PROOF OF INSURANCE (2017) CLOSEDDATE (MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 10/28/2016
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(les) must 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
NAMEm ,
Marsh USA, Inc.
............ .......
PHONIw
1166 Avenue of the Americas
f10 ..1f .Cdst9x------. _ _. . —
New York, NY 10036
E fillAtL
APr?E ..
Attn: Norwalk.certrequest@marsh.com Fax: 212-948-0929
INSUR RDING COVERAGE
849434mG 16.. ............... . . .
om an
INSURER A. ACE American Insurance C.....P........ - -
. ......... 111 .. W, ........
INSUREDOne
Indemnity Insurance Companycof North America
INSURER a
Iron Management Inc.
Fede
._.�_
raters Ins
ACE Fire Underyy�
al Street
INSURE C ----
Boston, MA 02110
INSURER D : Agri General Insurance Company
INSURER E.
INSURER F :
COVERAGES CERTIFICATE NUMBER.
NYC-008041461-13 REVISION NUMBER-01
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.
.�..�..,m- TYPE OF INSU.,.... ............ AUbL ' lbhA 1 _...�... �.....",,,.,.,. — --------
4L1TR INSURANCE POLICY NUMBER
,.�...._ POLICY EFF P606 r�"X _...._.._. ._._ ...
MMIDD YY MMIDD LIMITS
......� ......----....w,
A X COMMERCIAL GENERAL LIABILITY HDOG27859586
11/01/2016 11/01/2017 EACH OCCURRENCE $
1,000,000
CLAIMS -MADE I..X°. OCCUR
RLMi'yE.S{La�D;Cerr n e $
1 000000
MED EXP A y one persons $
--- 25 000
............__ .._.
PERSONAL & ADV INJURY $
1,025,000
F _...........
GEN'L AGGREGATE LIMIT PER.
T APPLIES
GENERAL G ATE $
AGREG
' _ 2,000,000
X
PRODUCTS COMP/OP AG G $
1,00 0,000
POLICY jECT LOC
_
OTHER'
$
_
A AUTOMOBILE LIABILITY ISAH09051880
r LIMIT
1110112016 11/01/2017 $
tFaM '1 Da INGLE........... .........--
2000000
_.......
X ANY AUTO
BODILY INJURY (Per person) $
—
ALL OWNED SCHEDULED
BODILY INJURY (Per accident) $
AUTOS AUTOS
NON -OWNED
"
PITOPf R I Y DAMAGE $
_
HIRED AUTOS AUTOS
UMBRELLA LIAB OCCUR
EACH OCCURRENCE $
EXCESS LIAB CLAIMS -MADE
AGGREGATE $
. ..-_
- ---
...�_ ..
$
B WORKERS COMPENSATIONi..._TION..$
ED RETENTION
WLRC4910554A (AOS)
11101/2016/1/0112017 X SEk OTH
AND EMPLOYERS' LIABILITY
A WLRC49105563 (AZ,CA,MA)
ANYCERMEMBERlPXCLUDED? CtI'TrIJI:
� I N
11/0112016 11/01/2017 E L EACH ACCIDENT
T $
100 00 000
OFFdClwfl"�e"dMaIMBLR EXCLUDED. � tNLRC49105575TN
D (Mandatary in NH) I )
1110112016 1110112017 E L DISEASE 1=A EMPLOYEE $
..— ,000
_
C If os, describe under SCFC49105551 (WI)
O-SCRIPTICNN OF OPE°RAT#ONS botaw
11/01/2016 11/0112017 E,L, DISEASE POLICY LIMIT $
1,000,000
A EXCESS WC & CUC49105587(OH & WA)
1110112016 11/01/2017 Each Accident/Emp for Disease
1,000,000
EMP. LIABILITY
SIR
500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is reciulred)
CERTIFICATE HOLDER
CANCELLATION
City of El Segundo
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
350 Main St.
THE EXPIRATION DATE THEREOF, NOTICE WILL BE
DELIVERED IN
El Segundo, CA 90245
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Sam Baliga
C 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD