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PROOF OF INSURANCE (2023 - 2023) CLOSED�w EFFIC-1 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)061092022 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 Nicholson Insurance, Inc. License 1110498116 4317 Northstar Way, Ste B Modesto„ CA 95356 Karen A. Nicholson X-Ray Inc Tanga Canyon Place rth, CA 91311 Karen A. Nichol 209-526-2697 F: Homeland Ins Co of New York State Cnsation In...... Fund" o sF d Atlantic Specialty Ins Co C VERA E'S CER'TIFICAT MBER: REVISION NUMBER: 34452 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, EDUCED BY PAID CLAIMS LIMITS MAY HAVE _ OF SUCH SHOWN A H POLICIES EXCLUSIONS _..."�. ES 1NSR TYPE DDL;,SUBR Y POLICY EFF POLICY EXP LIMITS I TR E OF INSURANCE VVVQ PO CNUMBER COMMERCIAL X CIAL GENERAL LIABILITY EACH OCCURRENCE OCCURRENCE W �. N � 2,000,000 _ .. CLAIMS -MADE X OCCUR Xd 793-01-08-70-0001 02/20/2022 02/20/2023 DAMAGE TO RENTEO luup�5u�fc�t�.., 50 000 .__ _ _ ....U1 5 000 MEP EXP,,, Anv one Berson 5... 2,000,000 PE�ONAL,&ADVINJ,,,,,,e .. 'POLICY ,000,000 N'TE LIMIT APPLIES PER: G� GENERALAGGREC�AT,E S ....,2,000,000 [XI !1p T1:1 LOC ,PRODUCTS COMP/OPT!. G : TITHER C '.. COMBINED LIMIT 1,000,000n AUTOMOBILE LIABILITY �.A�ji7inlA�SINGLE ......,.__�L $ . X ANY AUTO 793-01-08-71-0000 02/20/2022 02/20/2023 BO LY IN URY"(Per,person , � „ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per„accidenl� L_ — �g X..AUTOS AU70�I Y' PROPEFtf kAMFtI�E --...,. ...... ONLY —X ...IPer ,..m.m,_-- A X UMBRELLA LIAB X (OCCUR "EACH OCCIwIRRENCE b00000 1,, 5,m,� I( EXCESS LIAB CLAIM .... .. ---- I 793-01-08-72-0001 02/20/2022 02/20/2023 A995EGATE $......... .n.n. . DED RETENTION $ B WORKERS COMPENSATION H X I. PER IT .. _ AND EMPLOYERS'LIABILITY YIN ECUTIVE X 9054402 05/01/2022 - .. 05/01/2023 1,000,000 EXCLUDEDANY ? ❑ N / A .... _,..... 1,000,000 (9wlaridaC 8n NH) E L, D �EASEEDAEMPLOYEEI $ If yes, describe under RIPTI. N Fop,N b. I w DI. EASE -POLICY LIMIT 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of El Segundo is listed as Additional Insured with Waiver of Su6rogaltion to apply to Worker's Compensation. CITYOEL City of El Segundo 350 Main St El Segundo, CA 90245 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 ACORD 25 (2016/03) ©1988-2015 ACORD CORPURATIUN. All ngnts reservea. The ACORD name and logo are registered marks of ACORD Policy Number: 793 01 08 70 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSESS OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies coverage provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS ENVIRONMENTAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Any person or organization that the, Named Insured agreed to add as an additional insured In a written contract or written agreement that was fully executed by the Named Insured prior to the performance of the Named Insured"s worts that is the subject of such written contract or written agreement, Location And Description Of Completed Operations: Any location, and completed operations at such location„ where required by the written contract or written agreement in which the Named Insured agreed to add the person or organization qualifying as an additional insured under this endorsement. 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 environmental 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. However: 1. The insurance afforded to such additional insured only applies to the extent permitted bylaw; and 2. if coverage provided to the additional insured is required by a contract or agreement„ the insurance afforded. to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to 1. Limits of Insurance in SECTION III — LIMITS OF INSURANCE AND DEDUCTIBLE: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of Insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. All other terms and conditions remain the same. OBENV GE 351 (09 20) Contains copyrighted material of Insurance Services Office, Inc. with Its permisslon Page 1 of 1 Copyright 2020, OneBeacon Insurance Group LLC Policy Number: 793-01-08-70-0001 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies coverage provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS ENVIRONMENTAL LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Orga ��� nization: Any person or organization that the "Named Insured" agreed to waive its rights of recovery against in a fully executed written contract. The following is added to the Transfer Of Rights Of Recovery Against Others To Us condition of SECTION IV - CONDITIONS: 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 negligence during: 1. Your ongoing operations; or 2. Your work; performed under a written contract with such person or organization and "included in the products -completed operations hazard,. 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) in the written contract prior to loss. This waiver applies only to the person or organization shown in the SCHEDULE above. All other terms and conditions remain the same. OBENV GE 320 (11 20) Contains copyrighted material of Insurance Services Office, Inc. with its permission. Page 1 of 1 E-INSURED Policy Number: 793-01-08-70-0001 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies coverage provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS ENVIRONMENTAL LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to, and will not seek contribution from, any other insurance available to an additional insured under this policy provided that: a. The additional insured is a named insured under such other insurance; and b. The Named Insured has agreed in writing in a contract or agreement that this insurance would: (1) Act primary to any other insurance available to the additional insured; and (2) Would not seek contribution from any other insurance available to the additional insured. All other terms and conditions remain the same. OBENV GE 319 (11 20) Contains copyrighted material of Insurance Services Office, Inc. with Hs permission. Page 1 of 1 E-INSURED ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS HOME OFFICE SAN FRANCISCO EFFECTIVE MAY 1, 2022 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING MAY 1, 2023 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME EFFICIENT X-RAY INC 9650 TOPANGA CANYON PL STE F CHATSWORTH, CA 91311 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. REP 05 9054402-22 RENEWAL NA 2-17-73-22 PAGE 1 OF 1 THIS AGREEMENT APPLIES ONLY TO THE EXTENT THAT YOU PERFORM WORK UNDER A WRITTEN CONTRACT THAT REQUIRES YOU TO OBTAIN THIS AGREEMENT FROM US. THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 2.00% OF THE TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER JOB DESCRIPTION BLANKET WAIVER OF SUBROGATION NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: MAY 3, 2022 P 2572 AUTHORIZED REPRESENT IVE PRESIDENT AND CEO SCIF FORM 10217 (REV.7.2014) OLD DP 217