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PROOF OF INSURANCE (2024 - 2024) CLOSEDDATE (MMIDDNYYY)
C40R " CERTIFICATE OF LIABILITY INSURANCE
,,, 1 1 6/16/2023
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 NAkIg•._- Christian Brothers Services _
Artex Risk Solutions, Inc. (CB) PHONE FAX
2850 Golf Road, 5th Floor (A/p,N.q_Exty 800-807 0300 tArC N_a:630-378-2508 _
Rolling Meadows IL 60008-4050 E-MAIL nkfs
-- ----- -..
INSURER(S) AFFORDING COVERAGE NAIC #
-.-. ...... .
—
....
NSURERA: Old Republic Insurance Company 24147
INSURED CHRIBRO-14..... INSURERB: Old Republic Union Insurance Co 31143
Brothers of the Christian Schools & Affiliates -- _____. TT"""mm _.
Loc#1177028 DOC POW ST VINCENT SENIOR CITIZEN NTR INSURER :
..SURER D ... ---- ------ -........ w ... ...... ___ _.. __
1205 Windham ParkwayI.._INS _.r'....... ...................
Romeoville IL 60446-1679 INSURER E:
COVERAGES CERTIFICATE NUMBER:301416828 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.
.... .... .... .,..,.... .... ....„
...-...,............
........ ............ ................ .—____............r,. .__AADDLS0611k POLI1d
ILT R
POLICYNUMBER....
MMLDDPOLICYEFF
TYPE OF INSURANCE LIMITS
1'YYX
B
X COMMERCIAL GENERAL LIABILITY
N
N
8223001325596 6/15/2023
6/15/2024
EACH OCCURRENCE'.
$10,000,000
CLAIMS -MADE X, OCCURda,Mi/ri`1i�ft....
4gFurr�^raei
.w��tFnn��,�.1�s? ...$Induded
�,..r... ..... .... .... .....
MED EXP (Any one person)
$ 15 000 ..,.
PERSONAL 8 ADV INJURY
$Induded
GEN'LAGGR AGGREGATE APPLIES
GENERAL AGGREGATE
$ NO Ac��.
JLIIMIITA
PRO
POLICY LOG
S- AGG
... COMP/OP ..
... .....
$Induded
OTHER';
$
A
AUTOMOBILE LIABILITY
Y Y
MWTB 21543 6/15/2023
l
6/15/2024COMBINED SINGLE IT
JgAz'..
$ 1.000,000
X ANY AUTO
j
.__._.).
BODILY INJURY Per person)
'.. $
OWNED SCHEDULED
BODILY INJURY
$
_ AUTOS ONLY AUTOS
(Per accident)
HIREDX X
ROPER7Y DAMAGE
AUTOS ONLY AUTOS ONLY
.__ .I,
_(Per accident) ....
....
..........
UMBRELLA LIAB
�OCCUR
EACH OCCURRENCE
$
EXCESS LIAB
AGGREGATE
$
----
DED RETENTION $
$
. WORKERS COMPENSATION
PER OTH-
AND EMPLOYERS' LIABILITY Y / N
ER
_STATUTE
ANYPROPRIETOR/PARTNER/EXECUTIVE
E.L., EACH ACCIDENT
$
OFFICER/MEMBER EXCLUDED? ❑
N / A
— -------------------
--- _ .___.__
(Mandatory in NH)
E„L. DISEASE -EAEMPLOYEEI
$
If yes, describe under
DESCRIPTION OF OPERATIONS below
E,L. DISEASE- POLICY LIMIT
$
B
Excess Automobile
L
Y Y 822300 1325596
6/15/2023
6/15/2024
Occurrence/No Agg.
$9,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Waiver of Subrogation(where allowed by law) per attached endorsement is provided under the Automobile Liability coverages per fully executed written
contract. Certificate Holder is added 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.
CERTIFICATE HOLDER
City of El Segundo its Official and Employees Office of City
Clerk
350 Main Street
El Segundo CA 90245
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
©1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
IL 10 (12/06) 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 06/15/23 - 06/15/24
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 06/15/23 - 06/15/24
,10 11
ACC>RV CERTIFICATE OF LIABILITY INSURANCE 1DATE2/912(MWDDNYYY)
022
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, ih-epollcy(tes) 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 rimhts to the certificate holder in lieu of such endorsamanLs).
PRODUCER Christian Brothers Services
Artex Risk Solutions, Inc. (CB) _AWL__ TTA-9--
2850 Goff Road, 5th Floor
Rolling Meadows It. 600084050
CHRIBRO-14 INSURER 8 0!q
iNSURED
Brothers of the Christian Schools & Affiliates INSUflERC7,
Loc #1177028 DOC POW ST VINCENT SENIOR CITIZEN NTR
1205 Windham Parkway
,S4R REf
Romeoville IL 60446-1679 EJ�
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.
W
YEFF LIMITS TYPE OF INSURANCE x6or gTJ IN" wv POLICY ;UMBEH ;Y YY
rR
X COMMERCIAL GENERAL LIABILITY N N 822200 1325596 6/15/2022 6/15/2023 EACHOOCURRENCE 54,000.000
CLAIM. -MADE rR] OCCUR _1 I MED EXP IA(w one Person)
V �N
ffj$R�� 4��o JURY
sinduded
. . ....
GEN,L
AGGREGATE LIMIT APPLIES PER:
ENIPRAL �281'
S NIA
POLICY 0 [D LOC
PRODUCTS • COMMOP AGq_
$,Included
JERa
ALrromOBILELIABIUTY
OTHEW
Y
Y
MWTB 21543
6/1512022
6115/2023
COMBINED SiNGLE LIMIT
$1,000,000
)C
ANY AUTO
BODILY INJURY (Per person)
$
OWNED SCHEDULED
BODILY INJURY fPer accident)
$
AUTOS ONLY AUTOS
HIRED NON -OWNED
'A PERTY OAwa
$
AUTOS ONLY AUTOS ONLY
$
T__
UMBRELLALIAB OCCUR
I
OCCURRENCE
'!L H 0CPUAF�5t4c'
$
EXCESS LIAB AWe,.MAJ
;iH A
A WORKERSCOMPIENSATION y � MWC 305311 Oil 11112023 � 111/2024 IX J_R.'T TE
0
E",
AND EMPLOYERS' LIABILITY YIN
A 'YP" L. EACH ACCIDIE
14Y%PROP$IIEIOPJPARTNEM-XECUTtV'C FN 1 � N I A
OrrIC F
OFFICEPIMEMBEIREXCLUDED? ILL, DISEASE . CA
LIMIT
DESCRIPTION OF OPERAJIDNSO LOCATIONS t VEHICLES (ACOR0 101, Addiftr,44 Remarks ftbodulo, may twaltachad sr more spotois raqvirod)
waiver of Subrogatlon (where allowed by law) per attached endorsement is provided under Auto Liability & Worker's Com re nsalion Coverage when, required by
fully executed written contract. Certificate Holder is added as Aftitional Insured (per attached endorsement) for Automobile liability coverages solely, Strictly
and spedfloally with regards W
Consultant Services W 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 AEFRES 9
El Segundo CA 90245
0 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06
(Ed. 04-84)
POLICY NUMBER: MWC 306311 08
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 JOB DESCRIPTION
ALL PERSONS OR
ORGANIZATIONS WHERE
REQUIRED BY WRITTEN
CONTRACT
DATE OF ISSUE: 11-29-22
@1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved.
From the WCIRB's California Workers' Compensation Insurance Forms Manual@ 1999.