Loading...
PROOF OF INSURANCE (2024) CLOSEDDATE (MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 10/26/2023 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). ONTPRODUCER CAME Marsh U.S.O Operations MARSH USA, LLC. NAME: _ �-- 866-966-4664 AX 800 Market Street, Suite 1800 _(� NEp«..t��f) ___ 1 F .1 ... . .. St. Louis, MO 63101 E. � �11 Att.CertRequest@marsh.com 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,. ..._-......._..,�.,_ ....�..�..,.n.._,..m___.. _�....... ................. .......__ POLICY NUMBER---- OLICY IRSR TYPE OF INSURANCE..,..,...._.. AO'f5" UBA-­­­­­­- FF POLICY EXP LIMITS MMIDD A X COMMERCIAL GENERAL LIABILITY MWZY31363623 06/01/2023 06/01/2024 EACH OCCURRENCE $ 1,000,000 X K AW;M_1 LTOhkfvT'd'tS 1.000 000 CLAIMS -MADE OCCUR P '� frB,EIN4��,(,'e_�c�ccanreen�ca.. $ .._ ._ EXP MED (Any one person) ---------- $ N � ... ..IA _-- .............................. PERSONAL & ADV INJURY $ 1,000,000 GEN L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 10,000,000 X POLICY ( 1 J T'. LOC PRODUCTS - COMP/OP AGG $ 1 000,000 OTHER. $ A AUTOMOBILE LIABILITY _ MWTB 313635 23 06/01/2023 06/01/2024 COMBINED, SINGI.Z- LIMIT _QEa accadenll $ 1000 000 .. X ANY AUTO BODILY INJURY (Per person) $$',m.... OWNED SCHEDULED BODILY INJURY (Peracadenl)[ !. AUTOS ONLY AUTOS HIRED, NON -OWNED 'PF4OPR'GY GAMACE 14t' ... ... .,....-- $ AUTOS ONLY I AUTOS ONLY Per a=denk ................. .. ......... .._ F$ UMBRELLA LIAB OCCUR URRENCE $ ...... ...-. ------ EXCESS LIAB CLAIMS -MADE ....... ......... ..... ---- : AGGREGATE ..—,.., $ DED � 1 RETEN. TION $ A WORKERS COMPENSATION MWC 313638 23 (AOS) 061010023 06)01, 024 X I PER ER TAT AND EMPLOYERS' LIABILITY YIN -, mR 1,000,000 N �' N/A E.L EACH ACCIDENT OFFICER/MEMBEREXCLUDED?ECUTIVE (Mandatory m NH) E EA EMPLOYEE E.L DISEAS..., . ..� $ 1,000,000 ....... If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 A Excess Workers' Compensation / MWXS 313639 23 (OH,WA) 06/01/2023 06/01/2024 EL Each Accident / EL Disease 1,000,000 Employers' Liability See Second Page ' EL Disease -Policy Limit I 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: FA10086765 USID16456 348 Main Street, El Segundo, CA. 90245 City of El Segundo, its officials and employees is/are included as Additional Insured under the General Liability and Automobile Liability policies but only with respect to the requirements of the contract between the Certificate Holder and the Insured. This insurance is primary with respect to the interest of the Additional Insured and any other insurance maintained by Additional Insured is excess and non-contributory with this insurance. Waiver of Subrogation is provided for General Liability and Workers' Compensation as required by written contract and allowable bylaw. CERTIFICATE FOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Risk Management THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN 103150778 LOC #: St. Louis � ADDITIONAL REMARKS SCHEDULE � DULE Page 2 of 2 AGENCY NAMED INSURED MARSH USA, LLC, New Cingular Wireless PCS, LLC One AT&T Plaza POLICY NUMBER 208 South Akard Room 1820 ............. Dallas, TX 85301 CARRIER NAIC CODE 11 EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: ,Certificate of Liability Insurance Excess Workers' Compensation -MWXS 313639 23 (OH -WA) Self Insured Retentions OH & WA - $500,000,000 (except Terrorism) OH & WA - $600,000,000 Terrorism ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. 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 WHERE REQUIRED UNDER CONTRACT OR AGREEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM Paragraph 2. of SECTION II - WHO IS AN INSURED is amended to include any person or organization for whom you have agreed under contract or agreement to provide insurance. However, the insurance provided shag not exceed the scope of coverage or limits of this policy. Notwithstanding the foregoing sentence, in no event shall the insurance provided exceed the scope of coverage or limits required by said contract or agreement Where required by contract, we will consider our policy to be primary under any other insurance maintained by the additional insured for injury or damage covered by this endorsement and that their policy will be noncontributing with this insurance. GL 739 006a 0609 MWZY 313636 23 AT&T Inc. 06101J23 - OW01124 IL 10 (12/06) OLD REPUBLIC INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED ENTITY - NOTICE OF CANCELLATION PROVIDED BY US SCHEDULE Number of Days Notice of Cancellation: 30 Person or Organization: All persons or organizations as required by written contract or agreement. Address: The addresses as specified in the written contracts or agreements. Provisions If we cancel this policy for any statutorily 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 to the person or organization shown in the schedule above. We will mail such notice to the address shown in the schedule above at least the number of days shown for cancellation in the schedule above before the effective date of cancellation. PIL 028 05 10 MWZY 313636 23 AT&T Inc. 06/01/2023 - 06/01/2024 IL 10 (12106) OLD REPUBLIC INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, PRIMARY AND NON-CONTRIBUTORY ENDORSEMENT FOR ADDITIONAL INSUREDS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART/FORM SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): All Persons or Organizations as Required by Written Contract or Agreement. In no event shall the insurance provided exceed the scope of coverage or limits required by said contract or agreement. All locations associated with contract. For the Person(s) or Organization(s) that are listed in the Schedule above, that are also an Additional Insured under an endorsement attached to this policy, the following is added to SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance and supersedes any provision to the contrary: This insurance is primary to and will not seek contribution from any other insurance available to an Additional Insured under your policy, provided that: The Additional Insured is a Named Insured under such other insurance; and; 2. You have agreed with the Additional Insured that this insurance is primary and will not seek contribution from any other insurance available to the Additional Insured. GL 739 058 0617 Includes copyrighted material of Insurance Services Office, Inc., with its permission. MWZY 313636 23 AT&T Inc. 06/01/2023 - 06/01/2024 Page 1 of 1 POLICY NUMBER: 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 Organization(s): Any Person or Organization for whom you perform work under a Written Contract that Requires you to obtain this Agreement. In no event shall the insurance provided exceed the scope of coverage or limits required by said contract or agreement. All locations associated with contract. 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. CIS 24 04 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 MWZY 313636 23 AT&T Inc. 06/01/2023 - 06/01/2024 OLD REPUBLIC INSURANCE COMPANY WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY POLICY DESIGNATED ENTITY - NOTICE OF CANCELATION PROVIDED BY US ENDORSEMENT SCHEDULE Number of Days Notice of Cancellation: 30 Person or Organization: All persons or organizations as required by written contract or agreement. Address: The addresses as specified in the written contracts or agreements. If we cancel this policy for any statutorily permitted reason other than nonpayment of premium, and a number of days is shown for cancelation in the schedule above, we will mail notice of cancelation to the person or organization shown in the schedule above. We will mail such notice to the address shown in the schedule above at least the number of days shown for cancelation in the schedule above before the effective date of cancelation. WC 99 03 65 (03/11) Page 1 of 1 MW C 313638 23 AT&T Services, Inc. 06/01/2023 - 06/01/2024 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) POLICY NUMBER: 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 % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION All Persons or Organizations as Required by Written Contract or All locations associated with contract. Agreement. DATE OF ISSUE: 06/01/2023 @1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual@ 1999. MW C 313638 23 AT&T Services, Inc. 06/0112023 - 06/01/2024