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PROOF OF INSURANCE (2011) CLOSEDCC `1CTM CERTIFICATE OF LIABILITY INSURANCE DATE J PM PRODUCER 87227 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MARSH USA INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1166 AVENUE OF THE AMERICAS HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR NEW YORK NY 10036 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED 960B INSURER A: Commerce & Industry Insurance Company 19410 TIME WARNER NY CABLE LLC DBA TIME WARNER CABLE INSURER B: Ins. Co. State of Pennsylvanla 19429 WEST REGION INSURER C: Navigators Insurance Company 42307 550 N. CONTINENTAL BLVD. EL SEGUNDO CA 90245 INSURER D: ACE American Insurance Company 22667 INSURER E: New Hampshire Insurance Co. 23841 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ]NOR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INONG TYPE OF INSURANCE POLICY NUMBER DATE (MMIDDIYY) DATE (MWODIYY) LIMITS A GENERAL LIABILITY 7146110 1/1/2010 1/112011 EACHOCCURRENCE $ 3,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PRE fflEwS-(Es govArrea- (OOO,ODD $ CLAIMS MADE OCCUR DIED EXP (Any one person) °n) $ 10 000 I!� -,,�J PERSONAL& AOV INJURY $ 3,000,000 GENERAL AGGREGATE $ 20,000,000 GEN'L AGGREGATE LIMIT APPLIES PEP, PRODUCTS -COMPIOPAGG 5,000,000 X POLICY PROJECT LOG E AUTOMOBILE LIABILITY MA - 6647474 1/112010 1/112011 ooMemoswur LIMrr X ANYAUTO VA -6647473 (FO accldent $ 5,000,000 ALL OWNED AUTOS AOS - 6647472 BODILY INJURY (Per person) $ SCHEOULED AUTOS BODILY INJURY HIREDAUr'O (Peracadant) $ NON•OWNEDAUTOS � PROPERTY DAMAGE (Peraccident) $ QARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANYAUTO OTHER THAN EAACC AUTO ONLY: AGG $ D EXCESSIUMBRELLA LIABILITY 624902742 11112010 1/112011 EACH OCCURRENCE $ 26,000,000 X OCCUR 1:1 CLAIMS MADE AGGREGATE $ 25,000,000 1 DEDUCTIBLE $ RETENTION $ 1 H E WORKERS COMPENSATION Tk020342136,FL- 020342136 1/1/2010 1/1/2011 . AND EMPLOYERS` LIABILITY CA- 020342139, AOS- 020342133 TOBY ANY PROPRIETORIPARTNERIEXECUTNE YIN ND,NY,OH,WA,WI,WY- 020342137 E.L. EACH ACCIDENT $ 2,000,000 ifyesdR/M ABEREXCLUDEp? M if yes describe under OR- 020342134,MA-020342136 E.L.DISEASE - EAEMPLOYEE $ 2,000,000 SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 2,000,000 OTHER Ohlo Bureau of WIC 20004115 12/112009 12/112010 $ Monopolistic -WA WIC 735355 1/1/2010 12/31/2010 C Excess Auto Only NYIOEXC7022011V 1/1/2010 1/112011 Each Occurrence 2,500,000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS REF: PARKVISTA APARTMENTS, 616 E. HOLLY AVENUE, EL SEGUNDO, CA 90245 PARK VISTA SENIOR HOUSING CORPORATION AND THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSUREDS AIMAAS REQUIRED PER WRITTEN AGREEMENT. CERTIFICATE HOLDER .... ........ ........ m _..a. CANCELLAT SHOULD ANY OF LABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THE CITY OF EL SEGUNDO, C DATE` 71NEREOF OTICE WILL SEDEUVEREO IN ACCORDANCE WITH THE POLICY ATTN; CITY MANAGER PRr,'vlSlraNS. 360 MAIN STREET EL SEGUNDO CA 90246 AUTHORIZED REPRESENTATIVE "CORD 25 (2009109) C) ACORD CORPORATION 1988 POLICY NUMBER: GL 7146110 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) PARK VISTA SENIOR HOUSING CORPORATION AND THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES AND VOLUNTEERS Information required to complete this Schedule, if not shown above, will be shown in the Declarations, 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 your acts or omissions or the acts or omissions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 © ISO Properties, Inc., 2004 POLICY NUMBER: GL 7146110 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL. GENERAL LIABILITY COVERAGE PART Name of Additional Insured Person(s) or Organizations(s): PARK VISTA SENIOR HOUSING CORPORATION AND THE CITY OF EL SEGUNDO, ITS OFFICERS, OOOFF.� GI EMPLOYEES AN SCHEDULE Location and Description of Completed Operations As required per written contract Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section 11- 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 ". CG 20 37 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 ENDORSEMENT # This endorsement, effective 12:01 A.M. 01/01/2010 forms a part of Policy No. GL 7146110 issued to TIME WARNER CABLE, INC. By COMMERCE & INDUSTRY INSURANCE COMPANY ADDITIONAL INSURED - PRIMARY INSURANCE This endorsement modifies insurance provided under the following: COMMERCIAL LIABILITY COVERAGE FORM Section IV, Commercial General Liability Conditions, paragraph 4., Other Insurance, subparagraph a. Primary Insurance, is amended by the addition of the following: However, coverage under this policy afforded to an additional insured will apply as primary insurance where required by contract, and any other insurance issued to such additional insured shall apply as excess and noncontributory insurance. 74434 (10/99)