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PROOF OF INSURANCE (2022 - 2023) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 12/14/2021 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 Artex Risk Solutions, Inc. (CB) 2850 Golf Road, 5th Floor Rolling Meadows IL 60008-4050 IN _. , .., _, _ __. CHRIBRO 14� INSURED Brothers of the Christian Schools & Affiliates Loc#1177028 DOC POW ST VINCENT SENIOR CITIZEN NTR 1205 Windham Parkway Romeoville IL 60446-1679 NAME Christian Brothers Services PHONE 0 tAA_ N ; 63�0-378.-250 0 8 E-MAIL _ � INSUR(S)_AING FFORDCOVERAGE RE� NAIC #... ..... INSURER A: Old Re ublic Insurance Com an 24147 INSURERS Old ReUi)IIC Ur110n Insurance Coan�/ 31143 !NsuAERc:...�,.....�...._.............................._...............................................................................................................................m.....W..........�....------ !N§yF qD: lNsuRER E m..,.__............. .......... INSURER F : COVERAGES CERTIFICATE NUMBER:1499162004 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. ILNSg1 TYPEOFINSURANCE IADD -SUBR� R IN D WV i POLICY_ NUMBER POLI YEF� POLMICYEXE LIMITS MYdtl1) A Y i MMr"tYDrAyly f B X I COMMERCIAL GENERAL LIABILITY N I N822100 1325596 6/1512021 6/15/2022 EACH 4 OOO,OOD CCU((RaRENCoaEry mwA. r CLAIMS -MADE [OCCUR PX_' lOSa $Included J.. I MED EXP (Any one person) $15,000 PERSONAL & ADV INJURY $Included .-._--- ..... �... GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ NIA X J POLICY PRO. El LOC _ $Included PRODUCTS COMP/OP AGG JECT ry O THR: A AUTOMOBILE LIABILITY Y Y MWTB 21543 J 1115/2021 6111/2/22 COMBINED SINGLE LiMff $ 1,000,000 IC W dzcrtrrl�rtl� I__ X =ANY AUTO BODILY INJURY Per person} $ OWNED f SCHEDULED AUTOS $ BODILY INJURY (Per accident) ^ ONLY AUTOS X I HIRED X NON -OWNED bF Llti DAPVC1 $ � AUTOS ONLY AUTOS ONLY $ UMBRELLA LIAB OCCUR � `` I EACH OCCURRENCE $ N EXCESS LIAB CLAIMS -MADE AGGREGATE FA RETENTION $ $ A WORKERS COMPENSATION Y MWC 305311 07 1/1/2022 1/112023 X sra IITE , HRH y�y AND EMPLOYERS' LIABILITY Y I Ni E EACH ACCIDENT$ 1 000 ODD L OF ICER EMBEREXCLUDED?ANYPROPRIETOFUPARTNER/EXECUTIVE N INIAi 3 (Mandatoryin NH) E.L. DISEASE EA EMPLOYEE Y $1,000.000 describe under L '""" POLICYes, � 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE - LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached It more space Is required) Waiver of Subrogation (where allowed by law) per attached endorsement is provided under Auto Liability & Worker's Compensation coverage when required by fully executed written contract. Certificate Holder is addled as Additional Insured (per attached endorsement) for Automobile liability coverages solely, strictly and specifically with regards to; Consultant Services for the Community Development Block Grant Program for Home Delivered Meals. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of El Segundo Its Official and Employees Office Of City ACCORDANCE WITH THE POLICY PROVISIONS. Clerk 350 Main Street AUTHORIZED REPRESENTATIVE El Segundo CA 90245 .4�� 4& i 0 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 2" of 5 4198 OLD REPUBLIC UNION INSURANCE COMPANY Attaching to and forming part of Policy No. 8221001325596 Named Insured: THE RELIGIOUS AND CHARITABLE RISK POOLING TRUST OF THE BROTHERS OF THE CHRISTIAN SCHOOLS AND AFFILIATES Effective date of this endorsement is June 15, 2021 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED SCHEDULED PERSON OR ORGANIZATION This endorsement modif ies insurance provided under SECTION II INSURING AGREEMENT C, GENERAL LIABILITY COVERAGE defined within the Coverage Agreement SECTION 1: Schedule Name of Additional Insured Persons(s) or Designated Location(s) Of Covered Operations: Organization(s): ANY PERSON OR ORGANIZATION WHEN YOU HAVE AGREED IN A WRITTEN CONTRACT FOR THAT PERSON OR ORGANIZATION TO BE ADDED AS AN ADDITIONAL INSURED ON YOUR POLICY. If no entry appears above, information required to complete this endorsementw ill be show n in the Certificate of Coverage as applicable to this endorsement. Section II Ins uringAgreement C -Name of Insured Amended A Who Is An Ins ureddefined in the General Insurance Agreement is amended to include as an Additional Insured the person(s) or organization(s) show n in the Schedule above, but only w ith respect to liability in the performance of the Named Insured's ongoing operations fortheAdditional Ins ured(s)atthe Location(s) designated in the Schedule above for "bodily injury" or "property damage", caused in whole or in part, by the Named Insured's acts or omissions which takes place after the execution of a w ritten agreement with the Additional Insured(s). B For the coverage provided by this endorsement: the following paragraph is added to Section IV —General Conditions, Section II, Insuring Agreement C-General Liability This insurance is primary insurance as respects to this coverage to the additional insured person or organization, w here thew ritten contract or w ritten agreement requires thatthis insurance be primary and noncontributory In that event, w ew ill not seek contribution fromany other insurance policy available to the additional insured on w hich the additional insured person or organization is a Named Insured C. Who Is An Insured is also amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, w ith respect to liability for "bodily injury" or "property damage" caused, in w hole or in part by the "Named Insured's w ork" 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 most w ew ill pay is the amount of insurance requiredby thew ritten contract orthe amount of applicable limits of insurance under this policy; whichever is less. This Insurance does not apply to any claims or suits seeking damages, including defense, arising out of, directly or indirectly, from any actual or alleged participation in any act of sexual misconduct, sexual harassment, sexual molestation, sexual abuse or any claim sexual in nature, physical or mental, of any person. Except as amended in this endorsement, this insurance is subjectto all coverage terms, clauses and conditions in the policy to w hich this endorsement is attached and only applies to the extent permitted by law IL 10 (12106) OLD REPUBLIC INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM SCHEDULE Name of Person(s) or Organization(s): All persons or organizations as required by contract or agreement With respect to COVERED AUTOS LIABILITY COVERAGE, Who Is An Insured is changed with the addition of the following: Each person or organization shown in the Schedule for whom you are doing work is an "insured". But only for "bodily injury" or "property damage" that results from the ownership, maintenance or use of a covered "auto" by: 1. You; 2. an "employee" of yours; or 3. anyone who drives a covered "auto" with your permission or with the permission of one of your "employees". However, the insurance afforded to the person or organization shown in the Schedule shall not exceed the scope of coverage and/or limits of this policy. Not withstanding the foregoing sentence, in no event shall the insurance provided by this policy exceed the scope of coverage and/or limits required by the contract or agreement. PCA 001 10 13 MWTB 21543 Religious and Charitable Risk Pooling Trust 06/15/2021 - 06/15/2022 3" of 5 4198 IL 10 (12/06) OLD REPUBLIC INSURANCE COMPANY 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: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM SCHEDULE Name of Person or Organization: Only those persons or organizations for whom you are required to waive your rights of recovery under the terms of a written contract. (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 is changed by adding the following: We waive any right of recovery we may have against the person(s) or organization(s) shown in the Schedule because of payments we make for injury or damage. This waiver applies only to the person or organization shown in the Schedule. PCA 024 10 13 Page 1 of 1 MWTB 21543 Religious and Charitable Risk Pooling Trust 06/15/2021 - 06/15/2022 4• ors 4198 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 0484) POLICY NUMBER: MWC 305311 07 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA 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. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 0 % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION ALL PERSONS OR ORGANIZATIONS WHERE REQUIRED BY WRITTEN CONTRACT DATE OF ISSUE: 11-08-21 JOB DESCRIPTION ®1998 by the Workers' Compensation insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual © 1999. INSURED COPY 5° of 5 4198