Loading...
PROOF OF INSURANCE (2016) CLOSEDi CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 05/19/2015 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 CERTIFICATE �X " NAME: Marsh USA Inc. NUMBER: '.PHONE 701 Market Street, Suite 1100 (AI(L Nra Ext): ...... St. Louis, MO 63101 THIS E MAIL ADDRESS Attn: ATT.CertRequest @marsh.wm ----------- ISSUED TO THE INSURED --- INSURER(S) AFFORDINC 018566 -GAW- CRT -15 -16 X SCha X ___ m.,........... - - -- �� �, INDICATED INSURER A ;Old Republic Insurance Company INSURED New Cingular Wireless PCS, LLC INSURER B One AT &T Plaza CONTRACT INS1�c _ 208 South Akard TO WHICH THIS INSURER D Room 2731 PERTAIN, Dallas, TX 75202 THE POLICIES INSURER E: „ COVERAGES CERTIFICATE NUMBER: CHI - 005618171 -03 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 . IN SR LTR TYPE OF INSURANCE Ab(iL Ut3't POLICY NUMBER POLICY YYYY MMIDDIYYYY LIMITS ..._. A X COMMERCIAL GENERAL LIABILITY MWZY 304717 06101/2015 06/0112016 EACH OCCURRENCE $ 5,000,000 X ^� LiAMA%t 1b IkEN1 °LG . 11.000.0001 CLAIMS -MADE OCCUR PRh,MI5F.S,(Ee 909yrrenge) $ MED EXP (Anyone Peraon) $ N/A PERSONAL & ADV INJURY $ 5,000,000 GE.., ...,.____ ____ .._...... N'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 10 0...... $ 00,000 PRO- X RO- POLICY ❑ LOC ❑ JECT PRODUCTS COMP /OP AGG .. ........ $ 5,000,000 111­ 1 OTHER, $ A AUTOMOBILE LIABILITY MWTB 304716 06!0112:'015 06/0112016 COMBINED SINGLE L {MIT $ 5,000,000 A X ANY AUTO MWZX 304718 (MI) See Attached 0610112015 06/0112016 BODILY INJURY (Per person) $ "" ALL OWNED SCHEDULED er accident) BODILY INJURY (Pidt $ AUTOS AUTOS -- NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _._ _ (Per pcod9nl) ' UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE AGGREGATE $ DED I RETENTION $ $ A WORKERS COMPENSATION.... MWC30471900 0610112015 06/01/2016 X STATUTE OTH AND EMPLOYERS' LIABILITY Y / N Ff; — _ -- ANY PROPRIETORIPARTNER /EXECUTIVE -. I E L. EACH ACCIDENT $ 5,000,000 OFFICER /MEMBER EXCLUDED? N NIA " " ............ 5,000,000 (Mandatory in NH) EA LMPI OW1 $ __..... If DESCRIPTION OF OPERATIONS below SEASE POLICY LIMIT E DISEASE ....w..mW..LIMIT ... ..... '.. $ 5,000,000 A Excess Workers' Compensation I MWXS 304720 (OH -WA) 06/0112015 06101/2016 EL Each Accident/ EL Disease 1,000,000 Employers' Liability See Second Page EL Disease - Policy Limit 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: LAD095 /FA #100867651348 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. Shilling 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 .w., e _ ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 018566 LOC #: St. Louis......... A+I ADDITIONAL REMARKS SCHEDULE AGENCY NAMED INSURED Marsh USA Inc. New Cingular Wireless PCS, LLC One AT &T Plaza POLICY NUMBER 208 South Akard Room 2731 Dallas, TX 75202 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS Page 2 of 2 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Risk Management AT &T Services, Inc. One AT &T Plaza 208 South Akard, Suite 2731 Dallas, Tx 75202 April 21, 2415 To Whom It May Concern: Subject: Subsidiaries of AT&T Inc. Certificates of Insurance (COI) Memorandum of Insurance (MOI) You are receiving this because you have been identified as a Third Party who has requested a Certificate of Insurance from an AT &T Entity. AT &T has currently renewed its' Casualty Coverage(s) for the 6/11/15 — 6/1/16 policy period. Kindly note, AT &T also provides a Memorandum of Insurance (MOI) for Third Parties. Please take a moment to access the website below and review the information. If the MOI satisfies your organization's requirements and the COI is no longer required, please indicate on the front of the Certificate and fax to: 212 -945 -4341. 6 If the COI is still necessary and requires modifications, please contact the AT &T employee responsible for your business relationship and ask that employee to authorize the necessary updates by following their standard request protocol. COI's will only be sent or modified when requested by the AT &T employee responsible for the business relationship. This would also include COI renewals. Thank you for assisting Subsidiaries of AT &T Inc Sincerely, AT &T Services, Inc. Risk Management POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 2010 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INS D --- OWNERS, LESSEES O CONTRACTORS - SCHEDULED PERSO O ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anization s Locations) Of Covered Operations All Persons or Organizations as Required by Written Contract or The Locations as Specified in the Written Contracts or Agreements. Agreernent. in no event shall the insurance provided exceed the scope of coverage or lirtjits required by said contract or agreement. ct complete this Schedule, if not . .. m above 4viil be shown in the Declarations . shown .� _�nforr�ation re urred fo.. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage" or "personal and advertising injury" "property damage" occurring after: caused, in whole or in part, by 1 • All work, including materials, parts or 1. Your acts or omissions; or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work" Out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2, If coverage provided to the additional insured is principal as a part of the same project 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. CG 20 10 0413 Oc Insurance Services Office, Inc., 2012 Page 1 of 2 MWNZY 304717 A T& T Inc. 0610112015 - 0610912096 C. 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. Page 2 of 2 O Insurance Services Office, Inc., 2012 CG 2010 0413 MW7Y304717 AT &Tinc. 06/01/2015-061082016 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES O CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTSICOMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or antzation i[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 Information squired toort�plt this Sched��NO� if not shown above, will be shown in the Declarations,4 A. Section II -- Who is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III — Limits Of Insurance: with respect to liability for "bodily injury" or If coverage provided to the additional insured is "property damage" caused, in whole or in part, by required by a contract or agreement, the most we "your work" at the location designated and will pay on behalf of the additional insured is the described in the Schedule of this endorsement amount of insurance: performed for that additional insured and included in the "products- completed operations 1 • Required by the contract or agreement; or hazard ". 2. Available under the applicable Limits of However. Insurance shown in the Declarations; 1. The insurance afforded to such additional whichever is less. insured only applies to the extent permitted This endorsement shall not increase the applicable by law; and Limits of Insurance shown in the Declarations. 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. CG 20 37 04 13 0 Insurance Services Office, Inc., 2092 Page 1 of 1 MWZY 304717 A T& T Inc. 0610112015 - 0610112016 F'! 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 06/01/2015 at 12:01 A.M. standard time, forms a part of (DATE) 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 ortly 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 Where Required By Written Contract WC 124 (4 -84) WC 00 03 13 Copyright 1983 National Council on Compensation Insurance, Page 1 of 1