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PROOF OF INSURANCE (2016) CLOSED+Ir l CERTIirtCATE OF LIABILITY INSURA,gCE DATE (MM/DD/YYYY) 5/29/2015 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 F�FF uhrlstlan brothers ervlce Artex Risk Solutions, Inc. CB PHONE ,, 1- 800 - 807 -0300 , , 1- 630 - 378 -2508 Two Pierce H E MAIL Itasca IL 60143 -3141 _011.8F -St _ INSURERA:Pennsvlvania Manufacturers Assoc In 12262 INSURED _ CHRIBRO -14 INSURER B :Old Republic Insurance Companv 24147 Brothers of the Christian Schools & Affiliates INSURER C : Loc #1177028 DAUGHTERS OF CHARITY OF SVDP 1205 Windham Parkway INSURER D: Romeoville IL 60446 -1679 INSURER E COVERAGES CERTIFICATE NUMBER:. 363241216 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. IMtsR POLICY E'FF POLICY EXP LTR TYPE OF INSURANCE INen WVD POLICY NUMBER MM/DDPYYYY MIh FDOiYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y 601501 -05- 76 -61 -7 /15/2015 /15/2016 EACH OCCURRENCE $4,000,_000 _DAMAz=1 R5_ CLAIMS -MADE OCCUR PRFIALSFR /F, a gccqTercel $Included MED EXP (Any one person) $15,000 PERSONAL & ADV INJURY $Included GEN' ... L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $N /A X POLICY a PRO- ❑ LOC PRODUCTS - COMP /OP AGG $Included JECT OTHER: $ B AUTOMOBILE LIABILITY Y MWTB21543 3115/2015 115/2016 M I L 01911f $1.000,000 (Ea seddent X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED W� BODILY INJURY (Per accident) $ AUTOS -_ - -. AUTO . ..... ........ X HIRED AUTOS X AUTOS lPar acoldpras $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY Y/ N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE I�(' N / A E.L. EACH ACCIDENT OFFICER/MEMBER EXCLUDED? u (Mandatory In NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Only the General Liability Coverage will apply on a Primary and Non - Contributory basis (per attached endorsement) if required by fully executed written contract. Certificate Holder is added as Additional Insured (per attached endorsement) for General Liability and Automobile liability coverages solely, strictly and specifically with regards to: Consultant Services for the Community Development Block Grant Program for Home Delivered Meals CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo its Official and Emiployee `1 '; ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo CA 90245 -3813 USAI „M AUTHORIZED REPRESENTATIVE ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD PENNSYLVANIA MANUFACTURERS' ASSOCIATION INSURANCE COMPANY ENDORSEMENT NO. 43 Attaching to and forming part of Policy No. 601501 -05- 78-61 -7 Named Insured: THE RELIGIOUS AND CHARITABLE RISK POOLING TRUST OF THE BROTHERS OF THE CHRISTIAN SCHOOLS AND AFFILIATES Effective date of this endorsement is June 15, 2015 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under SECTION II INSURING AGREEMENT C, GENERAL LIABILITY COVERAGE defined within the Coverage Agreement SECTION 1: Schedule Name of Additional Insured Person(s) Or Organlzation(s): ANY PERSON OR ORGANIZATION WHEN YOU HAVE AGREED IN A WRITTEN CONTRACT FOR THAT PERSON OR ORGANIZATION TO BE ADDED AS AN ADDITIONAL INSURED ON YOUR POLICY, Designated Locatiou(s) Of Covered Operatioxrs If no entry appears above, information required to complete this endorsement will be shown in the Certificate of Coverage as applicable to this endorsement. Section II Insuring Agreement C -Name of Insured Amended A. A. Who Is An Insured defined in the General Insurance Agreement is amended to include as an Additional Insured the person(s) or organization(s) shown in the Schedule above, but only with respect to liability in the performance of the Named Insured's ongoing operations for the Additional Insured(s) at the Locatlon(s) designated in the Schedule above for "bodily injury" or "property damage ", caused in whole or in part, by the Named Insured's acts or omissions which takes place after the execution of a written agreement with the Additional Insured(s). B. For the coverage provided by this endorsement: the following paragraph is added to Section IV —General Conditions, Section II, Insuring Agreement C- General Liability. This insurance is primary insurance as respects to this coverage to the additional insured person or organization, where the written contract or written agreement requires that this insurance be primary and noncontributory. In that event, we will not seek contribution from any other insurance policy available to the additional insured on which the additional insured person or organization is a Named Insured, C. Who Is An Insured is also amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, with respect to liability for "bodily injury" or "property damage" caused, in whole or In part, by the "Named Insured's 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 ". The most we will pay is the amount of insurance required by the written contract or the amount of applicable limits of insurance under this policy; whichever is less. Except as amended in this endorsement, this insurance is subject to all coverage terms, clauses and conditions in the policy to which this endorsement is attached and only applies to the extent permitted by law. � �'I," AV", THIS FORM APPLIES IN STATES WHICH USE: CA 00 01 (03 -10) AND CA 00 01 (03 -06) IL 10 (12106) OLD REPUBLIC INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.. ADDITIONAL INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM SCHEDULE Name of Person(s) or Organization (s): All persons or organizations as required by contract or. agreement With respect to LIABILITY COVERAGE, Who Is An Insured is changed with the addition of the following: Each person or organization shown in the Schedule for whom you are doing work is an "insured ". But only for "bodily injury" or "property damage" that results from the ownership, maintenance or use of a covered "auto" by: 1. You; an "employee" of yours; or 3., anyone who drives a covered "auto" with your permission or with the permission of one of your "employees ". However, the insurance afforded to the person or organization shown in the Schedule shall not exceed the scope of coverage and /or limits of this policy. Not withstanding the foregoing sentence, in no event shall the insurance provided by this policy exceed the scope of coverage and /or limits required by the contract or agreement. PCA 001 03 06 MWTB 21543 Religious and Charitable Risk Pooling Trust 0611512015 - 06/15/2016 THIS FORM APPLIES IN STATES WHICH USE: CA 00 01 (10 -13) IL 10 (12/06) OLD REPUBLIC INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM SCHEDULE Name of Person(s) or Organization(s): All persons or organizations as required by contract or agreement With respect to COVERED AUTOS LIABILITY COVERAGE, Who is An Insured is changed with the addition of the following: Each person or organization shown in the Schedule for whom you are doing work is an "insured ". But only for "bodily injury" or "property damage" that results from the ownership, maintenance or use of a covered "auto" by: 1. You; 2. an "employee" of yours; or 3. anyone who drives a covered "auto" with your permission or with the permission of one of your "employees ". However, the insurance afforded to the person or organization shown in the Schedule shall not exceed the scope of coverage and /or limits of this policy. Not withstanding the foregoing sentence, in no event shall the insurance provided by this policy exceed the scope of coverage and/or limits required by the contract or agreement. PCA 001 1013 MWTS 21543 Religious and Charitable Risk Pooling Trust 06/15/2015 - 06/15/2016 CERTWiCATE OF LIABILITY INSURAI NCE DATE (MMMD/YYYY) 7/1/2015 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 cX;K!l Christian Brothers Services INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS Artex Risk Solutions, Inc. (CB) ONE PHONE - 1- 800 - 807 -0300 FAX IA 1- 630 - 378 -2508 G kIIS1° Two Pierce Place E COMMERCIAL GENERAL LIABILITY Itasca IL 60143 -3141 ^ ^Dr1E S INSURER(S) AFFORDING COVERAGE NAIC # $ INSURER O Old Republic Insurance Company'24147 CLAIMS -MADE N 9 OCCUR INSURED CHRIBRO-14 INSURER B: Brothers of the Christian Schools & Affiliates INSURER 0: pREa S S Ea oect rt n Loc #1177028 DAUGHTERS OF CHARITY OF SVDP 1205 Windham Parkway INSURER 0 Romeoville IL 60446 -1679 INSURER E; $ COVERAGES CERTIFICATE NUMBER:. 1084009087 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 S1W POLICY EFF POLIC EXP ._.......... LTR TYPE OF INSURANCE Ilacn wvn POLICY NUMBER. IMM/nr)NYVVI IMM1nQfVVVY1 LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE N 9 OCCUR pREa S S Ea oect rt n $ MED EXP (Any one Derson) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE i $ POLICY El JECT F LOC PRODUCTS COMP /OP AGG $ OTHER: $ AUTOMOBILE LIABILITY cc (Ea act donl $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED ..AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS BODILY INJURY (Per accident) . . . � . _ . . . . ............ . . . . . $ (Paraccidenit ) $ Is UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE AGGREGATE $ '... DED RETF_NTION $ $ A A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y /N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERiME:MBER EXCLUDED? (Mandatory In NH) N / A MWC 117248 03 MWC 305311 00 (CA) 11112015 71112015 1/1/2016 1/1/2016 X cTOn ITF ER" E.L. EACH ACCIDENT $1.000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 II es, describe render DESCRIPTION OF OPE'RATI'ONS beloyr E.L. DISEASE - POLICY LIMIT 1 $1.000,000 DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) Consultant Services for the Community Development Block Grant Program for Home Delivered Meals. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo its Official and Employees ACCORDANCE WITH THE POLICY PROVISIONS. Office of City Clerk y 350 Main Street AUTHORIZED REPRESENTATIVE El Segundo CA 90245 -3813 USA 1 ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 252 (4-84) 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 07101/15 at 12:01 A. M. standard time, forms a part of (DATE) 4 Policy No. MWC305311 00 � Endorsement No. of the Old Republic Insurance Company (NAME OF INSURANCE COMPANY) Issued to Daughters of Charity of St. Vincent DePaul Province of the West 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 All persons or organizations where required by written contract Schedule Job Description WC 252 (4-84) WC 04 03 06 (Ed. 4 -84) Page 1 of 1 WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 124 (4 -84) WC 00 03 13 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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 01/01/15 at 12:01 A.M. standard time, forms a part of (DATE) Policy No. MWC117226 03 of the Old Republic Insurance Company (NAME OF INSURANCE COMPANY) issued to Religious And Charitable Risk Pooling Trust of The Brothers of The Christian Schools And Affiliates Premium $ Included 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 All Persons Or Organizations Where Required By Written Contract. 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