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PROOF OF INSURANCE (2023) CLOSEDACC CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DDIYYYY)
10/11 /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 CONTACT
MARSH USA, INC. NAME'•,,,
FAX
—
TWO ALLIANCE CENTER PHONE FAX
xf4� atl1� .. .. ..
3560 LENOX ROAD, SUITE 2400 E-MAIL
ATLANTA, GA 30326 npoREsS: -- --- ................... .................. -----.. ............... .....,.........", --... .. .......-„
C N 130114897-EO/C-GAWU-22-23
INSURED
CentralSquare Technologies, LLC
Superion, LLC
TriTech Software Systems
1000 Business Center Dr.
Lake Mary, FL 32746
A: The Charter Oak Fire Insurance Co.
INSURER D : Travelers Casualty And
INSURER F t
CAVFRAr;FS CFRTIFICATF NUMBER: ATL-005306681-07 REVISION NUMBER: 3
.....................NAIL #
25615
25623
5674
19038
26883
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,,,,,...........,..,_.. .............. .m.m.,.. .__.., .,...... ..R..
„ ..............
_ _ POLICY Lip
LTR TYPE OF INSURANCE ............ L �...^^..m...,.POLICY NUMBER MPO MIpI�IYYYY MM/ ®�IYYYY....... LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
H-630-65758660-COF-22
08/31/2022
08131/2023
EACH OCCURRENCE
$ 1,000,000
�ArurA+;E'"f� i1E�"YEb
..
_.1�-
CLAIMS -MADE X-I OCCUR
PREMISES. Ea occurrence
_$ ..mm�
MED EXP (Any one person)
$ 1Q000
...
PERSONAL 8 ADV INJURY _
1,000,000
$
GEN'L
APPLIES
AGGREGATE LIMIT A
GENERAL AGGREGATE
$ 2,000,000
X
P"O'�
POLICY JECT D LOG
PRODUCTS COMP/OP AGG
$ _ 2,000 000
OTHER
$
B
AUTOMOBILE LIABILITY
_
BA-6S783539-22-13-G
08/31/2022
08131/2023
IaBccl enld SINGLE LIMIT.. .,$
1000,000
---
ANY AUTO
BODILY INJURY (Per person)
'.... $
OWNED SCHEDULED
(Per accident
BODILY INJURY Pe
$
AUTOS ONLY AUTOS
HIRED X
STY E
DAMAGE
AUTOS ONLY
.-..m AUTOS ONLY AU
I X--
(R�O,PE
$ _....—_.
X UMBRELLA LIAB OCCUR
CUP-6SW1390
08/31/2022
08/31/2023
EACH OCCURRENCE
$ 10,000,000
EXCESS LIAB CLAIMS -MADE
... d
"Pi
AGGREGATE
$ 10,00 0,000
DED RETFNTION $10 000
$
D
WORKERS COMPENSATION
UB-6S783668-22-13-G
081" 1l2
X STATUTE °IiH-
AND EMPLOYERS' LIABILITY-
YIN
_
OFFICEANYPRR MEMBE EXCL EXCLUDED?
OFFICERIMEMBEREXCLUDED? N
N/A
H ACCIDENT
,000
$ �..
._ _—_--
1,000,000
(Mandry
. E L. DISEASE - EA EMPLOYEE
....
_$..............................._—.�..
If yes, DESCRIPTION under
OF OPERATIONS below
EL DISEASE -POLICY LIMIT
1,000,000
E
E&O/Cyber
015930626
09/30/2022
0813112023
Limit
5,000,000
SIR
1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
City of El Segundo, its officials, and employees are included as additional insured where required by written contract with respect to General and Auto Liability, Waiver of subrogation is applicable where required by
writlen contract with respect to General Liability and Workers Compensation, The General Liability is primary and non-contributory over any existing insurance and limited to liability arising out of the operalions of the
named insured and where required by written contract.
f1rPTIClf*..A"T1= 94rM r1FR C..'ArdCFI I. ATH71M,..,
City of El Segundo
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Attn: City Clerk's Office 350 Main Street
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Segundo, CA 90245
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc
9)1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: CN130114897
LOC #: Atlanta
C ADDITIONAL REMARKS SCHEDULE
Page 2 of 2
AGENCY
NAMED INSURED
MARSH USA, INC.
CentralSquare Technologies, LLC
.. ........
Superior, LLC
POLICY NUMBER
TriTech Software Systems
1000 Business Center Dr,
Lake Mary, FL 32746
.... ... .._�..... ........_.—..
CARRIER
NAIC CODE
EFFECTIVE DATE:
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, I
V FORM NUMBER: 25 FORM TITLE: ,Certificate of Liability Insurance
Excess E&O/Cyber:
Carrier: Certain Underwriters at Lloyd's, London
Policy Number: ACX1045822
Effective Date: 09/30/2022
Expiration Date: 08/31/2023
Limit: $5M x $5M
ACORD 101 (2008/01)
0413-01-00-0001064-0002-0003604
© 2008 ACORD CORPORATION. All rights i
The ACORD name and logo are registered marks of ACORD R.
POLICY NUMBER: BA-5S783539-22-13-G
COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
:
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
PROVISIONS
1. The following is added to Paragraph A.1.c., Who
Is An Insured, of SECTION II — LIABILITY
COVERAGE:
This includes any person or organization who you
are required under a written contract or
agreement between you and that person or
organization, that is signed by you before the
bodily injury" or "property damage" occurs and
that is in effect during the policy period, to name
as an additional insured for Liability Coverage,
but only for damages to which this insurance
applies and only to the extent of that person's or
organization's liability for the conduct of another
"insured".
2. The following is added to Paragraph B.S., Other
Insurance of SECTION IV — BUSINESS AUTO
CONDITIONS:
Regardless of the provisions of paragraph a. and
paragraph d. of this part S. Other Insurance, this
insurance is primary to and non-contributory with
applicable other insurance under which an
additional insured person or organization is the
first named insured when the written contract or
agreement between you and that person or
organization, that is signed by you before the
"bodily injury" or "property damage" occurs and
that is in effect during the policy period, requires
this insurance to be primary and non-contributory.
CA T4 74 08 17 ® 2010 The Travelers Indemnity Company. All rights reserved. Page 1 of 1
Includes copyrighted material of Insurance Services ofllce, Inc, with Rs permission.
POLICY NUMBER: 6306S758660-COF-22
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED
(Includes Prod ucts-Completed pelretions If Required By Contract)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PROVISIONS
The following is added to SECTION II — WHO IS AN
INSURED:
Any person or organization that you agree in a
written contract or agreement to include as an
additional insured on this Coverage Part is an
insured, but only:
a. With respect to liability for "'bodily injury" or
"property damage" that occurs, or for "personal
injury' caused by an offense that is committed,
subsequent to the signing of that contract or
agreement and while that part of the contract or
agreement is in effect; and
b. If, and only to the extent that, such injury or
damage is caused by acts or omissions of you or
your subcontractor in the performance of "your
work" to which the written contract or agreement
applies. Such person or organization does not
qualify as an additional insured with respect to
the independent acts or omissions of such
person or organization.
The insurance provided to such additional insured is
subject to the following provisions:
a. If the Limits of Insurance of this Coverage Part
shown in the Declarations exceed the minimum
limits required by the written contract or
agreement, the insurance provided to the
additional insured will be limited to such
minimum required limits. For the purposes of
determining whether this limitation applies, the
minimum limits required by the written contract or
agreement will be considered to include the
minimum limits of any Umbrella or Excess
liability coverage required for the additional
insured by that written contract or agreement.
This provision will not increase the limits of
insurance described in Section III — Limits Of
Insurance.
(1) Any "bodily injury", "property damage" or
"personal injury" arising out of the providing,
or failure to provide, ary professional
architectural, engineering or surveying
services, including:
(a) The preparing, approving, or failing to
prepare or approve, maps, shop
drawings, opinions, reports, surveys,
field orders or change orders, or the
preparing, approving, or failing to
prepare or approve, drawings and
specifications; and
(b) Supervisory, inspection, architectural or
engineering activities.
(2) Any "bodily injury' or "property damage"
caused by 'dour work" and included in the
"products -completed operations hazard"
unless the written contract or agreement
specifically requires you to provide such
coverage for that additional insured during
the policy period.
c. The additional insured must comply with the
following duties:
(1) Give us written notice as soon as practicable
of an "occurrence" or an offense which may
result in a claim. To the extent possible, such
notice should include:
(a) How, when and where the "occurrence"
or offense took place;
(b) The names and addresses of any injured
persons and witnesses; and
(c) The nature and location of any injury or
damage arising out of the "occurrence"
or offense.
b. The insurance provided to such additional (2) If a claim is made or "suit is brought against
insured does not apply to: the additional insured:
CG 02 46 0419 Q 201 a The Travelers Indemnity Company_ NI rights reserved- Page 1 of 2
0413-01-00-0001064-0003-0003605 0
COMMERCIAL GENERAL LIABILITY
(a) Immediately record the specifics of the
claim or "suit" and the date received; and
(b) Notify us as soon as practicable and see
to it that we receive written notice of the
claim or "suit" as soon as practicable.
(3) Immediately send us copies of all legal
papers received in connection with the claim
or "suit", cooperate with us in the
investigation or settlement of the claim or
defense against the "suit'. and otherwise
comply with all policy conditions.
(4) Tender the defense and indemnity of any
claim or "suit" to any provider of other
insurance which would cover such additional
insured for a loss we cover. However, this
condition does not affect whether the
insurance provided to such additional
insured is primary to other insurance
available to such additional insured which
covers that person or organization as a
named insured as described in Paragraph 4r,
Other Insurance, of Section IV — Commercial
General Liability Conditions.
Page 2 of 2 0 2018 The Travelers Indernnity company. All rights reserved. CG D2 46 0419
POLICY NUMBER_ 630-6S758660-COF-22
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
GENERAL DESCRIPTION OF COVERAGE — This endorsement broadens coverage. However, coverage for any
injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or
limited by another endorsement to this Coverage Part, and these coverage broadening provisions do not apply to
the extent that coverage is excluded or limited by such an endorsement. The following listing is a general
coverage description only. Read all the provisions of this endorsement and the rest of your policy carefully to
determine rights, duties, and what is and is not covered.
A Non -Owned Watercraft — 75 Feet Long Or Less
B. Who Is An Insured — Unnamed Subsidiaries
C. Who Is An Insured — Employees — Supervisory
Positions
D. Who Is An Insured — Newly Acquired Or Formed
Limited Liability Companies
E. Who Is An Insured — Liability For Conduct Of
Unnamed Partnerships Or Joint Ventures
F. Blanket Additional Insured — Persons Or
Organizations For Your Ongoing Operations As
Required By Written Contract Or Agreement
G. Blanket Additional Insured —Broad Form Vendors
H. Blanket Additional Insured — Controlling Interest
PROVISIONS
A. NON -OWNED WATERCRAFT — 75 FEET LONG
OR LESS
1. The following replaces Paragraph (2) of
Exclusion g., Aircraft, Auto Or Watercraft
in Paragraph 2. of SECTION 1 —
COVERAGES — COVERAGE A — BODILY
INJURY AND PROPERTY DAMAGE
LIABILITY:
(2) A watercraft you do not own that is:
(a) 75 feet long or less; and
(b) Not being used to cant' any person or
property for a charge;
2. The following replaces Paragraph 2.e. of
SECTION 11— WHO IS AN INSURED:
e. Any person or organization that, with your
express or implied consent, either uses or
I. Blanket Additional Insured — Mortgagees,
Assignees. Successors Or Receivers
J. Blanket Additional Insured — Governmental
Entities — Permits Or Authorizations Relating To
Premises
K. Blanket Additional Insured —Governmental
Entities — Permits Or Authorizations Relating To
Operations
L. Medical Payments — Increased Limit
M. Blanket Waiver Of Subrogation
N. Contractual Liability —Railroads
O. Damage To Premises Rented To You
is responsible for the use of a watercraft
that you do not own that is:
(1) 75 feet long or less; and
(2) Not being used to cant' any person or
property for a charge.
B. WHO IS AN INSURED — UNNAMED
SUBSIDIARIES
The following is added to SECTION II — WHO IS
AN INSURED:
Any of your subsidiaries, other than a partnership
or joint venture, that is not shown as a Named
Insured in the Declarations is a Named Insured if:
a. You are the sole owner of. or maintain an
ownership interest of more than 50% in, such
subsidiary on the first day of the policy period;
and
b. Such subsidiary is not an insured under
similar other insurance.
CG D417 02 19 A 2D17 The Travelers Indemnity Company. All rights reserved.
Includes copyrighted material of insurance services Office, Inc. with its permission.
Page 1 of f
0413-01-00-0001064-0004-0003606
COMMERCIAL GENERAL LIABILITY
No such subsidiary is an insured for "bodily injury"
or °property damage" that occurred, or "personal
and advertising injury" caused by an offense
committed:
a. Before you maintained an ownership interest
of more than 50% in such subsidiary; or
b. After the date, if any, during the policy period
that you no longer maintain an ownership
interest of more than 50% in such subsidiary.
For purposes of Paragraph 1. of Section II — Who
Is An Insured, each such subsidiary will be
deemed to be designated in the Declarations as:
a. A limited liability company;
b. An organization other than a partnership, joint
venture or limited liability company; or
c. A trust;
as indicated in its name or the documents that
govern its structure.
C. WHO IS AN INSURED — EMPLOYEES —
SUPERVISORY POSITIONS
The following is added to Paragraph 2.a.(1) of
SECTION II — WHO IS AN INSURED:
Paragraphs (1)(a), (b) and (c) above do not apply
to "bodily injury' to a co -"employee"` while in the
course of the co -"employee's" employment by you
arising out of work by any of your "employees"
who hold a supervisory position.
D. WHO IS AN INSURED — NEWLY ACQUIRED
OR FORMED LIMITED LIABILITY COMPANIES
The following replaces Paragraph 3. of SECTION
11— WHO IS AN INSURED:
3. Any organization you newly acquire or form,
other than a partnership or joint venture, and
of which you are the sole owner or in which
you maintain an ownership interest of more
than 50%, will qualify as a Named Insured if
there is no other similar insurance available to
that organization. However:
a. Coverage under this provision is afforded
only:
(1) Until the 180th day after you acquire
or form the organization or the end of
the policy period, whichever is earlier,
If you do not report such organization
In writing to us within 180 days after
you acquire or form it; or
organization in writing to us within
180 days after you acquire or form it;
b. Coverage A does not apply to "bodily
injury" or "property damage" that occurred
before you acquired or formed the
organization; and
c. Coverage B does not apply to "personal
and advertising injury" arising out of an
offense committed before you acquired or
formed the organization.
For the purposes of Paragraph 1. of Section 11
— Who Is An Insured, each such organization
will be deemed to be designated in the
Declarations as:
a. A limited liability company;
b. An organ ization, other than a partnership,
joint venture or limited liability company;
or
c. A trust;
as indicated in its name or the documents
that govern its structure.
E. WHO IS AN INSURED — LIABILITY FOR
CONDUCT OF UNNAMED PARTNERSHIPS OR
JOINT VENTURES
The following replaces the last paragraph of
SECTION 11— WHO IS AN INSURED:
No person or organization is an insured with
respect to the conduct of any current or past
partnership or joint venture that is not shown as a
Named Insured in the Declarations. This
paragraph does not apply to any such partnership
or joint venture that otherwise qualifies as an
insured under Section II — Who Is An Insured.
F. BLANKET ADDITIONAL INSURED — PERSONS
OR ORGANIZATIONS FOR YOUR ONGOING
OPERATIONS AS REQUIRED BY WRITTEN
CONTRACT OR AGREEMENT
The following is added to SECTION II — WHO IS
AN INSURED:
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:
a. Occurs subsequent to the signing of that
contract or agreement; and
(2) Until the end of the policy period, b. Is caused, in whole or in part, by your acts or
when that date is later than 180 days omissions in the performance of your ongoing
after you acquire or form such operations to which that contract or
organization, if you report such
Page 2 of 5 ® 2a17 The Travelers Indemnity Company. All rights reserved. CG D4 17 02 19
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
COMMERCIAL GENERAL LIABILITY
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 minimum limits that you agreed to
provide in the written contract or agreement, or
the limits shown in the Declarations, whichever
are less.
G. BLANKET ADDITIONAL INSURED — BROAD
FORM VENDORS
The following is added to SECTION II — WHO IS
AN INSURED:
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;
a. Occurs subsequent to the signing of that
contract or agreement; and
b. Arises out of "your products" that 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:
a. The limits of insurance provided to such
vendor will be the minimum limits that you
agreed to provide in the written contract or
agreement, or the limits shown in the
Declarations, whichever are less.
b. The insurance provided to such vendor does
not apply to:
(1) Any express warranty not authorized by
you or any distribution or sale for a
purpose not authorized by you;
(2) Any change in "your products" made by
such vendor;
performed at such vendors premises in
connection with the sale of "your
products'; or
(6) "Your products" that, 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:
a. 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
b. Any vendor for which coverage as an
additional insured specifically is scheduled by
endorsement.
H. BLANKET ADDITIONAL INSURED —
CONTROLLING INTEREST
1. The following is added to SECTION II —WHO
IS AN INSURED:
Any person or organization that has financial
control of you is an insured with respect to
liability for "bodily injury", "property damage"
or "personal and advertising injury' that arises
out of:
(3) Repackaging, unless unpacked solely for
the purpose of inspection, demonstration,
testing, or the substitution of parts under
instructions from the manufacturer, and I.
then repackaged in the original container.
(4) 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';
(5) Demonstration, installation, servicing or
repair operations, except such operations
a. Such financial control; or
b. Such person's or organization's
ownership, maintenance or use of
premises leased to or occupied by you.
The insurance provided to such person or
organization does not apply to structural
alterations, new construction or demolition
operations performed by or on behalf of such
person or organization.
2. The following is added to Paragraph 4. of
SECTION II — WHO 15 AN INSURED:
This paragraph does not apply to any
premises owner, manager or lessor that has
financial control of you.
BLANKET ADDITIONAL INSURED —
MORTGAGEES, ASSIGNEES, SUCCESSORS
OR RECEIVERS
The following is added to SECTION II — WHO IS
AN INSURED:
Any person or organization that is a mortgagee,
assignee, successor or receiver 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 its
CG D417 02 19 ® 2017 The Travelers Indemnity Company. All rights reserved.
Includes copyrighted mafeAal of insurance Services Office, Inc. with Ns permission.
Page 3 of r
0413-01-00-0001064-0005-0003607
COMMERCIAL GENERAL LIABILITY
liability as mortgagee, assignee, successor or
receiver for "bodily injury", "property damage" or
"personal and advertising injury" that:
a. Is "bodily injury' or "property damage" that
occurs, or is "personal and advertising injury"
caused by an offense that is committed,
subsequent to the signing of that contract or
agreement, and K.
Is. Arises out of the ownership, maintenance or
use of the premises for which that mortgagee,
assignee, successor or receiver is required
under that contract or agreement to be
included as an additional insured on this
Coverage Part.
The insurance provided to such mortgagee,
assignee, successor or receiver is subject to the
following provisions:
a. The limits of insurance provided to such
mortgagee, assignee, successor or receiver
will be the minimum limits that you agreed to
provide in the written contract or agreement,
or the limits shown in the Declarations,
whichever are less.
b. The insurance provided to such person or
organization does not apply to:
(1) Any "'bodily injury' or "property damage"
that occurs, or any "personal and
advertising injury' caused by an offense
that is committed, after such contract or
agreement is no longer in effect; or
(2) Any "bodily injury, 'properly damage" or
"personal and advertising injury arising
out of any structural alterations, new
construction or demolition operations
performed by or on behalf of such
mortgagee, assignee, successor or
receiver.
J. BLANKET ADDITIONAL INSURED —
GOVERNMENTAL ENTITIES — PERMITS OR
AUTHORIZATIONS RELATING TO PREMISES
The following is added to SECTION II — WHO IS
AN INSURED:
Any governmental entity that has issued a permit
or authorization with respect to premises owned
or occupied by, or rented or loaned to, you and
that you are required by any ordinance, law,
building code or 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", "property damage" or "personal
and advertising injury' arising out of the
existence, ownership, use, maintenance, repair,
construction, erection or removal of any of the
following for which that governmental entity has
issued such permit or authorization: advertising
signs, awnings, canopies, cellar entrances, coal
holes, driveways, manholes, marquees, hoist
away openings, sidewalk vaults, elevators, street
banners or decorations.
BLANKET ADDITIONAL INSURED —
GOVERNMENTAL ENTITIES — PERMITS OR
AUTHORIZATIONS RELATING TO OPER-
ATIONS
The following is added to SECTION II — WHO IS
AN INSURED:
Any governmental entity that has issued a permit
or authorization with respect to operations
performed by you or on your behalf and that you
are required by any ordinance, law, building code
or written contract or agreement to include as an
additional insured on this Coverage Part is an
insured, but only with respect to liabi lily for "bodily
injury", "property damage" or "personal and
advertising injury' arising out of such operations.
The insurance provided to such governmental
entity does not apply to:
a. Any "bodily injury", "properly damage" or
"personal and advertising injury" arising out of
operations performed for the governmental
entity; or
b. Any "bodily injury' or "property damage"
included in the "products -completed
operations hazard".
L. MEDICAL PAYMENTS— INCREASED LIMIT
The following replaces Paragraph 7, of SECTION
III — LIMITS OF INSURANCE:
7. Subject to Paragraph S. above, the Medical
Expense Limit is the most we will pay under
Coverage C for all medical expenses
because of "bodily injury" sustained by any
one person, and will be the higher of:
a. $10,000: or
b. The amount shown in the Declarations of
this Coverage Part for Medical Expense
Limit.
M. BLANKET WAIVER OF SUBROGATION
The following is added to Paragraph S., Transfer
Of Rights Of Recovery Against Others To Us,
of SECTION IV — COMMERCIAL GENERAL
LIABILITY CONDITIONS:
If the insured has agreed in a contract or
agreement to waive that insured's right of
recovery against any person or organization, we
Page 4 of 5 ® 2017 The Travelers Indemnity Company. All rights reserved. CG D4 17 02 19
Includes copyrighted material of Insurance Services Office, Inc. with Is permission.
COMMERCIAL GENERAL LIABILITY
waive our right of recovery against such person or
organization, but only for payments we make
because of:
a. "Bodily injury" or "property damage' that
occurs; or
b. "Personal and advertising injury" caused by
an offense that is committed;
subsequent to the execution of the contract or
agreement.
N. CONTRACTUAL LIABILITY — RAILROADS
1. The following replaces Paragraph c. of the
definition of "insured contract' in the
DEFINITIONS Section:
c. Any easement or license agreement;
2. Paragraph C(l) of the definition of "insured
contract" in the DEFINITIONS Section is
deleted,
O. DAMAGE TO PREMISES RENTED TO YOU
The following replaces the definition of "premises
damage" in the DEFINITIONS Section:
"Premises damage" means "property damage" to:
a. Any premises while rented to you or
temporarily occupied by you with permission
of the owner; or
b. The contents of any premises while such
premises is rented to you, if you rent such
premises for a period of seven or fewer
consecutive days.
CG D417 02 19 ® 2Q17 The Travelers Indemnity Company. All rights reserved.
Includes copyrighted material of insurance Services Office, Inc. with Its permission.
Page 5 of r
0413-01-00-0001064-0006-0003606
POLICY NUMBER: $-630-68758660-COF-22
ISSUE DATE. 09-22-22
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
NOTICE OF CANCELLATION OR NONRE�NEWAL
PROVIDED
This endorsement modifies insurance provided under the following:
ALL COVERAGE PARTS INCLUDED IN THIS POLICY
SCHEDULE
CANCELLATION: Number of Days Notice: 90
WHEN WE DO NOT RENEW (Nonrenewal):
PROVISIONS
A. If we cancel this policy for any legally permitted
reason other than nonpayment of premium, and a
number of days is shown for Cancellation in the
Schedule above, we will mail notice of
cancellation at least the number of days shown
for Cancellation in such Schedule before the
effective date of cancellation.
Number of Days Notice: 9 0
B. If we do not renew this policy for any legally
permitted reason other than nonpayment of
premium, and a number of days is shown far
When We Do Not Renew (Nonrenewal) in the
Schedule above, we will mail notice of
nonrenewal at least the number of days shown for
When We Do Not Renew (Nonrenewal) in such
Schedule before the effective date of nonrenewal.
IL T3 20 05 19 02019 The Travelers Indemnity Company. All rights reserved. Page 1 of 1
TRAVELERS WORKERS COMPENSATION
AND
ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY
RMTFORD CT 06183
ENDORSEMENT WC 00 0313 (00) - 001
POLICY NUMBER: II3-68783668-22-13-G
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:
DESIGNATED ORGANIZATION:
ANY PERSON OR ORGANIZATION FOR WHICH TEE INSURED HAS AQREED
BY WRITTEN CONTRACT MMCQTED PRIOR TO LOSS TO FURNISH THIS
WAIVER.
Any person or organisation for which the employer has agreed by written contract,
executed prior to lass, may execute a waiver of subrogation. However, for purposes of
work performed by the employer in Kissouri, this waiver of subrogation does not apply
to any construction group of classifications as designated by the waiver of right *n
recover from others (subrogation) rule in our manual.
n
DATE OF ISSUE: 09-23-22 STASSIGN: PAGE l OF
0413-01-00-0001064-0007-0003609