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PROOF OF INSURANCE (2024 - 2025) CLOSEDy Page 1 of 2 0 DATE (MMIDDIYYYY) ACCrR P CERTIFICATE OF LIABILITY INSURANCE 112/27/2023 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 Willis Towers Watson Certificate Center Willis Towers Watson Northeast, Inc. PHONE �� 88-467-2378 rl1y c/o 26 Century Blvd W,9d, Xt) 77 995 7378 AEA 1 „8 Nashville, 307TN 372305191 USA ADD�iE-MA�E3� certi NSU ER(S) AFFORDING COVERAGE INSURED Kyocera Document Solutions West, LLC 14101 Alton Parkway Irvine, CA 92618 F: n c^.cw^rrcrr+A-r u� RAmco. w32132809 s............„„-.,.,........____.__-......................,..............�...__ ......... „..... ompo America Insurance Company 11126 Valley Forge Insurance_.__. Company 20508 Continental Insurance Company 35289 RFVICIANI NIIrdIFtPRI 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. .... ... .......... .. .....,..TYPE OF INSURANCE,....... .� ......... .........._ ... .. _ _;..... .... ......... ....... _.....-- -................... ILTR ,.. .„ �,sINSD'Sl)91It1 POLICY NUMBER PMJDDIY"IY Y i MMLODr EXP LIMITS J DOL�„„„ dYY YY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ......„000 000 CLAIMS -MADE X OCCURmAM/1x`i"T �..__..1 Rt"aY'EI 000 000 Fd)yMl„� (d;a or^,u.nunerur���. . 1 Py,one person_) $ 15,000 Y Y TGM30035226900 04/01/2023 04/01/2024 PERSONAL ADV IN, 1000000 - CF�hVLAGG'R'E�GATE;LIMITAPPLIES PER. GENERAL AGGREGATE $ 2 000 00 0 PRO- OC� t.IQ Y JECT PRODUCTS-COMP/OP AGG $ 2,000,000 ........ ...... ..... N $ 477t-4E'P: AUTOMOBILE LIABILITY CO�+IBINE&7 SUNtaLE� LIME T QE'iryr�clidc.nt ... ....,..... $ 1 000 000 __....... ............. . _.. X ANY AUTO BODILY INJURY (Per person) ,. ... ........ ,.,-....,m----- _------ $ ,..... ..,._.., A ..�.,. OWNED ' SCHEDULED TAM30017921401 04/01/2023 04/01/2024 BODILY INJURY (Per accident) $ AUTOS ONLY ......... .. AUTOS HIRED NON -OWNED .-P PROPERIYDAMAf`.D $ ....._.. AUTOS ONLY .....,..,' AUTOS ONLY .... .... ...--...,, ..................... $ X UMBRELLA X OCCUR A L.I.A...B... EAH OCCURRENCE $ 10,000,000 EXCESS LIAB SME CPU41021VO 04/01/2023 04/01/2024 AGGREGATE .. $ 10,000,000 ...... m__ X _ .m._ DE.TION$ 10,000 $ WORKERS PER STATUTE ER B AND EMPLOYERS' LIABILITYI'll EMPLOYCOMPENSATION EMPLOYERS' ANYPROPRIETOR/PARTNER/EXECUTIVE Y No NIA Y 7036371671 01/Ol/2029 Ol/O1/2025'E. E.L.F1�CHACCIDENT $ 1,000 00 WW - 0 OFFICERIMEMBER EXCLUDED? YEE S 1,000,000 (Mandatory in NH) ...E�. �.,DISEASE-EA.E..........,O.........„_..,..,..,__.------ ............. If yes, describe under DESCRIPTION OF OPERATIONS below El. DISEASE -POLICY LIMIT 1,000,000 $ C Workers Compensation 6 Y 7036371685 01/01/2024 01/01/2025 E.L., Each Accident $1,000,000 Employers Liability (CA Policy)7 E.L„, Disease -Each Em $1,000,000 Per Statute E-L, Disease -Pal Lm $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) SCOPE OF WORK: Copier Sales, Leasing 6 Maintenance City of El 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. r-Aklf Cl M A.Tinkl 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 Attu: City Clerk 350 Main Street E1 Segundo, CA 90245-3813 JT`JU6-LUTDAt,VRUL,VRt'VrViIwrV. r%unynwrcao1vcu. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD sH ID: 25186835 sATcH: 3259586 AGENCY CUSTOMER ID: LOC #: ADDITIONAL REMARKS SCHEDULE Page _ z _ of 2 AGENCY NAMED INSURED Willis Towers Watson Northeast, Inc. Kyocera Document Solutions West, LLC w_ 14101 Alton Parkway POUCYNUMBER Irvine, CA 92618 See Page 1 CAR....... ARRI ..� ...,.............. �...r ......_.�.. _. ER NAIC CODE ...._------- .. ..... �.._.......... .,_.............. ..._. See Page 1 See Page 1 EFFECTIVE DATE: See Page 1 AnnlTIr1NIA1 RFMAPW-q THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance _..._ _._..... p . Y g._.,. Y_..,,(.,.. _.._..... if required in the written contract, agreement or permit, the Insured waives an right of recover 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 rlgnts reservea. The ACORD name and logo are registered marks of ACORD SR ID:25186835 HATCH:3259586 CERT: W32132809 POLICY NUMBER: TGM30035226900 COMMERCIAL GENERAL LIABILITY CG 20 10 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OIL CONTRACTORS - SCHEDULED PERSON OIL ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 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: 1. 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 additional exclusions apply: This insurance does not apply to "bodily injury" or "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. C. 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 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 AL INSURED - OWNERS, S, LESSEES OIL 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 RED ERED LOCATION COVE 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. m_ this Schedule, if not shown above, will be shown in the Declarations required to complete above, Information......... .......... M .. ............... ... .... .....___ __....... ... ������. ��������. ....... _........ . ��������...... ..... ���������... ........-------- A. Section II - Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only with Section III - Limits Of Insurance: respect to liability for "bodily injury" or "property If coverage provided to the additional insured is damage" caused, in whole or in part, by "your work" required by a contract or agreement, the most we at the location designated and described in the will pay on behalf of the additional insured is the Schedule of this endorsement performed for that amount of insurance: additional insured and included in the products -completed operations hazard". 1. Required by the contract or agreement; or However: 2. Available under the applicable limits of 1. The insurance afforded to such additional insurance; insured only applies to the extent permitted by whichever is less. law; and This endorsement shall not increase the applicable 2. If coverage provided to the additional insured is limits of insurance. 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. 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 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) Policy No: WC 7036371685 Endorsement Effective Date: Endorsement Expiration Date: Policy Effective Date: 01 /01 /2024 Endorsement No: 3; Page: 1 of 1 Policy Page: 35 of 51 Underwriting Company: The Continental Insurance Company, 151 N Franklin St, Chicago, IL 60606 a 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) Policy No: WC 7036371671 Endorsement Effective Date: Endorsement Expiration Date: Policy Effective Date: 01 /01 /2024 Endorsement No: 11; Page: 1 of 1 Policy Page: 229 of 378 Underwriting Company: Valley Forge Insurance Company, 151 N Franklin St, Chicago, IL 60606 Copyright 1983 National Council on Compensation Insurance.