Loading...
PROOF OF INSURANCE (2016) CLOSEDL __- CERTIFICATE OF LIABILITY INSURANCE I DATE /27/2DI15 L �' 08/27/2015 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 wnlAcr INSURED MARSH USA, INC. 1166 AVENUE OF AMERICAS NEW YORK, NY 10036 NEW LINE PRODUCTIONS, INC. 4000 WARNER BLVD BURBANK, CA 91522 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A ACE AMERICAN INSURANCE COMP_ ANY 22667 INSURER B. ACE INA INSURANCE 1560515 11539 R I HRs IS I (..E.HI It- Y IMAI. I''.... HE NOLIUIES UI• INNUMANUE LIS Ibl) h1ELCPW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TH..E, 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 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ._ _..____m..,...w..._E �k AS'.R G7. —..�— ..,m.....,,- „��...,.�.� POLICY ,� ��.Y'). ........_.,__ .__ .. LIMITS_ rR TYPE OF INSURANCE SR Y EFF tlCY J I POLICY NUMBER fMMIDp GENERAL LIABILITY EACH OCCURRENCE $ 5,000'',.( A X HDO 627393949 6/1/15 6/1116 G —� �: PREMI S (Ee ocT O X COMME;RCI'AS. GENERAL LIABILITY PREMISES fEa occuraencot�, _Sm � ,000,( _1 CLAIMS -MADE OCCUR MED EXP (Any one person) S 10,( PERSONAL 8 AOV INJURY $ 5,000,000 S 10,000,000 GENERAL �. AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOPAGG S 10,000,000 AUTOMOBILE LIABILITY P00.1CY L 11 t.00 _ $ - .w...... �,., ...._,..._ ........� ........ ............. ... _....,. ......, X ISA H08857404 611/15 6/1116 E� accide�ntyS I iT T 5 5,000,000 !+ ANY AUTO BODILY INJURY (Per person) ... 8 ........ ......................_........ -.' ALL pWNED SCHEDULED _.... �,,,,a...,._......_........_... ....- ....__ m, AUTOS AUTOS BODILY INJURY (Per accident) S a, HIRED AUTOS NON-OWNED 4 er a dm.nl S UMBRELLA LIAB EXCESS LIAB �� OCCUR � EACH OCCURRENCE 5 DED�,RETENTION S CLAIMS MADE - �- �� AGGREGATE FF AND EMPLOYERS NSA nON VIA.. STA"fLT 07 LIABILITY YIN mgYIIMLrS�� -R .. OFFICE IM 1 0�OH'�dR EXCLUDED ECUTIVE” NIA EL EACH EASE�EA EMPLOYEE S- - IMt Cf' under P IIPTI� G nP nPFPGTIr)NR h.1— F In i Rr ARF - P(A 1r`.V I IMIT I ••G •• ••••,J..•,, DESCRIPTION OF OPERATIONS J LOCATIONS I VEHICLES (AHach ACORD 101, Additional Remarks Schedule, if more space is required) THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS 8 CERTIFIED VOLUNTEERS ARE INCLUDED AS AN ADDITIONAL INSURED UNDER THE GENERAL LIABILITY AND AUTO LIABILITY POLICIES BUT ONLY AS REQUIRED BY CONTRACT WITH RESPECT TO THE OPERATIONS OF THE NAMED INSURED. THE GENERAL LIABILITY AND AUTO LIABILITY POLICIES ARE PRIMARY AND ANY INSURANCE HELD BY THE ADDITIONAL INSURED IS NON CONTRIBUTORY AS REQUIRED BY CONTRACT OR AGREEMENT. THE INSURANCE COMPANY WILL ENDEAVOR TO SEND WRITTEN NOTICE OF CANCELLATION, VIA SUCH ELECTRONIC NOTIFICATION AS THEY DETERMINE, TO THE PERSONS OR ORGANIZATIONS LISTED IN THE SCHEDULE THAT THE NAMED INSURED OR ITS REPRESENTATIVE PROVIDE OR HAVE PROVIDED TO THE INS,. CO. (THE - SCHEDULE -). THE INS CO. WILL ENDEAVOR TO SEND SUCH NOTICE TO THE E -MAIL ADDRESS CORRESPONDING TO EACH PERSON OR ORGANIZATION INDICATED IN THE SCHEDULE AT LEAST 30 DAYS PRIOR TO THE CANCELLATION DATE APPLICABLE TO THE POLICY. PRODUCTION: THE HOUSE CANCELLATION i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF EL SEGUNDO CITY CLERK THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATTN: DIRECTOR OF FINANCE ACCORDANCE WITH THE POLICY PROVISIONS. 350 MAIN ST, ROOM 5 EL SEGUNDO, CA 90245 -3813 AUTHORIZED REPRESENTATIVE 1988.24110 ACORD CORPORATION. Alt rights reserve ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD NOTICE; THESE POLICY FORMS AND THE APPLICABLE RATES ARE EXEMPT FROM THE FILING REQUIREMENTS OF THE NEW YORK INSURANCE LAW AND REGULATIONS. HOWEVER, THE FORMS AND RATES MUST MEET THE MINIMUM STANDARDS OF THE NEW YORK INSURANCE LAW AND REGULATIONS. NOTICE TO OTHERS ENDORSEMENT - SPECIFIC PARTIES Named nsu—red Inc. -- EndorsementNumber -' Named Insured y symbol Poly Number Pollcy Period Effective Date of Endorsement HDO 627393949 6/7/2015 to 6/1/2016 81.26/2015 Issu ed By ( Name of Insurance Company) ACE American Insurance Com p an y ° hsert 1he poffoy number. The Pemalnder ortlie Information fs 6�a �� corn 9� pnly aulronm� llbli� earodn� invent Is h�s�woek stYt�aorpur�od f� tla4� ryo�fr,�ahtNq.n pf the pollcy. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. A. If we cancel the Policy prior to its expiration date by notice to you or the first Named Insured for any reason other than nonpayment of premium, we will endeavor, as set out below, to send written notice of cancellation, via such electronic or other form of notification as we determine, to the persons or organizations listed in the schedule set out below (the "Schedule "). You or your representative must provide us with both the physical and e-mail address of such persons or organizations, and we will utilize such e-mail address or physical address that you or your representative provided to us .on such Schedule. B. We will endeavor to send or deliver such notice to the a =mail address or physical address corresponding to each person or organization indicated in the Schedule at least 30 days prior to the cancellation date applicable to the Policy. C. The notice referenced in this endorsement is intended only to be a courtesy notification to the person(s) or organization(s) named in the Schedule in the event of a pending cancellation of coverage. We have no legal obligation of any kind to any such person(s) or organization(s). Our failure to provide advance notification of cancellation to the person(s) or or•ganization(s) shown in the Schedule shall Impose no obligation or liability of any kind upon us, our agents or representatives, will not extend any Policy cancellation date and will not negate any cancellation of the Policy. D: We are not responsible for verifying any information provided to us in any .Schedule, nor are we responsible for any incorrect information that you or your representative provide to us. If you or your representative does not provide us with the information necessary to complete the Schedule, we have no responsibility for taking any action under this endorsement. In addition, if neither you nor your representative provides us with e-mail and physical address information with - respect to a particular person or organization, then we shall have no responsibility for`taking action with regard to such person or entity under this endorsement. E. We may arrange with your representative to send such notice in the event of any such cancellation. F. You will cooperate with us in providing, or` in causing your representative to provide, the a -mail address and physical address of the persons or organizations listed in the Schedule. G. This endorsement does not apply in the event that you cancel the Policy ALL -32688 (01 /11) Page 1 of 2 NYFTZ 2 -14057 MI't= r J_ Name of Certificate Holder E -Mail Address Physical Address THE CITY OF EL SEGUNDO, ITS 350 MAIN ST., ROOM 5 OFFICERS, OFFICIALS, EMPLOYEES, EL SEGUNDO, CA 90245 - AGENTS & VOLUNTEERS 3813 Name of Certificate Holder E -Mail Address - Phvsical Addressor All other terms and conditions of the Policy remain unchanged. )KNI Aut1forized Representative _- ALL -32688 (01/11) Page 2 of NYFTZ 2 -14057 Policy Number: HDO G27393949 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 NOTICE: THESE POLICY FORMS AND THE APPLICABLE RATES ARE EX- EMPT FROM THE FILING • REQUIREMENTS OF THE NEW YORK INSUR- ANCE LAW AND REGULATIONS. HOWEVER, THE FORMS AND RATES MUST MEET THE MINIMUM STANDARDS OF THE NEW YORK INSURANCE LAW AND REGULATIONS. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CARE . w FULLY. 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 Organizatlon(s): THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS & VOLUNTEERS Information required to complete this Schedule. if not shown above. will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an addltlonal 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: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. 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 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 shown in the Declarations; whichever Is less. This endorsement shall not increase the applicable Limits of Insurance shown in the ° Declarations. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 Class Code: 2- 14057 NOTICE: THESE POLICY FORMS AND THE APPLICABLE RATES ARE EXEMPT FROM THE FILING REQUIREMENTS OF THE NEW YORK INSURANCE LAW AND REGULATIONS. HOWEVER, THE FORMS AND RATES MUST MEET THE MINIMUM STANDARDS OF THE NEW YORK INSURANCE LAW AND REGULATIONS. NON - CONTRIBUTORY ENDORSEMENT FOR ADDITIONAL INSUREDS Insert the potldy_number. The remainder of the informmaWn Is to be completed only when this endorsement is issued subsequent to the orenaratlon of the oolicv. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY COMMERCIAL GENERAL LIABILITY COVERAGE Schedule Ot agTni kcrr P dditional Insured Endorsement THE CITY OF EL SEGUNDO, ITS OFFICERS, Cr. 20 26 OFFICIALS, EMPLOYEES, AGENTS & VOLUNTEERS (If no information is filled in, the schedule shall read: All persons or entities added as additional insureds through an endorsement with the term `Additional Insured" in the title) For organizations 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.4.a: If other insurance is available to an insured we cover under any of the endorsements listed or described above (the "Additional Insured ") for a loss we cover under this policy, this insurance will apply to such loss on a primary basis and we will not seek contribution from the other insurance available to the Additional Insured. Authorized Representative Class Code: e, oaTE (MMlDDrrYYY) 8 06.,5 CERTIFICATE OF LIABILITY INSURANCE 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 tho certificate holder Is an ADDITIONAL INSURED, the Policy(;les) 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 endorsomont(s). PRODUCER Marsh Risk 8 Insurance Services CA License #0437153 777 South Figueroa Street Los Angeles, CA 90017 Attn: Ross Pebley 213.346-5208 102388515- Domes•WC -15-16 INSURED ....... ---- Cast d Crew Payroll LLC dba Cast 8 Crew Entertainment Services 2300 Empire Avenue, 5th Floor Burbank, CA 91504 Insurance Company COVERAGES CERTIFICATE NUMBER: 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 CO NDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID LAIMS. ITT EFF _y w_ YW9R LIMITS TYPE of INSURANCE POUCYNUE M ,.,..,.,.__ ....._.. GENERAL LIABILITY EACH OCCURRENCE ± COMMERCIAL GENERAL LIABILITY J?FRC•iliJES ..r.neoJ _S _ - .. -....- °� -. °- MEDEXPrA,,,iartla r�tm...L....µ........ _....— CLAIMS-MADE El OCCUR PERSONAI. S AOV INJURY S _...._,.... «..w.. ..®... �' GENERAL AGGREGAT'S GENT. AGGREGATE LIMIT APPLIES PER: — , POLICY R M [ ... 1 LOO AUTOMOBILE LIABILITY ANY AUTO A O SCHEDULED AUTOS I AUTOS NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAR I... � OCCUR EXCESS LIAR i C..I.AMR A WORKERS CO.NSATION. rrA. ar;araswa au t..vu.p AND EMPLOYERS' LIABILITY YIN ANY PRO YETOWfxAftlNEPJEXFCIITIIIIn N I A OrfICEWMEMBER EXCLUDEO7 'See Attached for Other' (Mander" In NHI II' Yese t wto'bo gndnr Stale SoJaa�dic Policies' !DOILY INJURY (Per person) $ er eodtl BODILY INJURY (P n -- — .�.�.� eT,t) $ PROPERl OAMAGE S CP4LR�o15� ®.... S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remsrka Schedule, N more space N required) Evidence of workers' compensation coverage for NEW LINE PRODUCTIONS, INC. -'THE HOUSE" CERTIFICATE HOLDER .___. -. w«wryA- A,r*AA kR P ArrCYDENT S __. SE EA EMPLOYE, S a r 1 III NEW LINE PRODUCTIONS, INC. ww SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN WARNR BLVD. BUILDING WG SEROOM 103 i ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE BURBAN, CA 91522 of Marsh Risk &Insurance Services 4,V, 044(yC)"` d ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 0313 (Ed. 04-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS 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. Schedule Person or Organization Job Description This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise staled. (The Information below Is required only when this endorsement Is Issued subsequent to preparation of the policy.) Endorsement Effective 01/0112016 Effective Policy No. WC 9299239.111 Endorsement No. 4 Insured CAST 3 CREW PAYROLL, LLC Premium $ Insurance Company AMERICAN ZURICH INSURANCE CO. Countersigned by /. Aw. Page 1 of 1 WC 00 03 13 Copyright 1983 National Council on Compensallon Insurance, Inc. Un6forrn FWMBTO Cast & Crew Payroll, LLC WC 4857681 -04 Eff 01/29/2015 End't. #2 WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4 -84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA 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 01/29/2015 at 12:01 A.M. standard time, forms a part of (DATE) Policy No. WC 4857681 -04 of the issued to Cast & Crew Payroll, LLC Premium (if any) $ Endorsement No. 2 American Zurich Insurance Company (NAME OF INSURANCE COMPANY) f 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 % of the California workers' compensation pre- mium otherwise due on such remuneration. Schedule Person or Organization City of El Segundo 350 Main Street El Segundo, CA 90245 WC 252 (4 -84) WC 04 03 06 (Ed. 4 -84) Job Description Page 1 of 1 WC State- Specific Policies and Corresponding Resident Offices Worker's Comp - Alaska Marsh Resident Office — Alaska American Zurich Insurance Company The Brady BulldIng WC 4857679 04 (AK) 1031 West 4"' Avenue Eff. Date: 1/1/2015 - Exp. Date: 1/1/2016 Anchorage, AK 99501 Statutory Limits: $1,000,000 Worker's Comp - California Marsh Resident Office — California American Zurich Insurance Company 777 South Figueroa Street WC 4857681 D4 (CA) ' Los Angeles, CA 90017-5822 Eff. Date: 1/1/2015 - Exp. Date: 1/1/2016 Statutory Limits: $1,000,000 Worker's Comp - Connecticut Marsh Resident Office — Connecticut American Zurich Insurance Company 20 Church Street, 8"' Floor WC 4857682 D4 (CT) Hartford, CT 06103 -3187 Eff. Date: 1/112015 - Exp. Date: 1/1/2016 Statutory Limits: $1,000,000 Worker's Comp - Florida Marsh Resident Office - Florida American Zurich Insurance Company Wachovia Flnandal Center, Suite 950 WC 3999275 08 (FL) 200 South Biscayne Boulevard Eff. Date: 1/1/2015 - Exp. Date: 111/2016 Miami, FL 33131 -2334 Statutory Limits: $1,000,000 Worker's Comp - Georgia Marsh Resident Office — Georgia American Zurich Insurance Company 3500 Lenox Road WC 3999286 07 (GA) Atlanta, GA 30326 Eff. Date: 1/1/2015 - Exp. Date: 1/1/2016 Statutory Limits: $1,000,000 Worker's Comp - Hawaii Marsh Resident Office — Hawaii American Zurich Insurance Company 745 Fort Street WC 3999287 07 (HI) Honolulu, HI 96813 Eff. Date: 1/1/2015 - Exp. Date: 1/1/2016 Statutory Limits: $1,000,000 Worker's Comp - Illinois Marsh Resident Office — Illinois American Zurich Insurance Company 540 West Madison Street WC 3999288 07 (IL) Chicago, IL 60661 -3630 Eff. Date: 111/2015 - Exp. Date: 1/1/2016 Statutory Limits: $1,000,000 Worker's Comp - Kansas Marsh Resident Office — Kansas American Zurich Insurance Company 7015 College Blvd. WC 4503347 06 (KS) Overland Park, KS 66211 -1626 Eff. Date: 1/1/2015 - Exp. Date: 1/1/2016 Statutory Limits: $1,000,000 Worker's Comp - Louisiana Marsh Resident Office — Louisiana American Zurich Insurance Company One Shell Square WC 3999289 07 (LA) 701 Poydras Street, Suite 4125 Eff. Date: 1/1/2015 - Exp. Date: 1/1/2016 New Orleans, LA 70139 Statutory Limits: $1,000,000 Worker's Comp - Maryland Marsh Resident Office — Maryland American Zurich Insurance Company One South Street, Suite 1001 WC 5911611 02 (MD) Baltimore, MD 21202 Eff. Date: 1/1/2015 - Exp. Date: 1/1/2016 Statutory Limits: $1,000,000 Worker's Comp - Michigan Marsh Resident Office — Michigan American Zurich Insurance Company 125 Ottawa Avenue, N.W., Suite 400 WC 5963814 07 (MI) Grand Rapids, MI 49503 Eff. Date: 1/1/2015 - Exp. Date: 1/1/2016 Statutory Limits: $1,000,000 Worker's Comp - Mississippi Marsh Local Office — Mississippi American Zurich Insurance Company c/o Jennifer Helfrich WC 4857683 D4 (MS) 1717 Hillshire East Eff. Date: 1/1/2015 - Exp. Date: 1/1/2016 Hernando, MS 38632 Statutory Limits: $1,000,000 Worker's Comp - New Mexico Marsh Local Office — New Mexico American Zurich Insurance Company c/o Shane Muth HUB International Insurance Services WC 5963813 07 (NM) Eff. Date: 1/1/2015 - Exp. Date: 1/1/2016 7770 Jefferson NE Statutory Limits: $1,000,000 Albuquerque, NM 87109 Worker's Comp - North Carolina American Zurich Insurance Company Marsh Resident Office — North Carolina WC 4857684 04 (NC) 100 North Tryon Street, Suite 3600 Eff. Date: 1/1/2015 - Exp. Date: 1/1/2016 Charlotte, NC 28202 Statutory Limits: $1,000,000 Worker's Comp - Oklahoma Marsh Resident Office — Oklahoma American Zurich Insurance Company 401 South Boston Avenue Tulsa, OK 74103 -4016 WC 4857665 04 (OK) Eff. Date: 1/1/2015 - Exp. Date: 1/1/2016 Statutory Limits: $1,000,000 Worker's Comp - Pennsylvania Marsh Resident Office — Pennsylvania American Zurich Insurance Company Six PPG Place Pittsburgh, PA 15222 -5499 WC 3999290 07 (PA) Eff. Date: 1/1/2015 - Exp. Date: 1/1/2016 Statutory Limits: $1,000,000 Worker's Comp - Tennessee Marsh Resident Office —Tennessee American Zurich Insurance Company 1801 West End Avenue Nashville, TN 37203 WC 3999291 07 (TN) Eff. Date: 1/112015 - Exp, Date: 1/1/2016 Statutory Limits: $1,000,000 Worker's Comp - Texas Marsh Resident Office —Texas American Zurich Insurance Company Comerica Bank Tower 1717 Main Street, Suite 4400 WC 3999297 06 (lX) Eff. Date: 1/1/2015 - Exp. Date: 111/2016 Dallas, TX 75201 -7357 Statutory Limits: $1,000,000 Worker's Comp - Utah Marsh Resident Office — Utah American Zurich Insurance Company 15 West South Temple Salt Lake City, UT 84101 WC 3999292 07 (UT) Eff. Date: 1/1 /2015 - Exp. Date: 1/1/2016 Statutory Limits: $1,000,000 Worker's Comp - Virginia Marsh Resident Office — Virginia American Zurich Insurance Company 1051 East Cary Street Richmond, VA 23219 WC 5911610 02 (VA) Eff.'Date: 1/1/2015 - Exp. Date: 1/1/2016 Statutory Limits: $1,000,000 Worker's Comp - West Virginia Marsh Local Office — West Virginia American Zurich Insurance Company c/o Michelle Myers Marsh Captive Solutions WC 3999293 07 (WV) Eff. Date: 1/1/2015 - Exp. Date: 1/1/2016 100 Bank St., Ste 610 Statutory Limits: $1,000,000 Burlington, VT 05401 Worker's Comp - Wisconsin Marsh Resident Office -Wisconsin Zurich American Insurance Company Z 411 East Wisconsin Avenue, Suite 1300 WC 9141037 08 (WI) Eff. Date: 1/1/2015 - Exp. Date: 1/1/2016 Milwaukee, WI 53202 statutory Limits: $1,000,000