PROOF OF INSURANCE (2016) CLOSEDCERTIFICATE OF LIABILITY INSURANCE I DATE 1(M11111 YYY)
THIS CERTIFICATE 18 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 CertMcabe holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WANED, subject to
the terns and Conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
PRODUCER
Palmer 5 A, LLC
22 Bernard Street
Suite 200
Savannah GA 31401
l>
INSURED
153 uJr U
Old Scouts of Greater Los Angeles
801 S. Grand Avenue
Suite 300 _.,., .. ........
....u,,,,,
Los Angeles CA 90017 -021
INS""
1519324415 M
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.
�_. .._.' AWL ._..w _...,. r
TYPE OF ON= RANCE iu n wyn POLJCVNUUB UNITS
A COMMERCIAL GENERAL LIABILITY KKI5040900 !1!2016 1!1!201!! $1,000 000
X r"AC11 OCCURRENCE
CLAIM84AADE FXIOCCUR H $1000 °000
MED EXP (MvanP owunl 810AOD
F a � PERSONAL A. AM INJURY {1.000.000
Iq NPOOOYEGATE� MITAPPLIESPIM GENERAL AGGREGATE $510001000
LOC PRODUCTS COMP /OP AGO $5.000.000
.. _�..
OTHER: i
A AUTOINOSILE LIABILITY KKI5040000 !1!2015 1!1!2015 BODILY INJU (Pa Pwson) $1,0001000
RY _..
AUTOS � ULEG BODILY INJURY (Pw w>ol' ) $ " ._W __ .
HIRED AUTOS X AUTOS' ED rP.r.dw,I 175,000
UMBRELLA WE OCCUR EACH OCCURRENCE $
EXCESS LIAe
CLAIMB.MADE, A6OREGATE $
DEO 1 RE7EIiT1ON III
A Wo aGI SRS COMPENSATION WCC33000200 /1/2015 111/2016 X sTAnrrE
AND AN PRO�ET��INEI�XL'C4J71VE NIA E.L EACHA�
YIN CCIDENT $1.000.000
OFA ^ROEM,iEA'N0'EI8 ECLUDEDI """"""""""""
(Mandatory In NH) E.L. DISEASE EA EMPLOYER 2 1.000 000
I E L N( � oiTW0 r DISEASE • POLICY LIMIT $1.000.000
D ESC RIPTION OF OPERATIONS LOCATION S I VEHICLES (ACORD 101, Additional
Si may be rtlaohad N more spas M ntrP11ma4)
The City of El Segundo, tilts officers, officials employees, s ent's and voluntears.are Included additional Insured' on the general Ilability policy
With respect to the Use of a premises for G10 Scout activities of the Insured Girl Seoul Council. Should any of the above described olioles be
cancelled before the expiration date thereof, the issuing company Will mail 30 days, written notice to the certificate holder named to lie haft.
This endorsement modifies Insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
IIICHIIIDULE
Name of Additional Insured Parson(s) or Organization(s):
The City of El Segundo, ft offloers, employee, agents
and volunteers
350 Main Street
El Segundo, CA 90245
$ #1 111 1 91 =Fr41r*1rtWrm#; , i 11 11" 1 11 1 1
11miuri'Mme 01 1
111TWIT A
0milmW1518 or 1110 acts or omillsiortS 01, Yng
on your behalf,
A. In the performanom of your ongoing operations; or
0. In connection with your Pnornises owned by or rented to you,
C.0 D41104 08 0 208 TM TrmWmComponles, WA pop I of i
11WW" " 00POOM 111914flill Of InWrWm SOMM 0", I= With Rs pwmbdm
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY,
•� S 01 , t#'
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
GENERAL DESCRIPTION OF COVERAGE — This endorsement broadens coverage. However, oovsrago for any
Injury, damage or onedlcal expensait described In any, of the provisions of this endorsement, may be excluded or
limited by another ofidorsamont to this Coverage mart, and those average broadening provisions do not apply to
the extent that coverage Is excluded or limited icy saute an endorsement. The following Ilsling Is a general cover.
ape description only. Limitations and excluelons may apply to theses coverag -es. Read all the provisions of this en-
dorsement and the rest of your policy carefully to determine rights, dudes, and what Is and Is not covered,
A. Reasonable Force Properly Damage — Exception
To Ex ,led Or Intended Injury Exclusion
B. Non -Owned Watercraft 76 Feet Long Or Less
C. Owned Watercraft
D. Aircraft Chartered With Pilot
E. Damage To Promises Rented To You
F. Girt Scouting Activities — Damage To Property Of
Others
G. increased Supplementary Payments
H. Medlcal Payments — Athletic Activities — Excess
Insurance For Participants In Activities Sponsored
By You
I. Who Is An Insured — Unnamed Subsldlerlas
J. Who Is An Insured — Newly Acquired Or Formed
Organizations
IL Who Is An Insured — Employees And Volunteer
Workers
L. Who Is An Insured — Old Scouts Of The USA
PROVISIONS
A. REASONABLE FORCE PROPERTY DAMAGE —
EXCEPTION TO EXPECTED OR INTENDED IN-
JURY EXCLUSION
M. Blanket Additional Insured — Providers Of Funds
Or Grants
N. Blanket Additional Insured — Persons Or Organl-
zatlons As Required By Written Contract Or
Agreement
O. Blanket Additional Insured — Owners, Managers
Or Lassors, Of Premises
P. Blanket Additional Insured — Lessors Or Providers
Of Equipment
Q. Blanket Additional Insured — Mortgagoes, Assign-
ees, Successors Or Receivers
R. Blanket Additional Insured — State Or Political
Subdivisions
S, increased Medical Payments
T. Dirt Scout Council Acts, Errors Or Omissions
U. Incidental Medical Malpractice
V. Knowledge And Notice Of Occurrence Or Offense
W. Unintentional Omission
X. Blanket Waiver Of Subrogation
the use of reasonable force to proteot any
person or property.
B. NON -OWNED WATERCRAFT 76 FEET LONG
OR LESS
The following replaces Exclusion a., Expected Or 1. The following replaces Paragraph (2) of Ex-
Intended Injury, In Paragraph 2., Exclusion*, of duslon 10., Aircraft, Auto Or Watercraft, In
SECTION I — COVERAGE A BODILY INJURY Paragraph 2. of SECTION I — COVERAG0
AND PROPERTY DAMAGE LIABILITY, — COVERAGE A BODILY INJURY ANO
a. Expected or Intended Injury or Damage PROPERTY DAMAGE LIABILITY:
"Bodily Injury" or "property d'srnage" expected (2) A wateroreft you do not own that Is:
or Intended from the standpoint of the In- (a) Seventy -five, feet long or lose; and
sured, This exclusion does not apply to "bod- (b) Not being used by you to carry any
Ily Injury" or "property damage" resulting from person or property for a charge.
CO Da N 01 12 0 2011 The Traveler Indemnity Company. AU rtohts reserved. Page 1 of 8
COMMERCIAL GENERAL LIABILITY
2. The following Is added to Paragraph 2. of
SECTION 11— WHO 13 AN INSURED:
Any person or organization that, with your ox-
press or Implied consent, either uses or Is re-
sponsible for the use of a wateroraR that you
do not own that Is:
This exclusion does not apply to a watercraft
you own that la:
(1) Loss than:
(a) 25 fast long; or
(b) b'tl feet lonig that Is not motor-
powered or sail Bred; and
(2) Not being used by you to carry any par-
son or property for a charge.
2. The following Is added to Paragraph 2. of
$RCTION 11— WHO IS AN INSURED:
Any person or organization that, with your ex-
press or Implied consent, either uses or Is re-
sponslbls for the use of a watororeft that you
own that Is:
(1) Loss than:
(a) 26 feet long; or
(b) 50 feet long that Is not motor -
powered or Sall- powered; and
(2) Not being used by you to carry any per-
son or property for a charge.
D. AIRCRAFT CHARTERED WITH PILOT
The following Is added to Exoluslon g., AlraraN
Auto Or Watercraft, In Paragraph 2. of SECTION
I — COVERA0E0 — COVERAGE A SODILY IN-
JURY AND PROPERTY DAMAGE LIA131LITY:
This exclusion does not apply to an aircraft that
Is:
a. The amount shown for the Damage
To Promises Rented To You Limit on
the Deolaratlons of this Coverage
Part or $1,000,000, whichever Is
greater; or
b. $1,000,000 If no amount Is shown for
the Damage To Promises Rented To
You Limit on the Declarations of this
Coverage Part,
4. The following replaces Paragraph a. of the
definition of "Insured oontroot" In the DEFINI-
TION$ Section:
(a) Chartered with a pilot to any Insured; a. A Contract for a lease of premises. How -
b) Not owned by any Insured; and aver, that portion of the contract for a
( lasso of promises that indernnifles any
(a) Not being used by you to carry any person or person or orgenlzation for "premises
property for a charge. damage" Is not an "Insured contract ":
Page 2 of 6 0 2011 The Trevelen tndemnity Company. AN Aghts reserved, CO Dd 00 0112
S. The following Is added to the DEFINMONS
Section,
"Premises damage" means "property dam-
age" to:
a. Any premises while rented to you or tem-
porarily occupied by you with porrnisslon
of the owner; or
Is. The contents of any premises while such
prvmlmw are rented to you, If you rent
such Promises for a period of soven or
fewer, consecutive days.
S. The following replaoee Paragraph 4.b.(1)(b)
of SECTION IV — COMMERCIAL GENERAL
LIABILITY CONDITIONS:
(b) That Is Insurance for "premi s damage ";
or
T. Paragraph 4.b.(1)(c) of SECTION IV —
COMMERCIAL GENERAL LIABILITY CON-
DITIONS is deleted.
R. GIRL SCOUTING ACTIVITIES DAMAGE TO
PROPERTY OF OTHERS'
The following Is added to Exclusion J., Damage
To Property, In Paragraph 2. of SECTION I —
COVtERAGR$ — COVOR'AGE A BODILY IN-
JURY AND PROPERTY DAMAGE LIABILITY:
Paragraphs (4) and (S) of this exclusion do not
apply to "property damage" to property of others
caused by "your work" In connection with GIN
Scouting activities sponsored by your GIN Scout
Cournoil.
0. INCREASED SUPPLEMENTARY PAYMENTS
1. The following replaces Paragraph 1.b. of
SUPPLEMENTARY PAYMENTS — COVER -
AGES A AND B of SECTION 1 — COVER-
AGES:
b. Up to $2,WO for coat of bell bonds re-
quired because of accidents or traffic law
violations arising out of the use of any
vehicle to which the Bodily Injury Liability
Coverage applies. We do not have to fur-
nish these bonds.
2. The following replaces Paragraph 1.d. of
SUPPLEMENTARY PAYMENTS — COVER-
AGES A AND 0 of SECTION I - COVER -
AGl6:
d. All reasonable expenses Incurred by the
Insured at our request to assist us In the
Investigation or defense of the claim or
"suit ", Including actual lose of earnings up
to ;600 a day because of time off from
work.
COMMERCIAL GENERAL LIABILITY
H. MEDICAL PAYMENTS -- ATHLETIC ACTM-
TIES — EXCESS INSURANCE FOR PARTICI-
PANTS IN ACTIVITIES SPONSORSO BY YOU
1. Exclusion e., Athletic Activitles, In Pars -
graph 2. of 'SECTION I — COVERAGES —
COVERAGE C MEDICAL PAYMENTS Is de-
low.
2. The following Is added to Parearaph 4.b., Ex-
aass insurance, of SECTION IV — COM-
MERCIAL GENE. ! L LIABILITY CONDI-
TIONS:
This Insurance Is excess over that part of any
other Insuranos that provides coverage for
medical payments that are Incurred by any
member of the GIN Scouts of the USA organi-
zation and Its volupteers who are parti'olpants
of a supervised and approved GIN Scout so-
tivity sponsored by your council,
I. WHO 18 AN INSU'RE'D — UNNAMED SUBSIDI-
ARIES
The foliowin Is added to SECTION II - WHO IS
AN INS'UR
Any of your subsidiaries, other than a partnership,
joint venture or limited liability company. that is
not shown as a Named Insured In the D sdtlara-
tions Is a Named Insured If:
a. You maintain an ownership Interest of more
than 60% In such subsidiary on the first day
of the policy period; and
b. Such subsidiary Is not an Insured under alml-
lar other Insurance.
No such subsidiary Is an insured for "bodlly Injury "
or "property damage" that ocourred, or "personal
Injury" or "advertising Injury" caused by an of-
fense committed;
a. Before you maintained an ownership Interest
of more than 50% In such subsidiary; or
b. After the date, if any, during the policy period
that you no longer maintain an ownership In-
terest of more than 60% In such subsidiary.
J. WHO IS AN INSURED — NEWLY ACQUIRED
OR FORMED ORGANIZATIONS
The following ropleces Paragraph 4. of SECTION
11— WHO 18 AN INSURED:
4. Any organization you newly acquire or form,
other than a partnership, joint venture or lim-
Iled liabliittt company, of wwhkA yoga are the
sole owner or In which you maintain the ma-
jority ownership Interest, will qualify as a
Named Insured If there Is no other Insurance
CG D3 Of 0112 0 2011 The Travelers Indomnity Company. All rlghts relarwd. Page 3 of 8
COMMERCIAL GENERAL LIABILITY
which provides similar coverage to that or-
ganlzation. However.
a. Coverage under this provision Is afforded
only:
(1) Until the 180th day after you "Ulm
or form the organization or the and of
the policy poriod, whichever to earlier„
If you ado not report such organization
In writing to us within 180 days after
you acquire or form It or
(Z) Until tha and of the policy period,
when that date Is later then 180 days
after you acquire or form such or-
ganization, If you report such orpanl-
zatlon In writing to us within 190 days
after you acquire or form I4 and we
agree In writing that It will continue to
be a Named Insured until the end of
Me policy period;
Is. Coverage A does not apply to "bodily in-
jury" or "property damage" that occurred
before you acquired or formed the or-
ganization; and
a. Coverage B does not apply to "personal
and advertising Injury" arising out of an
offense committed before you aoqulred or
formed the organization.
IC. WHO IS AN INSURED — EMPLOYEES AND
VOLUNTEER WORKERS
1. The following Is added to Parafitaph Z, of
89CTION 11— WHO IS AN INSURED:
Any of your "employees" appointed at your
request to serve with an "side tax exempt
entity will be deemed to be acting within the
scope of their employment by you or perform -
Ing duties related to the conduct of your bual..
noes,
Z. The following Is added to Paragraph 2.a.(1) of
SECTION 11— WHO IS AN INSURED:
Paragraphl)(a) above does not apply to
"bodily Injury" to a co-"employes" or to a co-
"volunteer worker" while In the course of his
or her employment or while performing duties
related to the conduct of your bue[nssa.
a. The following is added to Paragraph 3. of
SECTION If — WHO 18 AN INSURE13:
Paragraph a. abgve doss not apply to "bodily
Injury" to a co» "employee" while in the course
of his or her employment or while performing
dudes related to the conduct of your bust-
noes.
L. WHO 18 AN INSURED — GIRL SCOUTS OF THE
U'
The following [s added to SECTION II — WHO M
AN INSURED:
1. The Girl Scouts of the USA, but only with rs-
spect to Ilabll[ty caused by:
a. The ownership, maintenance or use of
promises which you own, rsnt, lease or
temporarily occupy with permission of the
owner,
b. Your asps or omissions In the pedorm-
encs of "your work" for the (Uri Scouts of
the USA; or
a. Your providing or falling to provide "Girl
Scout Council services ".
Z. An Interim executive director or chief ecu-
tive officer of the Old Scouts of the USA, but
only wNto performing duties for the Girl
Scouts of the LISA at your counoll.
M. BLANKET ADDITIONAL INSURED — PROVID-
ERS OF FUNDS OR GRANTS
The following Is added to SECTION 9 — WHO IS
AN INSURED:
Any person or organization that provloss funds or
grant& to you, but only with respect to liability
caused by your activltles or operations that are
funded or financially supported by or with funds or
grants received from or provided by that person
or organization.
However, In the event that the limits of Insurance
shown in the Declarations of this Coverage Pert
exceed the limits of liability required by a written
contract or agreement between you and such ad-
ditlonal Insured, the Insurance provided to the ad-
ditional Insured shall be limited to the limits of 11-
ability required by that written contract or agree.
ment. This endorsement shall not Increase the
Omits of Insurance described In Section III — Limits
Of Insurance,
N. BLANKET ADDITIONAL INSURED PERSONS
OR ORGANIZATIONS AS RIOUItND BY
WRITTEN CONTRACT OR AGREEMENT
The following Is added to SECTION 11 — WHO IS
AN INSURED:
Any person or organization that is not otherwise
an Insured under this Coverage Part and that you
have agreed in a written contract or agreement to
Include as an additional Insured on this Coverage
Part Ili an Insured, but only with reaped to liability
for "bodily Injury", "property damage ", "personal
Injury" or "advertising Injury" that:
Page 4 of 8 02011 The Trawlers Indemnity Compeey. All rights reserved, CO Da 06 0112
COMMERCIAL GENERAL LIABILITY
b, The Insurance provided to such person or or-
ganlzatlon does not apply to:
(1) Any "b0dlly Injury" or "property damage
that occurs, or any "personal Injury" or
"'advertising Injury" caused by an offenes
committed, after such contract or agree-
ment Is no longer In effect; or
(2) Any, "'bodily Injury ", "property dam s ",
"personal Injury "" or l advertiaing Injury"
arising out of any structural atteratloms,
new construction or demolition oporations
CO D3 66 01 12 a 2011 The Tmvslers indemnity Company. All rights reserved, Page 5 of 8
COMMERCIAL GENERAL LIABILITY
performed by or on behalf of such mort-
gagee, assignee, successor or receiver.
R. BLANKET ADDITIONAL INSURED — STATE OR
POLITICAL SUNDIVISiONE
The following are added to SECTION p — WHO Is
INSURED:
1. Any state or political subdivision that has Is-
sued a permit In connection with promises
owned or occupied by, or rented or loaned to,
you Is an Insured, but only with respect to li-
ability for "bodily injury", '"property damage",
"personal Injury ", or "advertlaing Injury" arising
out of the existence, ownership, use, mainte-
nance, repair, construction, erection or re-
moval of advertising signs, awnings, cano -
ples, cellar entrances, coall holes, driveways,
manholes, marquess, hoist away openings,
sidewalk vaults, elevators, street banners or
decorations for which that state or political
subdivision has Issued such permit.
2. Any state or political subdivIslon that has Is-
sued a permit In comwollon with operations
perfo d by you or on your behalf Is an In-
sured, but only with reaper'st to liability for
"bodily Injury ", "property damage ", "personal
Injury " or f'advertioing Injury" arising out of
such operations.
Coverage under this provision does not apply
to:
a. Any "bodily injury", "property damage ",
°" parsonal Injury" or " advertising Injury"
arising out of operations performed for
that state or political subdivision; or
b. Any "bodily Injury" or "property damage"
Included In the "produoto- computed op-
erations hazard ".
S.
INCREASED MEDICAL PAYMENTS
The following replaces Paragraph 7. of SECTION
111 — LIMITS OF INSURANCE:
T. Subject to ti, above, ffte Medical Expense
Limit Is the most we will pay under Coverage
C for all medical expenses bemuse of "bodily
Injury" sustained by any one person.
The Medical Expense Limit will be:
a. The amount shown for the Medical Ex-
penses Limit on the Declarations of this
Coverage Part or $10,000, whichaver Is
greater, or
b. $10,000 If no amount Is shown for the
Medical Expense Limit on the Declare-
tons of this Coverage Part.
T. GIRL SCOUT COUNCIL ACTS, ERRORS OR
OMISSIONS
1. Tho following Is added to the definition of "oc-
currence In the DEFINITIONS Section:
"Occurrence" also means an act, senor or
omission In providing or filling to provide "Girl
Scout Council services ".
2. The following is added to the DEFINITIONS
Section,
"Girl Scout Council services" moons the care.
Instruction or supervision of Girl Scouts, and
the development or Implementation of educa-
tional, developmental or recreational activity
programs in connection with the Girl Scouts
of the USA and pursuant to your operation as
a Girl Scout Council.
3. The following Is added to Paragraph S. of
SECTION IN — LIMITS OF INSURANCE:
For the purposes of determining the applica-
ble Each Occurrence Limit, all related acts,
errors or omissions committed In providing or
falling to provide "Girl Scout Council emlcee"
to any one Girl Scout will be deemed to be
one "occurrence ".
U. INCIDENTAL MEDICAL MALPRACTICE
1. The following Is added to the definitlon of "oo-
currence" in the DEFINITIONS Section:
" Ocourrence" also means an sot or omission
committed In providing or failing to provide
"Incidental medical services ", first aid or
"Good Samaritan services" to a person.
2. The following is added to Paragraph 2.e.(1) of
SECTION II — WHO IS AN INSURED:
Paragraphs (1)(s), (b), (a) and (d) above do
not apply to "bodily Injury" arising out of pro-
viding or failing to provide:
(1) "Incidental medical services" by any of
Your "employees" who Is a nurse praoti-
tloner, registered nurse, licensed practical
nurse, nurse assistant, emergency modt-
caI technician, paramedic, athletic trainer,
audiologist, dietician, nutritionist, occups-
tionai therapist, occupational therapy as-
slatent, physical therapist or speech pa-
thologist; or
(11) First aid or "Good Samaritan services',' by
any of your "employees " or "volunteer
workers ", other tt "on an employed or vol-
unteer doctor, Any, such "employees" or
"volunteer workers" providing or falling to
provide first aid or "Good Samaritan ser-
Page 0 of IS o 2011 The Travelers Indemnity Company. AN rights reserved. CA D3 t1t161 12
vices" during their work hours for you will
be deemed to be acting within the scope
of their employment by you or performing
duties related to the conduct of your busf-
ness.
3. The follovMg Is added to Paragra h 5. of
SECTION' III — LIMITS OF INSI, DICE:
For the purposes of determining the applica-
ble Each Occurrence Limit, all related sots or
omissions committed In providing or failing to
provide "Incidental medical services ", first aid
or "Good Samaritan servloss" to any one per`
son will be deemed to be one "occurrence".
4. The following exclusion Is added to Para -
graph 2., Exclusions, of SECTION I — COW
ERAOES — COVERAGE A BODILY INJURY
AND PROPERTY DAMAGE LIABILITY:
Sais Of Pharmaceuticalls
"Body injury" or "property damage" arising
out of the willful violation of a penal statute or
ordinance relating to the sale of pharm oull-
cals committed by, or with the knowledge or
consent of, the Insured.
ti. The following Is added to the DEFINITIONS
section:
"Incidental medical services" means:
a. Medical, surgical, dental, laboratory, x-ray
or nursing service or treatment, advice or
Instruction, or the related fumishing of
food or beverages; or
b. The furnishing or dispensing of drugs or
medical, dental, or surgical supplies or
appliances.
"Good Samaritan services" means any emer-
gency medical services for which no oompen-
satfon Is demanded or received.
6. The following Is added to Paragraph 4.b., Ex-
cess Insurance, of SECTION IV — COM-
MERCIAL GENERAL LIABILITY CONDI-
TIONS:
This Insurance Is excess over any valid and
collectible other Insurance, whether primary,
excess, contingent or on any other basis, that
Is available to any of your "employees" for
"bodily injury" that arises out of providing or
falling to provide "Incidental medical services"
or Ant aid to any person to the extent not
subject to Paragraph 2.a,(1) of Section 11 —
Who Is An Insured,
COMMERCIAL GENERAL LIABILITY
V. KNOWLEDGE AND NOTICE OF OCCj,JR-
RENCE OR OFFENSE
The Mowing Is added to Paragraph 2., Duties In
The Event Of Occurrence, Offense, Claim or
Suit, of SECTION IV — COMMERCIAL GEN-
ERAL LIABILITY CONDITIONS:
e. The following provlslons apply to Paragraph
a. above, but only for the purposes of the In-
surence provided under this Coverage Part to
you or any Insuredlisted In Paragraph 1. or 2.
of Sectlo 11 —Who Is An Insured:
(1) Notice, to us of such " rren c ," or of-
fense must be given as soon as practica-
ble only after the ""orourrenos" or offense
Is known to you (If you ore an Individual),
any of your partners or members who Is
an Individual (if you arcs a partrierWilp or,
joint venture), any of your managers who
Is an Individual (if your are a limited liability
company), any of your trustees who Is an
Individual (If you are a trust), any of your
"executive otfiows" or directors (if you are
an organization other than a partnership,
joint venture, limited liability oarnpany or
trust) or any "employee" authorized by
you to give notice of an "occurrence" or
offense.
Knowledge by any other "employee" of an
"occurrence" or offense does not Imply
that you also have such knowledge.
(2) if you are a partnership, joint verdure, Hm-
Ited liability company or trust, and none of
your partners, joint venture members,
managers or trustees are Individuals, no.
tics to us of such "occurrence" or offense
must be given as soon as practicable only
after the "occurrence" or offense is known
by:
(a) Any Individual who Is:
(1) A partner or member of any part-
nership or joint venture;
(11) A manager of any limited liability
company;
(111) A trustee of any trust; or
(W) An executive offloer or dhvdor of
any other organization;
that Is your partner, joint venture
member, manager or trustee; or
(b) Any "erndployee " authorized by such
partnership, joint venture, limited 14.
,ability company, trust or other organl.
CO D3 04 0112 0 2011 The Travelere Indemnity Company. AN rights reserved. Page 7 of 8
COMMERCIAL GENERAL LIA131UTY
zation to give notice of an "occur-
rence" or offense.
(S) Notice to us of such "occurrence" or of-
fense will be deemed to be given as soon
as predicable If It Is given In good faith as
soon as practicable to your workers'
compensation Insurer or activity accident
insurer. This applies only If you sub -
quently glve notice to us of the "'oco r-
rence" or offense as soon as practicable
after any of the persons desuribed M
Paragraphs a. (1) or (2) above discovers
that the "occurrence" or offense may re-
sult In sums to which the Insurance pro -
vided under this Coverage Part may ap-
ply
However, If thle policy Includes an endorse-
ment that provides limited coverage for "bod-
nY Injury" or "property damage" or pollution
costs arising out of a discharge, release or
escape of "pollutaaats" wl,ilch contains a re-
qulrement that this disoliarga, release or es-
cape of "pollutants" must be reported to us
within a specific number of days after Its
abrupt commencement, this Paragraph a.
does not affect that requirement.
W. UNINTENTIONAL OMISSION
The foUowft Is added to Paragraph G., Repre-
sentations, of BECTIO14 IV — COMMERCIAL
GENERAL LIABILITY CONDITIONS:
The unintentional omission of, or unintentional
error In, any Information provided by you which
we relied upon In Issuing this policy will not preju-
dice your rights under this Insurance. However,
this provision does not affect our right to collect
additional premium or to exercise our rights of
cancellation or nonrenewal In accordance with
applicable Insurance laws or regulations,
X. OILANKEY'WAtVER OF SUBROGATION
The t'ollowin Is added to Paragraph S., Transfer
of Rights of'Recovery Against Others to Us. of
SECTION W — COMMERCIAL GENERAL LI-
ILITY CONDITIONS:
If the Insured has agreed In a oontnict or agree-
ment to waive that Insureds right of recovery
against any person or organization, we waive our
right of recovery against such person or organizs-
tlon, but only for payments we make bocauss of,
a. "Bodily Injury" or "property damage" caused
by an "occurrence that takes place; or
b. "Personal Injury" or "advertising Injury"
caused by an offense that is commuted:
subsequent to the execution of the contract or
agreement.
Page 8 of 8 0 20111 The Travelers Indemnity Com"my. All rWhae reserved. CO D9 60 0112
For., WN,9 Request for Taxpayer
lRev, Oftber 2007) Identification Number and Certlflcatlon
Depar"Wt of the Treasury
N
Name (as shown on your Income tax retumi
Girl Scouts of Greater Lo!IA lt ,ales
name, Wainess If different from Oxwe
Check appropriate box: ❑ IndivlduANOW proprietor 0 CorporsUon ❑ Partnership
❑ Urnfted Ilabllfty company, Enter the tax ogao ticatlon (D.disrepsrdsd entity, C- corporation, 13-partnership) ► ...... ,.
n Otter Inter Iu tru oorel ►
addrrsss (rsrrribw, st asst. or sutlo no,
801 S. Grand Avenue, Suite
City„ sta%, and l'Ip cado
Los An e l e , CA, 90017
Uat account numbers) here (optlonao
Requester's tame ami
plve form to the
requester. Do not
send to On IR&
Exempt
Pam
bntor your TIN In the appropriate box, The TIN provided must match the narna givan on Une 1 to avoid e0ew eeouAgr rwnnber ��
backup withholding, For Individuals, this Is your social security number CSSN). However, for a resident
allen, sole proprietor, or disregarded entity, aw the Part I Instructions on page 3. For other entities, It Is
your employer Identification number (EIN). If you do not have a number, see Now to get e nN on page 3, or
Note. If the account Is In more than one name, see the chart on page 4 for guidelines on whose a r kfermahoseon numoor
number to enter, 95 1 YJ v 1
Under penattles of perjury, I certify that;
1. The number shown on this form Is my correct taxpayer identification number (or I am waiting for a number to be Issued to me), and
2, 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all Interest or dividends, or (c) the IRS has
notltled me that I am no longer subject to backup withholding, and
3. 1 am a U.S. citizen or other U.S. person (defined below),
0e411111oatlon Instruotlons. You must cross out Rom 2 above If you have been notified by the IRS that you are currently subject to backup
w4hholdIng because your have failed to report ail Interest and dividends on your tax return. For coal estate transactions, itern 2 does not apply.
For mortgage, Interest paid, acquisition or abandonmem of sar urad property, canosllatl'on of debt:, contrlbullons to an individual retirement
arrangement (IRA), and generally, payments outer than Wereat and dividends, you art not required to sign the Ovirtlfk;atlon, but you must
provide your correct rIN. See the 'Instructions on pane 4.
Sign elpnalure of
I
HDrO U e. person 0 Dale ►
Cat. No. 10231X Form W-W (Rev, 10.2007)
Ramos, Vine
From:
Garcia, Angelina
Sent:
Wednesday, October 08, 2014 10: 11 AM
To:
Ramos, Vina
Cc:
Bobbett, Jesse
Subject
RE: Girl Scouts at Camp Eucalyptus
=, f M f.
Angelina Garcia
From: Ramos, Vlna
Sent: Tuesday, October 07, 2014 11:28 AM
To: Garcia, Angelina
Cc: Bobbed, Jesse
Subj : Girl Scouts at Camp Eucalyptus
Hi Angie,
The Girl Scouts partnered with the City years and years ago (maybe over 15 years ?) to utilize Camp Eucalyptus for their
activities. Due to the recent fee Implementation, some groups can be affected unless Council approves a License
Agreement with an agreed amount or fees are waived. Staff is taking a License Agreement with Girl Scouts for Council
approval to formalize the partnership.
The License Agreement will help us implement insurance requirements. Attached is what they provided. GS did not
provide the Waiver of Subrogation Endorsement as they only use volunteers in our facility. But I see that they have
Workers Comp on their certificate. Please advise if what they provided are acceptable.
Thank you,
Vina