PROOF OF INSURANCE (2016) CLOSEDA O8
®I� CERTIFICATE OF LIABILITY INSURANCE
DATE ( YYW)
�
/2015
0610912015
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 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
NAME:
Marsh USA Inc.
PHOE FAX
701 Market Street, Suite 1100
IAICN, No Ext : A/C No):
E -MAIL
ADDRESS:
St. Louis, MO 63101
Attn: ATT.CeaRequest @marsh.com
EACH OCCURRENCE
S 1,000,000
INSURERS AFFORDING COVERAGE
NAIC #
INSURER A: Old Republic Insurance Company
24147
018566 -GAW- CRT -15 -16 X X SCHA
INSURED
New Cinguiar Wireless PCS, LLC
INSURER B :
AGE
Ea
PREMISES occu ante
S 1,000,000
One AT &T Plaza
INSURER C:
INSURER D:
208 South Akard Street,
Room 2731
Dallas, TX 75202
INSURER E:
PERSONAL & ADV INJURY
INSURER F:
COVERAGES CERTIFICATE NUMBER: CHI - 006342861 -03 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.
INSR
LTR
TYPE OF INSURANCE
ADDL
UBR
POLICY NUMBER
POLICY EFF
MMIDD/YYYY
POLICY EXP
MM /DD/YYYY
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
MWZY 304717
06/01/2015
06/01/2016
EACH OCCURRENCE
S 1,000,000
CLAIMS -MADE OCCUR
AGE
Ea
PREMISES occu ante
S 1,000,000
MED EXP (Any one person)
S N/A
PERSONAL & ADV INJURY
S 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
s 10,000,000
X POLICY FI PRO F-] LOC
JECT
PRODUCTS - COMP /OP AGG
S 1,000,000
S
OTHER:
A
AUTOMOBILE LIABILITY
MWTB 304716
06101/2015
06/01/2016
COMBINED SINGLE LIMIT
Ea accident
s 1,000,000
BODILY INJURY (Per person)
S
A
X ANY AUTO
MWZX 304718 (MI) See Attached
06/01/2015
06/01/2016
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident)
S
PROPERTY DAMAGE
Per accident
$
NON -OWNED
HIRED AUTOS AUTOS
S
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
S
HCLAIMS-MADE
AGGREGATE
5
EXCESS LIAR
DED RETENTIONS
I S
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR /PARTNER /EXECUTIVE YIN
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
N /A
MWC 304719 00
06101/2015
06/01/2016
X STATUTE OERH
E.L. EACH ACCIDENT
_
5 1,000,000
E.L. DISEASE - EA EMPLOYE
S 1,000,000
E.L. DISEASE - POLICY LIMIT
S 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
A
Excess Workers' Compensation /
MWXS 304720 (OH -WA)
06/01/2015
06/01/2016
EL Each Accident / EL Disease 1,000,000
Employers' Liability
See Second Page
EL Disease - Policy Limit 1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Re: FA #12992945; GSM ID: NL0515; Address: 400 Lomita St., El Segundo, CA 90245; CountyL Los Angeles.
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 Workers' Compensation, as required by written contract and allowable by law.
L;tK I If-IUA I t HULUtK
City of El Segundo
Attn: Risk Management
350 Main Street
El Segundo, CA 90245
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukhedee _S+i.auaotiu
@ 1988 -2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: 018566
LOC #: St. Louis
ACC)R1:> ADDITIONAL REMARKS SCHEDULE Page 2 of 2
AGENCY
NAMED INSURED
Marsh USA Inc.
New Cingular Wireless PCS, LLC
One AT&T Plaza
208 South Akard Street,
POLICY NUMBER
Room 2731
Dallas, TX 75202
CARRIER
NAIC CODE
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 304720 (OH-WA)
Self Insured Retentions
OH & WA - $500,000,000 (except Terrorism)
OH & WA - $600,000,000 Terrorism
Excess Automobile Liability - MWZX 304718 (MI)
Combined Single Limit - S1,000,000
Self Insured Retention - $1,000,000
ACORD 101 (2008/01) @ 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
NOTICE OF CANCELLATION TO CERTIFICATE HOLDERS
This endorsement modifies the notice of cancellation of insurance provided hereunder by adding the
following:
A. In the event this policy is cancelled for any permissible reason, other than for nonpayment of
premium, we shall endeavor to provide advance written notice of cancellation to certificate
holders set out in the schedule on file with the Company, after notifying the first Named Insured of
such cancellation. Notice of cancellation to certificate holders may be made by any commercially
reasonable means, including mail, electronic mail, facsimile transmission or courier service.
B. This advance written notification of a cancellation of coverage Is Intended as a courtesy only. Our
failure to provide such advance written notification will not extend the policy cancellation date, nor
negate cancellation of the policy.
All other terms and conditions of this policy remain unchanged.
PIL 029 10 10
MWTB 304716 AT &T Inc. 46/01/2015.0010112016
jlliffij1 i. N Iti 0 11 10
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY.
NOTICE OF CANCELLATION TO CERTIFICATE HOLDERS
This endorsement modifies the notice of cancellation of insurance provided hereunder by adding the
following:
A. In the event this policy Is cancelled for any permissible reason, other than for nonpayment of
premium, we shall endeavor to provide advance written notice of cancellation to certificate
holders set out in the schedule on file with the Company, after notifying the first Named Insured of
such cancellation. Notice of cancellation to certificate holders may be made by any commercially
reasonable means, including mail, electronic mail, facsimile transmission or courier service.
81 This advance written notification of a cancellation of coverage is intended as a courtesy only. Our
failure to provide such advance written notification will not extend the policy cancellation date, nor
negate cancellation of the policy.
All other terms and conditions of this policy remain unchanged,
MVVZY 304747 AT&T Inc. 0610112015.06101 /2016
FINUE
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY
NOTICE OF CANCELATION TO CERTIFICATE HOLDERS
This endorsement modifies the notice of cancelation of insurance provided hereunder by adding the
fallowing:
A. in the event this policy is canceled for any permissible reason, other than for nonpayment of
premium, we shall endeavor to provide advance written notice of cancelation to certificate holders
set out in the schedule on file with the Company, after notifying the Insured first named in item 1
of the Information Page of such cancelation. Notice of cancellation to certificate holders may be
made by any commercially reasonable means, Including mail, electronic mail, facsimile
transmission or courier service,
B. This advance written notification of a cancelation of coverage is Intended as a courtesy only. Our
failure to provide such advance written notification will not extend the policy cancelation date, nor
negate cancelation of the policy.
All other terms and conditions of this policy remain unchanged.
PC 010 10 10
MWC304719 00 AT &T Services, Inc. 05/01/2015 - 06/0112015
IL 10 (12106) OLD REPUBLIC INSURANCE COMPANY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies Insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
Paragraph 2. of SECTION 11 - 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 shall 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.
MKIZY304717 ATATIric. 0610112016.06 /0112016
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY
WC 252
(4.84)
WC 04 03 06 (Ed. 4 -84)
N W. ii-A HERE
w 6 4
This endorsement changes the policy to which it is attached effective on the inception data of the policy unless a
different date is indicated below.
(The following "attaching clause" need be completed only when this endorsement Is Issued subsequent to preparation of the policy.)
This endorsement, effective on 06/01/2015 at 12:01 A. M. standard time, forms a part of
(GATE)
Policy No. MWC304719 00 Endorsement No,
of the
Old Republic Insurance Company
(NAME OF INSURANCE COMPANY)
Issued to AT &T Services, Inc,
Premium (if any) $
Authorized Representative
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.
Person or Organization
On File With Company
WC 252 (4 -84)
WC 04 03 06 (Ed. 4.84)
Schedule
Jab Description
If Any
Pago 1 of t
VIT141 N 1144ff-�*Tjira
WC 00 03 13
4
WC 124
(4-84)
This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a
different date is indicated below.
(The following 'attaching clause' need be completed only when this endorsement is issued subsequent to preparation of the policy.)
This endorsement, effective on 06101/2015 at 12:01 A.M. standard time, forms a part of
(DATE)
Policy No. MWC304719 00 of the Old Republic Insurance Company
(NAME OF INSURANCE COMPANY)
issued to AT&T Services, Inc.
Premium
Authorized Representative
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 any one not named in the Schedule.
Schedule
Where Required By Written Contract
WC 124 (4-84)
WC 00 0313 Copyright 1953 National Council on Compensation Insurance. Page 1 of 1