or "property damage" that:
1. Is caused by an "occurrence" that takes place after you have signed and executed that contract or
agreement; and
2. Arises out of "your products" which are distributed or sold in the regular course of such vendor's business.
The insurance provided to such vendor is subject to the following provisions:
1. The limits of insurance provided to such vendor will be the limits which you agreed to provide in the written
contract or agreement, or the limits shown in the Declarations, whichever are less.
2. The insurance provided to such vendor does not apply to:
a. Any express warranty not authorized by you;
b. Any change in "your products" made by such vendor;
c. Repackaging, unless unpacked solely for the purpose of inspection, demonstration, testing, or the
substitution of part under instructions from the manufacturer, and then repackaged in the original
container;
d. Any failure to make such inspections, adjustments, tests or servicing as vendors agree to perform or
normally undertake to perform in the regular course of business, in connection with the distribution or
sale of "your products";
e. Demonstration, installation, servicing or repair operations, except such operations performed at such
vendor's premises in connection with the sale of "your products"; or
f. "Your products" which, after distribution or sale by you, have been labeled or relabeled or used as a
container, part or ingredient of any other thing or substance by or on behalf of such vendor.
Coverage under this provision does not apply to:
1. Any person or organization from whom you have acquired "your products", or any ingredient, part or
container entering into, accompanying or containing such products; or
2. Any vendor for which coverage as an additional insured specifically is scheduled by endorsement.
D. ADDITIONAL INSURED -WRITTEN CONTRACTOR AGREEMENT
Under Section II - Who Is An Insured, the following is added:
Any person or organization that is not otherwise an insured under this Coverage Part and that you have agreed
in a written contract or agreement to include as an additional insured on this Coverage Part is an insured, but
only with respect to liability for "bodily injury" or "property damage" that:
1. Is caused by an "occurrence" that takes place after you have signed and executed that contract or
agreement; and
2. Is caused, in whole or in part, by your acts or omissions in performance of your ongoing operations to
which that contract or agreement applies or the acts or omissions of any person or organization performing
such operations on your behalf.
The limits of insurance provided to such insured will be the limits which you agreed to provide in the written
contract or agreement, or the limits shown in the Declarations, whichever are less.
E. AGGREGATE LIMIT PER LOCATION
1. Under Section III -Limits Of Insurance, the following is added:
The General Aggregate Limit applies separately to each of your "locations" owned by or rented or leased to
you.
2. Under Section V - Definitions, the following is added:
"Location" means premises involving the same or connecting lots, or premises whose connection is
interrupted only by a street, roadway, waterway or right-of-way of a railroad.
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Services Office, Inc., with its permission.
F. AMATEUR ATHLETIC PARTICIPANTS
Under Section II - Who Is An Insured, the following is added:
Any person representing you while participating in amateur athletic activities that you sponsor. However, no
such person is an insured for:
1. "Bodily injury" to:
a. A co -participant, your "employee" or "volunteer worker" while participating in amateur athletic activities
that you sponsor; or
b. You, any partner or member (if you are a partnership or joint venture), or any member (if you are a
limited liability company), or any "executive officer" (if you are an organization other than a partnership,
joint venture, or limited liability company); or
2. "Property damage" to property owned by, occupied or used by, rented to, in the care, custody, or control of,
or over which physical control is being exercised for any purpose by:
a. A co -participant, your "employee" or "volunteer worker"; or
b. You, any partner or member (if you are a partnership or joint venture), or any member (if you are a
limited liability company), or any "executive officer" (if you are an organization other than a partnership,
joint venture, or limited liability company).
G. BODILY INJURY
Under Section V - Definitions, the definition of "bodily injury" is deleted and replaced by the following:
"Bodily injury" means physical injury, sickness, or disease sustained by a person, including death resulting from
any of these. "Bodily injury" also means mental injury, mental anguish, humiliation, or shock sustained by a
person, if directly resulting from physical injury, sickness, or disease sustained by that person.
H. BROADENED NAMED INSURED
Under Section II -Who Is Insured, the following is added:
Any person or organization named in the Declarations and any organization you own, newly acquire or form, other
than a partnership, joint venture, or limited liability company, and over which you maintain more than 50% of
the interests entitled to vote generally in the election of the governing body of such organization will qualify as a
Named Insured if there is no other similar insurance available to such organization until the end of the policy
period.
Coverage under this provision does not apply to any person or organization for which coverage is excluded by
endorsement.
I. BROADENED PROPERTY DAMAGE - BORROWED EQUIPMENT, CUSTOMERS' GOODS AND USE OF
ELEVATORS
The insurance for "property damage" liability is subject to the following:
1. Under Section I - Coverages, Coverage A, Bodily Injury and Property Damage Liability, paragraph 2.,
Exclusions, item j., Damage To Property is amended as follows:
a. The exclusion for personal property in the care, custody or control of the insured does not apply to
"property damage" to equipment you borrow while at a job site and provided it is not being used by
anyone to perform operations at the time of loss.
b. The exclusions for:
(1) Property loaned to you;
(2) Personal property in the care, custody or control of the insured; and
(3) That particular part of any property that must be restored, repaired or replaced because "your work"
was incorrectly performed on it;
do not apply to "property damage" to "customers' goods" while on your premises nor do they apply to
"property damage" arising from the use of elevators at premises you own, rent, lease or occupy.
2. Subject to the Each Occurrence Limit, the most we will pay for "property damage" to "customers' goods" is
$25,000 per "occurrence".
3. Under Section V - Definitions, the following is added:
"Customers' goods" means goods of your customer on your premises for the purpose of being:
a. Repaired; or
b. Used in your manufacturing process.
CG 83 60 12 16 Includes copyrighted material of Insurance Page 3 of 5
Services Office, Inc., with its permission.
4. Under Section IV - Commercial General Liability Conditions, the insurance afforded by this provision is
excess over any other valid and collectible property insurance (including any deductible) available to the
insured whether such insurance is primary, excess, contingent or on any other basis. Any payments by us
will follow the Other Insurance - Excess Insurance provisions.
J. GOOD SAMARITAN SERVICES
1. Under Section II - Who Is Insured, paragraph 2., item d., the following is added:
This exclusion does not apply to your employees or volunteer workers, other than an employed or
volunteer physician, rendering "Good Samaritan services".
2. Under Section V -Definitions, the following definition is added:
"Good Samaritan services" means any emergency medical services for which no compensation is
demanded or received.
K. DUTIES IN THE EVENT OF OCCURRENCE, OFFENSE, CLAIM OR SUIT
Under Section IV - Commercial General Liability Conditions, paragraph 2., Duties In The Event Of
Occurrence, Claim or Suit is amended to include the following:
1. The requirements that you must:
a. Notify us of an "occurrence" offense, claim or "suit"; and
b. Send us documents concerning a claim or "suit" apply only when such accident claim, "suit" or loss is
known to:
(1) You, if you are an individual;
(2) A partner, if you are a partnership;
(3) An executive officer of the corporation or insurance manager, if you are a corporation; or
(4) A manager, if you are a limited liability company.
2. The requirement that you must notify us as soon as practicable of an "occurrence" or an offense that may
result in a claim does not apply if you report an "occurrence" to your workers compensation insurer which
later develops into a liability claim for which coverage is provided by this policy. However, as soon as you
have definite knowledge that the particular "occurrence" is a liability claim rather than a workers'
compensation claim, you must comply with the Duties In The Event Of Occurrence, Offense, Claim Or Suit
Condition.
L. EXPECTED OR INTENDED INJURY OR DAMAGE (PROPERTY DAMAGE)
Under Section I - Coverages, Coverage A, Bodily Injury And Property Damage Liability, paragraph 2.,
Exclusions, item a., Expected Or Intended Injury, is deleted and replaced by the following:
a. Expected or Intended 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 or property.
M. MEDICAL PAYMENTS
1. Under Section I - Coverages, Coverage C, Medical Payments, paragraph 1., Insuring Agreement, the
requirement that expenses are incurred and reported to us within one year of the date of the accident is
changed to three years.
2. The Medical Expense Limit is $15,000 per person or the amount shown in the Declarations as the Medical
Expense Limit, whichever is greater.
3. This provision M. does not apply if Coverage C, Medical Payments, is otherwise excluded either by the
provisions of the Coverage Form or by endorsement.
N. NON -OWNED AIRCRAFT
1. Under Section I - Coverages, Coverage A, Bodily Injury and Property Damage Liability, item 2.,
Exclusions, item g., Aircraft, Auto Or Watercraft, does not apply to an aircraft that is:
a. Hired, chartered or loaned with a paid crew; and
b. Not owned by any insured.
2. The insurance afforded by this provision N. is excess over any other valid and collectible insurance
(including any deductible or Self Insured Retention) available to the insured, whether such insurance is
primary, excess, contingent or on any other basis. Any payments by us will follow the Other Insurance -
Excess Insurance provisions in the Commercial General Liability Conditions.
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Services Office, Inc., with its permission.
O. NON -OWNED WATERCRAFT
1. Under Section II -Who Is Insured, is amended as follows:
To include as an insured for any watercraft that is covered by this policy, any person who, with your
expressed or implied consent, either uses or is responsible for the use of a watercraft. However, no person
or organization is an insured with respect to:
a. "Bodily injury" to a co -"employee" of the person operating the watercraft; or
b. "Property damage" to property owned by, rented to, in the charge of or occupied by you or the
employer of any person who is an insured under this provision.
2. In the exception to the Aircraft, Auto Or Watercraft exclusion under Coverage A, Bodily Injury And
Property Damage Liability, the limitation on the length of a watercraft is increased to 75 feet.
3. The insurance afforded by this provision O. is excess over any other valid and collectible insurance
(including any deductible or Self Insured Retention) available to the insured, whether such insurance is
primary, excess, contingent or on any other basis. Any payments by us will follow the Other Insurance -
Excess Insurance provisions in the Commercial General Liability Conditions.
P. NEWLY ACQUIRED OR FORMED ORGANIZATIONS
Under Section II - Who Is An Insured, item 3.a. is deleted and replaced by the following:
a. Coverage under this provision is afforded only until the end of the current policy period.
Q. SUPPLEMENTARY PAYMENTS
Under Section I - Coverages, Supplementary Payments - Coverages A and B is amended as follows:
1. The limit for the cost of bail bonds is amended to $2,500; and
2. The limit for reasonable expenses incurred by the "insured" is amended to $500 a day.
R. UNINTENTIONAL OMISSION
Under Section IV - Commercial General Liability Conditions, paragraph 6., Representations, the following
is added:
The unintentional omission of, or unintentional error in, any information provided by you which we relied upon in
issuing this policy will not prejudice your rights under this insurance. However, this provision does not affect our
right to collect additional premium or to exercise our rights of cancellation or nonrenewal in accordance with
applicable insurance laws or regulations.
S. WAIVER OF SUBROGATION - BLANKET
Under Section IV - Commercial General Liability Conditions, paragraph 8., Transfer of Rights of
Recovery Against Others to Us the following is added:
We will waive any right of recovery we may have against any person or organization because of payments we
make for injury or damage arising out of your ongoing operations done under a written contract or agreement
with that person or organization and included in "your work" or the "products -completed operations hazard".
This waiver applies only to persons or organizations with whom you have a written contract, executed prior to
the "bodily injury" or "property damage", that requires you to waive your rights of recovery.
CG 83 60 12 16 Includes copyrighted material of Insurance Page 5 of 5
Services Office, Inc., with its permission.
COMMERCIAL GENERAL LIABILITY
CG 83 63 01 12
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY NON-CONTRIBUTORY ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERICAL GENERAL LIABILITY COVERAGE PART
Under Section IV, Commercial General Liability Conditions, paragraph 4., Other Insurance, item a., Primary
Insurance is amended to include the following:
However, if you are obligated pursuant to a written contract or agreement entered into prior to a loss to provide
a person or organization that is included in the Who Is An Insured section of this insurance with primary
insurance such as is afforded by this policy, then this insurance is primary and we will not seek contribution
from insurance available to such person or organization.
THIS ENDORSEMENT MUST BE ATTACHED TO A CHANGE ENDORSEMENT WHEN ISSUED AFTER THE
POLICY IS WRITTEN.
CG 83 63 01 12 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1