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PROOF OF INSURANCE (2017) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 9/22/2016 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 endorsementlsl. PRODUCER "AN aA�t Christian Brothers Services ArteX Risk Solutions, Inc. (CB) Two Pierce Place ONE FAX _(� 10 X1,_800- 807 -0300 _w_wwwww� 0..630 378 2508 Itasca IL 60143 -3141 E-MAIL - -_ _- INSURER S AFFORDING COVERAGES NAIC # ........._.. ........._... INSGNRER A Pelcrlylvarlia Manufacturers Assoc In 12262 -.,. INSURED CHRIBRO -14 ITITIT INSURERe:OId Republic Insurance Company 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: 1725120767 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. `I R ........ TYPE OF INSURANCE ... ......... .=E a ........ - -..� ,,.•..,..... ,.•. .......... ....._- -.. POLICY EFF POLICY E'XP LIMITS INSD WV POLICY NUMB +ER MMIDD. MM DDYYYY A X COMMERCIAL GENERAL LIABILITY Y 821600 0578617 6/1512016 6/15/2017 EACH OCCURRENCE $2,000 „400. '5idt Y6.k '.CLAIMS -MADE X OCCUR PRCM SAM iS arcacE.sr,). $Included _ MED EXP (An one person) $15,000 PERSONAL & ADV INJURY $Included ....._ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 JECT r PRODUCTS - COMP /OP AGG $Included X PROs LOC POLICY OTHER: ...... �. .. $ B AUTOMOBILE LIABILITY 6/1512016 /15/2017 IMN SINGLE LIMIT $1,000,0Ea 00 X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY .... rtmmmmmmmmmmmmm ....... ..•..•.. _ AUTOS AUTOS � _ INJURY (Per accident) $ NON -OWNED X HIRED AUTOS X AUTOSITLAMA... $ - I er a�lxlmr�rrt $_ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB AGGREGATE $ .. - - -. CLAIMS-MADE DED RETENTION $ $ B WORKERS COMPENSATION MWC 305311 01 1/1/2016 1/1/2017 PER uTH- AND EMPLOYERS' LIABILITY YIN X „„ ,,STAT TE ER ANY PROPRIETOR/PARTNER/EXECUTIVE EN OFFICER/MEMBER EXCLUDED ? N/A E Lw EACH ACCIDENT $1,000,000 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,000,000 A Limited Professional Healthcare 821600 0578617 6115/2016 6/15/2017 $1,000,000 Occ. $2,000,000 Agg, DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe 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 coverage solely, strictly and specifically with regards to: Renewal of St Vincent Peals on Wheels Agreement to provide home meal delivery to El Segundo homebound residents from October 1, 2015 through September 30,2017. CERTIFICATE HOLDER ,r ANrr -11 I ATInN W SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of El Segundo Its Officials and Employees” THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main St t ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo CA 92045 j” _,• t t1 RIZDFEf'/%ESEN7ATI5PE � a` Auwa,,....� ACORD 25 (2014/01) ©1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD PENNSYLVANIA MANUFACTURERS' ASSOCIATION INSURANCE COMPANY Attaching to and forming part of Policy No. 821600 0578617 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, 2016 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under SECTION II INSURING AGREE COVERAGE defined within the Coverage Agreement SECTION 1: Schedule Name of Additional Insured Person(s) Or Organization(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. t� MENT C, GENERAL LIABILITY Designated Location(s) Of Covered operations 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 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 Location(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. This Insurance does not apply to any claims or suits seeking damages, including defense, arising out of, directly or indirectly, from any actual or alleged participation in any act of sexual misconduct, sexual harassment, sexual molestation, sexual abuse or any claim sexual in nature, physical or mental; of any person. 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. WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 252 a „ (4 -84) ) WC 04 03 06 (Ed. 4 -84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERSr` ENDORSEMENT - CALIFORNIA k °. 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 01/01/16 at 12:01 A. M. standard time, forms a part of (DATE) Policy No. MWC305311 01 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) $ 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.)* 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 WC 252 (4 -84) WC 04 03 06 (Ed. 4 -84) Schedule Job Description Page 1 of 1