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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