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PROOF OF INSURANCE (2023 - 2023) CLOSEDPage 1 of 2 AC7 R � CERTIFICATE OF LIABILITY I DATE (MMIDD/YYYY) OS/06/2022 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 CONNAMF', Willis Towers Watson Certificate Center Willis Towers Watson Northeast, Inc. "„ ....... ..... ..... ..... _,. c/o 26 Century Blvd PHONE 1 877-945-7378 FAX 1-688-967-2378 (AlO. Nq Ext) E-MAIL certificates@willis.com P.O. Box 305191 ADDRE,SS.,,,,,,.............. Nashville, TN 372305191 USA INSURER(S)AFFORDINGCOVERAGE NAIC# INSURERA: Sompo America Insurance Company 11126 INSURED INSHRERH. Travelers Property Casualty Company of Ame 25674 Kyocera Document Solutions West, LLC 14101 Alton Parkway Irvine. CA 92618 1IPE%10 M A 11 C C /'COTICIr ATC All IMRCR• W24731940 INSURER D : INSURER E: RFVlglON 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, ...... .,.._ EFF EXP ILTfi .,.......... ADDL S4 BR ........ .. POLIO �,_ .-. ,,,.,.,. _-, LIMITS TYPE OF INSURANCE POLICY NUMBER /ODY IPA ---ICY D/YYYY '.. X '... COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 0AK4dt i`TO RENT E _ 1,000,000 CLAIMS -MADE X''... OCCUR PROMrP.eE ffiuova urrrnc) S A f,MrO EXP(Any one wsgr a $ 5,000 CPL40361JO 04/01/2022.04/01/2023',PERSONAL&ADVINJURY 5 1,.000,000 .,. .,... ............ GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE S 2,000,000 .. X Pal ley 7 ,NECT ( _"I LOC .,...PRODUCTS-COMP/OP ......., M�(CT AGG $2,000,000 ., ,- , Olj1 E6 r $ AUTOMOBILE LIABILITY COMB NED SiNGLE LIMIT $ 1,000,000 m. X ANY AUTO BODILY INJURY (Per person) $ A OWNED SCHEDULED TAM30017921400 04/01/2022 04/01/2023 BODILY INJURY (Per a ccidenl) $ AUTOS ONLY AUTOS ,..PRO - ----. . HIRED NON -OWNED '.. EI�I PTYDAMAGE S ... AUTOS ONLY 1 AUTOS ONLY ',.. E"tnn a odol,,11) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,0090 A...__ .., EXCESS LIAB '.CLAIMS -MADE. CPU41021VO �04/01/2022'04/01/2023 ... .-. ...._ AGGREGATE $ 10,000,000 DELI X RETENTIONS 10,000 S WORKERS COMPENSATION '... '... X PER r 3fA"fLl f Fr _, f-RIf AND EMPLOYERS' LIABILITY ,, Y I ... ,,,,,,, 1,000,000 B ANYPROPRIETORIPARTNERIEXECUTIVE I OFFICER/M EMBER EXCLUDED? ] NIA y UB-9N324130-22-14-G 01/01/2022 01/01/20234EL, E L EACH ACCIDENT $ l (Mandatory in NH) """'"' ASE EA EMPLOYEE $ 1,000,000 DISEASE _ If yes, describe under "-� DESCRIPTION OF OPERATIONS below E L DISEASE • POkIGeY I IMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) SCOPE OF WORK: Copier Sales, Leasing & Maintenance City of E1 Segundo with whom the Insured has agreed in written contract, agreement or permit is included as an Additional Insured with respect to liability arising out of the Insured's operations, personal property leased to the insured, premises owned or rented by, or temporarily occupied by the insured with permission of the owner. UhK I IrIt;A I h hULUtK %,1A1M r_LLa a 1', 1%JN City of El Segundo Attn: City Clerk 350 Main Street E1 Segundo, CA 90245-3813 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 REPRESENTATIVE © 1988-2016 ACORD CORPORATION. All rlgnts reservea. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 22562355 BATCH: 2516491 AGENCY CUSTOMER ID: AC CWZ" ADDITIONAL REMARKS SCHEDULE Page 2 Of 2 AGENCY NAMED INSURED Willis Towers Watson Northeast, Inc. Kyocera Document Solutions West, LLC ,._ ---------- .,,,,,,,,,, 14101 Alton Parkway POLICY NUMBER Irvine, CA 92618 See Page 1 FNAIER CODE _..... .................................._.__--- gSee Page 1 Page 1EFFECTIVE DATE: See Pag� THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM TITLE: 25 Certificate o£ Liability Insurance FORM NUMBER: .......... — t �..........._................. --- ..�........... If required .. �............��.. �, w,,,,....._ ._......._.a.........................................�._. .�., _ qu' in he written contract, agreement or permit, the Insured waives any right of recovery (where permitted by law) that they may have against City of E1 Segundo because of payments that may be made for injury or damage. Waiver of Subrogation applies in favor of City of E1 Segundo with respects to Workers Compensation as permitted by law. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID: 22562355 BATCH: 2516491 CERT: W24731940 POLICY NUMBER: CPL40361JO COMMERCIAL GENERAL LIABILITY CG20371219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATION This endorsement modifies insurance provided under the following:. COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations ANY PERSON OR ORGANIZATION WHERE COVERED PROPERTY YOU ARE OBLIGATED PURSUANT TO A WRITTEN CONTRACT OR AGREEMENT EXECUTED PRIOR TO A LOSS TO PROVIDE SUCH INSURANCE AS IS AFFORDED BY THIS POLICY. Information required to complete this Schedule, if not shown above, will be shown in the Declarations, CG 20 37 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 3 POLICY NUMBER: CPL40361JO COMMERCIAL GENERAL LIABILITY CG20101219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED ERSO O ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Locations Of Covered O erations ANY PERSON OR ORGANIZATION WHERE COVERED PROPERTY YOU ARE OBLIGATED PURSUANT TO A WRITTEN CONTRACT OR AGREEMENT EXECUTED PRIOR TO A LOSS TO PROVIDE SUCH INSURANCE AS IS AFFORDED BY THIS POLICY. Information required to complete this Schedule„ it not shown above,, wail be shown In the Declarations. CG 20 10 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 3 POLICY NUMBER: CPL40361JO COMMERCIAL GENERAL LIABILITY CG24041219 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ELECTRONIC DATA LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART POLLUTION LIABILITY COVERAGE PART DESIGNATED SITES POLLUTION LIABILITY LIMITED COVERAGE PART DESIGNATED SITES PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART UNDERGROUND STORAGE TANK POLICY DESIGNATED TANKS SCHEDULE The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery against the person(s) or organization(s) shown in the Schedule above because of payments we make under this Coverage Part. Such waiver by us applies only to the extent that the insured has waived its right of recovery against such person(s) or organization(s) prior to loss. This endorsement applies only to the person(s) or organization(s) shown in the Schedule above. CG 24 04 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 AM TRAVELERSJ' , WORKERS COMPENSATION AND 01', rF, r Mvl. R SQ[JARF..� EMPLOYERS LIABILITY POLICY lIC1R 1. C)l�'D C.. 1 06183 ENDORSEMENT WC 00 03 13 (00) - 001 POLICY NU1 ER; UB-9N324130®22®14®G WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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.) This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. SCHEDULE DESIGNATED PERSON. II:'NI' SIIIta 19A't"III;;I1'.) OII OAINVJ%'11'IIION, ANY 1'l]I:;`ON 0rt C}RC:'rAN1lAT]C)N IFOR WHICH 1'}:'E I1VSUTiIE) 1"1/1S AGREED BY In1RT'I"I'lEN r.X7,C U1.ED 111RIOR CO 1:,0SS `I0 FURNISH THIS /3nY 0-r orclas.r r,tct: �i..or2 f or wh.:'i..c,h the, e r.I.PI <7ye-rhas aga ec.(a. h,)y written c:oirl .act:„ eyec'ut cMc:l P.1 :Ii or to lass, may execute a wa-l-ve r of st:rl tc:a.t::_a c:>ia , Tloweve:rir, fair, purposes cv:l:: y t:h.G EO.�.� I O� er: rr 1 :" nc , i tYr i o-crr_i v; c. .o f ta..�i t�c�c���t: � crr� does ri.ot C����p y. V / y we>:rlr rc r c:>i trc,c.. l c> r:� i i c c� rx .� t i. a <., t.. r. <:> r� group cz a r� ca f: c...L G;..� .s t. f i c.°. ��. t .i u � y. �� �� c t c. �:, i. e� i.7 c� t. e c3. by t.. ] X c. w a iv c.. it of. .ir �. el l:i t:: to a e,covc.is t_ro.i. other's ( :ubr.,ogat:_ion) rule _l.n our, manual.. 0061197 l'..A.t`IE OF ISSUE: 01--04 ,,.22 ST ," »&GN; PA('.-., : 1 OF 1