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PROOF OF INSURANCE (2015) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE 06109//2014 2014 /YYYY)
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
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
NAME'
Marsh USA Inc.
,. ............... FY #POLICY EXP
I
fLT TYPE OF INSURANCE SRL &'UDik,.. POLI NUMBER MMIDD/YYY LIMITS
D /XXYY
..
701 Market Street, Suite 1100
W Aa,.t nt)< .._____ ....._ ((AAhC_NQ). - --------------------------------
St, Louis, MO 63101
06/0112014
E-MAIL
Attn: ATT.CedRequest @marsh.com
$ 5,000,000
4 DrsFE s
X
INSURER(S�AFFOROING COVERAGE
NAIC #
018566-GAW- CRT -14 -15 X SCha
- -- ........ – _ .,. _,_,
IJAMAd'g" YO RENT
INSURER : Old Republic Insurance Company
24147
.. --
INSURED
New Cingular Wireless PCS, LLC
INSURER B - - - - - --
One AT&T Plaza
INSURER C
,000,000
208 South Akard
CLAIMS -MADE OCCUR
� X
INSURER D
Room 2731
__ ~
... ............. -- - — – - - --
ME,D,EXP AnyoneP,e
.( ., Y rson)
Dallas, TX 75202
INSURER E
COVERAGES CERTIFICATE NUMBER: CHI - 004948736 -02 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.
,. ............... FY #POLICY EXP
I
fLT TYPE OF INSURANCE SRL &'UDik,.. POLI NUMBER MMIDD/YYY LIMITS
D /XXYY
A
GENERAL LIABILITY
MWZY 302356
06/0112014
06/01/2015
EACH OCCURRENCE
$ 5,000,000
X
IJAMAd'g" YO RENT
...
1
COMMERCIAL GENERAL LIABILITY
CO
PREMISES occurrence)....,,
,000,000
CLAIMS -MADE OCCUR
� X
ME,D,EXP AnyoneP,e
.( ., Y rson)
$ ..... ... .NIA..
..v� ..�
PERSONAL & ADV INJURY
$ 5,000,000
GENERAL AGGREGATE
$
GEN'L AGGREGATE LIMIT A PPLIES PER
PRODUCTS - COMP /OP AGG
$ 5,000,000
POLICY PRO° LOC
$
A
AUTOMOBILE LIABILITY
MWTB 302129
06/01/2014
06/0112015
COMBINED SINGLE LIMIT
CEsa epadom)
5,000,000
A
X ANY AUTO
MWZX 302130 (MI) See Second Page
0610112014
06/0112015
BODILY INJURY (Per person)
.....
$
ALL OWNED SCHEDULED
—
BODILY INJURY (Per accident)
$
AUTOS AUTOS
- -- - - - -... ..
NON -OWNED
PROPERTY DAMAGE.
$
HIRED AUTOS AUTOS
_LPPr?ccld pt)__ __ __..__
UMBRELLA LIAB OCCUR
EACH OCCURRENCE
—
$
– —
EXCESS LIAR CLAIMS -MADE
°
AGGREGATE
$
DED RETENTION$
+'
$
A
WORKERS COMPENSATION
MWC 302340 00 r °"
06/01/2014
06/01/2015
X J WC STATU O rH-
AND EMPLOYERS LIABILITY YIN
~ TOR:Y_l„)MtT.S ER. .... ......................
5,000,000
ANY PROPRIETOR /PARTNER /EXECUTIVE
F
NIA
E L. EACH ACCIDENT $
----
OFFICER /MEMBER EXCLUDED?
5,000,000
(Mandatory in NH)
E L, DISEASE - EA EMPLOYEE $
If yes, describe under
5,000,000
DESCRIPTION OF OPERATIONS below
EL, DISEASE -POLICY LIMIT $
A
Excess Workers' Compensation/
MWXS 302341 (OH -WA)
06101/2014
06/0112015
EL Each Accident / EL Disease 1,000,000
Employers' Liability
See Second Page
EL Disease - Policy Limit 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Re: LAD095 /FA #10086765/ 348 E. Main Street, El Segundo, CA 90245
City of El Segundo (Landlord), its officials, and employees 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. Waiver of Subrogation is provided for Workers' Compensation, as required by written contract and allowable by law.
CERTIFICATE HOLDER
CANCELLATION
City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Attn: Deputy City Clerk I; City Clerk's Office— Mona F Sh ( THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
350 Main Street (" ACCORDANCE WITH THE POLICY PROVISIONS.
El Segundo, CA 90245
` AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukherjee _rCaLUO+ot.:
@ 1988 -2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: 018566
LOC #: St. Louis
AC "R
ADDITIONAL REMARKS SCHEDULE Page —2 of 2
AGENCY NAMED INSURED
Marsh USA Inc. New Cingular Wireless PCS, LLC
_._.._....._....._..__...w_ _- _......�- One AT &T Plaza
POLICY NUMBER 208 South Akard
Room 2731
... . ._. .._.._._........._ ......... .............._ ..... _.......�....D.E Dallas, TX 75202
'.. CARRIER IT NAIC CODE
EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance
Excess Workers' Compensation - MWXS 302341 (OH -WA)
Self- Insured Retentions
OH - $500,000,000
WA - $500,000,000
Excess Automobile Liability - MWZX 302130 (MI)
Combined Single Limit - $9,000,000
Self- Insured Retention - $1,000,000
ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER:
COMMERCIAL GENERAL LIABILITY
CG 2010 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED -- OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organizations
Locations Of Covered 2perations
All Persons or Organizations as Required by Written Contract or
The Locai+ons as Specified in the Written Contracts or Agreements.
Agreement.
In no event shall the Insurance provided exceed the scope of coverage
or Gets required by said contract or sgrer4erit� "° " ^w
413
Information ne aired to corn lete this Sc edule if not shown above, will be shown in the Declarations.
A. Section 11 — Who Is An Insured is amended to
include as an additional 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:
1. Your acts or omissions; or
B. With respect to the insurance afforded to these
additional insureds, the following additional
exclusions apply:
This Insurance does not apply to 'bodily injury" or
"property damage" occurring after:
1.
2. The acts or omissions of those acting on your
behalf; z
in the performance of your ongoing operations for
the additional insured(s) at the location(s)
designated above.
However. 2.
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.
All work, including materials, parts or
equipment furnished in connection with such
work, on the project (other than service,
maintenance or repairs) to be performed by or
on behalf of the additional insured(s) at the
location of the covered operations has been
completed; or
That portion of 'your work" out of which the
injury or damage arises has been put to its
intended use by any person or organization
other than another contractor or subcontractor
engaged in performing operations for a
principal as a part of the same project
CG 2010 0413 © Insurance Services Office, Inc., 2012 , Page 1 of 2
MKW 302356 AT&T kw. OUM112014 - 06MI2015
C. With respect to the insurance afforded to these
additional insureds, the following is added to
Section III — Units 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
applicable Limits of
Declarations.
shall not increase the
Insurance shown In the
Page 2 of 2 0 Insurance Services Office, Inc., 2012 CG 2010 0413
M WZY 302356 AT&T kW. OLOM14 - 06M11 M5 5
POLICY NUMBER:
COMMERCIAL GENERAL LIABILITY
CG 20 3T 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or O anization s Location And Description Of Completed Operations
All Persons or Organizations as Required by Written The Locations as Specified in the Written Contracts or
Contract or agreement In no event shall the insurance Agreements.
provided exceed the scope of coverage or limits as required
by said contract or agreement m,�
a, a
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 additional insured the person(s) or
organization(s) shown in the Schedule, but only
with respect to liability for "bodily injury" or
"property derma ,ge` caused, in whole or in part, by
"your 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'.
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 37 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1
M WZY 302356 AT& r Ma 06)01IM 4 - 0610112015
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY
WC 124
(ma)
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 Wowing "attaching clause" need be completed only when this endorsement is Issued subsequent to preparation of the policy.)
This endorsement, effective on 6-1 -14 at 12:01 A.M. standard time, forms a part of
(DATE)
Policy No. MWC302340 00 of the Old Republic Insurance Company
(NAME OF INSURANCE COMPANY)
issued to AT &T Services, Inc., and Affiliates
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 direqtly or ndirectly to benefit any one not named in the Schedule.
On File With Company
Schedule
WC 124 (4-84)
WC 00 0313 Copyright 1983 National Council on Compensation Insurance. Page 1 of 1