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PROOF OF INSURANCE (2024) CLOSEDPage 1 of 2 DATE (MMIDD/YYYY) A► ..wwR" CERTIFICATE OF LIABILITY INSURANCE 08/28/2o23 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 CONT Willis Towers Watson Certificate Center Willis Towers Watson Northeast, Inc. -_"""""""-_____ PHONE 1-888-467-2378 � c/o 26 Century Blvd 1.„877-945-73�8 Nc X MAIL P.O. Box 305191 0 RE certificates@ c m........... eWeeeeeeeeees _ Nashville, TN 372305191 USA INSURE,,,,,, (, F,,,,,,,,,,,,,,,,,,,L....... E NAIC # R S„A,,,F,O,R,D,,,,NG COVERAG,,.:.:.:.:.:.__......._ _ INSURER A: Sompo America Insurance Company 11126 RED INSURED INSURERS: Valley Forge Insurance Company 20508 Kyocera Document Solutions West, LLC N ISURERC:continental Insurance mCompany m-35289 14101 Alton Parkway _.. Irvine, CA 92618 INSURERD: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: W29916871 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. INS li� TYPE OF INSURANCE Al L $ itl POLICY NUMBER POL ICY E POLL EXpY LTR INRn LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1, 000, 000 X hA l 7 i i� �----��.......- r. 1,000,000 0 CLAIMS -MADE OCCUR PRMI�S$„(nEaogr„prrnce,)„ $ A ( Y, 5,000 ---- y y TGb30035226900 04/01/2023 04/01/2024 PERSONALBADV INJURY $ 1,000,000 GEN L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- ... PROS- LOC GG PRODUCTS.:.C,O.M.P,O,P..'0`.........� 2,000,000 .,.$___ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE. LIMIT $ 1,000,000 ...,._--- X ANY AUTO BODILY INJURY (Per person) $ - OWNED SCHEDULED TAM30017921401 04/01/2023 04/01/2024 IL Pera tA codeo.....�.„r..._--- c .)$AUTOS ONLY AUTOS DILYI(Per RNJURY -- HIRED LNON-OWNED D� $ AUTOS ONLY AUTOS ONLY. .. X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10 ,000,000 A .. ... EXCESS LIAB CLAIMS -MADE CPU41021VO 04/01/2023 04/01/2024 AGGREGATE $ 10,000,000 DED X RETENTION $ 10,000 $ WORKERS COMPENSATION PER O TH STATUTE R AND EMPLOYERS' LIABILITY 1,000,000 B ANYPROPRIE'TOMPARTNERIEXECtJTIVE po N/A y EACH ACCIDENT ..µ$ OFFICER1MEMBEREXCIWADCD7 �....... 7036371671 01/01/2023 01/01/2024 1,000,000 (Mandatory In NHI E.L. DISEASE EA EMPLOYEE" — 9P'yyes deacTibe under OI SCRIPTION OF OPERATIONS below E.L. DISEASE POLICY LIMIT $ 1,000,000 C Workers Compensation & y 7036371685 01/01/2023 01/01/2024 E.L. Each Accident $1,000,000 Employers Liability (CA Policy) E.L. .. Disease -Each EnT $1,000,000 Per Statute E.L. Disease -Pol Lmt'$1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / 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. CERTIFICATE HOLDER 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. City of El Segundo AUTHORIZED REPRESENTATIVE Attn: City Clerk 350 Main Street El Segundo, CA 90245-3813 ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 24591677 BATcH: 310841E AGENCY CUSTOMER ID:. LOC #: A 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 ..................................... CARRIER CODE TNeAe1C See Page 1 Page 1 1 EFFECTIVE DATE: See Page 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance ...................—_..__..._......... if required in the 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: 24591677 BATCH:3108418 CERT: W29916871 POLICY NUMBER: TGM30035226900 COMMERCIAL GENERAL LIABILITY CG 20 10 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES ES OR CONTRACTORS S - SCHEDULED PERSON O ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anization s Location(s) Of Covered Operations ANY PERSON OR ORGANIZATION THAT YOU COVERED LOCATION ARE OBLIGATED PURSUANT TO A WRITTEN CONTRACT OR AGREEMENT EXECUTED PRIOR TO LOSS TO PROVIDE SUCH INSURANCE AS IS AFFORDED BY THIS POLICY FOR "YOUR WORK" FOR SUCH PERSON OR ORGANIZATION BY OR FOR YOU. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. 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 "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. 1. The insurance afforded to such additional C. With respect to the insurance afforded to these insured only applies to the extent permitted by additional insureds, the following is added to law; and Section III - Limits Of Insurance: 2. If coverage provided to the additional insured is If coverage provided to the additional insured is required by a contract or agreement, the required by a contract or agreement, the most we insurance afforded to such additional insured will will pay on behalf of the additional insured is the not be broader than that which you are required amount of insurance: by the contract or agreement to provide for such additional insured. 1. Required by the contract or agreement; or 2. Available under the applicable limits of B. With respect to the insurance afforded to these insurance; additional insureds, the following additional whichever is less. exclusions apply: This endorsement shall not increase the applicable This insurance does not apply to "bodily injury" or limits of insurance. CG 20 10 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 POLICY NUMBER: TGM30035226900 COMMERCIAL GENERAL LIABILITY CG 20 37 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES ONE CONTRACTORS - COMPLETED OPERATIONS 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 THAT YOU COVERED LOCATION ARE OBLIGATED PURSUANT TO A WRITTEN CONTRACT OR AGREEMENT EXECUTED PRIOR TO LOSS TO PROVIDE SUCH INSURANCE AS IS AFFORDED BY THIS POLICY FOR "YOUR WORK" FOR SUCH PERSON OR ORGANIZATION BY OR FOR YOU. Information required to complete p this Schedule, if not shown above, will be shown in the Declarations _____.............................................................. . .................. 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" or "property 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: The insurance afforded to such additional insured only applies to the extent permitted by law; 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 Section III - Limits Of Insurance: 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; whichever is less. This endorsement shall not increase the applicable limits of insurance. CG 20 37 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 POLICY NUMBER: TGM30035226900 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 Name Of Person(s) Or Organ ization(s): PARTIES WITH WHOM THE INSURED HAS ENTERED INTO A WRITTEN WAIVER AGREEMENT PRIOR TO THE DATE OF LOSS. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. 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 Workers Compensation And Employers Liability Insurance CNAPolicy Endorsement I i This endorsement changes the policy to which it is attached. It is agreed that Part One - Workers' Compensation Insurance G. Recovery From Others and Part Two - Employers' Liability Insurance H. Recovery From Others are amended by adding the following: We will not enforce our right to recover against persons or organizations. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) PREMIUM CHARGE - Refer to the Schedule of Operations The charge will be an amount to which you and we agree that is a percentage of the total standard premium for California exposure. The amount is 1 %. All other terms and conditions of the policy remain unchanged, This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, takes effect on the Policy Effective Date of said policy at the hour stated in said policy, unless another effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy unless another expiration date is shown below. Form No: G-19160-B (11-1997) Endorsement Effective Date: Endorsement Expiration Date: Endorsement No: 3; Page: 1 of 1 Underwriting Company: The Continental Insurance Company, 151 N Franklin St, Chicago, IL 60606 Policy No: WC 7 36371685 Policy Effective Date: 01 /01 /2023 Policy Page: 35 of 51 Copyright CNA All Rights Reserved. Workers Compensation And Employers Liability Insurance CNAPolicy 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 anyone not named in the Schedule. Any person or organization for which the employer has agreed by written contract, executed prior to loss, may execute a waiver of subrogation. However, for purposes of work performed by the employer in Missouri, this waiver of subrogation does not apply to any construction group of classifications as designated by the waiver of right to recover from others (subrogation) rule in our manual. Schedule Any Person or Organization on whose behalf you are required to obtain this waiver of our right to recover from under a written contract or agreement. The premium charge for the endorsement is reflected in the Schedule of Operations. All other terms and conditions of the policy remain unchanged. This endorsement, which forms a part of and is for attachment to the policy issued by the designated Insurers, takes effect on the Policy Effective Date of said policy at the hour stated in said policy, unless another effective date (the Endorsement Effective Date) is shown below, and expires concurrently with said policy unless another expiration date is shown below. Form No: WC 00 03 13 (04-1984) Endorsement Effective Date: Endorsement Expiration Date: Endorsement No: 1 1; Page: 1 of 1 Underwriting Company: Valley Forge Insurance Company, 151 N Franklin St, Chicago, IL 60606 Policy No: WC 7 36371671 Policy Effective Date: 01 /01 /2023 Policy Page: 229 of 378 Copyright 1983 National Council on Compensation Insurance.