PROOF OF INSURANCE (2017) CLOSED ACS CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
�" 9/30/2017 l 9/28/2016
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(les)must have ADDITIONAL INSURED provisions or 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 Lockton Companies gg CONTACT P II.NPIMEr
195 Scott Swamp Road,Suite 201 PHONE �FAX
Farmington CT 06032 [ADDRESS-,E-MAI I (A6c.Nraa.
860-678-4000
INSURERS)AFFORDING COVERAGE NAIC#
INSURER A:Liberty Mutual Fire Insurance Compativ 23035
INSURED Galls,LLC INSURER B:L1ber y 1psurangp, C r�JO at on 42404
1345090 1340 Russell Cave Road INSURER C:Chubb Custom Insurance Comaanv 38989
Lexington KY 40505 INSURER D:Navigators'Specialty Insurance C 0111patty 36056
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 12104450 REVISION NUMBER: XXXXXXX
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 )ERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH 'OLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY 'AID CLAIMS.
..i-.w................................................................................................................................................... .. .. ..............................................................................................................................._...... ......_.,......... ... .......,.....V..--.............._.......1.1.1.1.
INSR �tl� �"tl � POLNCY EFF POLNCY EXP
LTR TYPE OF INSURANCE I ,WVD POLICY NUMBER kMIM/DDrYYYYL_IMMidODNYYY4 LIMITS
A COMMERCIAL GENERAL"
L�IABILITY Y N TB7-Z11-261104-036 9/30/2016 9/30/2017 EACH OCCURRENCE.. E 1,00�
0.000
MXGt To'RENiEh
CLAIMS-MADE OCCURB,I
............. ........................................................................................................................
PERSONAL S ADV INJURY $ 1.000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE_ $ 2.000.000
ECT X
POLICY L R: LOC ,,,PRO
O T HDUCTS„-COMP/OPAGG $ 2.000.000
.. $
A AUTOMOBILE
.. ...........
ANY AUTO N N AS2-Z11-261104-026 9/30/20]6 9/30/2017 eoM Y N (Per $ 1.000.000
LIABILITY I n SINGLE CIMI
O IL INJURY(Per acci
^ 1111
HIRED TtS ONLY —. NON-OWNED .�PERF.... .,. ............dent) $ XXXXXXX
............ AUTOS Y
AUTOS ONLY AUTOS ONLY (Par acadnflADAGE $ XXXXXXX
X Comp:$1,00 X COIL $'1,000 $ XXXXXXX
X”.
UMBRELLA LIAR OCCUR
DE N N 79940689 9/30/2016 9/30/2017 EACH OCCURRENCE $ 10,000,000
EXCESS LIAB AGGREGATE $ 10.000.000
pp R-
....DEDL...... I RETENTIONb �.....M.S MA........
$ XXXXXXX
B
WORKERS COMPENSAT10N
PROPRIETOR/PARTNER/EXECUTIVE YIN NIA N WC7-Z11-261]04-016 9/30/2016 9/30/2017 E �CHACCI FIR
AND EMPLOYERS'LIABILITY X PEAT T
(Mandatory In NH) E L DISEASE FJ1 EMPLOYEE Y
OFyyFICER/MEMBER EXCLUDED? N
DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ 1.090.000 1.
1.000.000
D Excess Umbrella N N IS16EXC884525IC 9/30/2016 9/30/2017 Limit:$15,000,000;XS$10,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more apace Is required)
Re:El Segundo Police Department Services Agreement.The City of El Segundo,its officials and employees are included as Additional Insured on the General
Liability as required by written contract.Such insurance is primary and noncontributory.
CERTIFICATE HOLDER CANCELLATION
12104450
City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Office of the City Clerk THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Ty ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
El Segundo CA 90245 AUTHORIZED ATIVfyE
' L n"'M"wa'd!✓ �!f ����
01986.2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
295201600059600065
Policy Number TB7-Z1 1-261104-0 36
Issued by Liberty Insurance Corp.
THIS ENDORSEIENTCHANGES THE POLICY. PLEASE READ ITCAREFULLY.
COWMRCIAL GENERAL LIABILITY ENHANCENENT FOR WHOLESALERS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
index of modified Items:
Item 1. Reasonable Force
Item 2. Non-Owned Watercraft Extension
Item 3. Damage To Premises Rented To You-Expanded Coverage
Item 4. Bodily Injury To Co-Employees
Rem 5. Health Care Professionals As Insureds
Rem 6. Knowledge of Occurrence
Item 7. Notice of Occurrence
Item 8. Unintentional Errors And Omissions
Item 9. Bodilylnjury Redefinition
Item 10. Supplementary Payments—increased Limits
Item 11. Damage To Borrowed Equipment
Item 12. Aircraft With Chartered Crew
Rem 13. Property In Your Care,Custody Or Control
Rem 14. Mobile equipment Redefined
Rem 15. Newly Formed Or Acquired Entitles
Rem 16. Blanket Additional Insured Where Required By Written Contract
Lessors of Leased Equipment
Managers or Lessors of Premises
Mortgagees,Assignees or Receivers
Grantor of Franchise
Vendors
Any Person or Organization
Rem 17. Blanket Additional Insured—Grantors Of Permits
Rem 18. Waiver Of Right Of Recovery By Written Contract Or Agreement
Rem 19. Other Insurance Amendment
Rem 1. Reasonable Force
Exclusion a.of Section I-Coverage A-Bodly Injury And Property Damage Liability is replaced by the following:
a. Expected Or Intended Injury
'Bodily Injury' or "property damage' expected or intended from the standpoint of the insured This exclusion
does not apply to 'bodily injury' or 'property damage' resulting from the use of reasonable force to protect
persons or property.
Rem 2. Non-Owned Watercraft Extension
Paragraph(2)of Exclusion g. of Section I-Coverage A-Bodily Injury And Property Damage Liabdity is replaced by
the following:
(2) A watercraft you do not own that is:
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(a) Less than 55 feet long;and
(b) Not being used to carry persons or property for a charge;
Rem 3. Damage To Premises Rented To You-Expanded Coverage
A. The final paragraph of 2. Exclusions of Section I-Coverage A - Bodily Injury And Property Damage Liability is
replaced by the following:
Exclusions c.through n. do notapply to damage by fire.lightning or explosion or subsequent damages resulting
from such fire, lightning or explosion including water damage to premises while rented' to you or temporarily
occupied by you with permission of the owner. A separate limit of insurance applies to this coverage as
described in Section III-Limits Of Insurance.
B. Paragraph 6. of Section III—Limits Of Insurance is replaced by the following:
6. Subject to Paragraph S. above, the Damage To premises Rented To You Limit Is the most we will pay
under Coverage A for damages because of"property damage'to any one premises, while rented to you, or
in the case of damage by fire, lightning, explosion or subsequent damages resulting from such fire, lightning
or explosion including water damage to premises while rented to you or, temporarily occupied by you with
permission of the owner.
The Damage To Premises Rented To You Limit is the greater of
a. $300.000: or
b. The Damage To Premises Rented To You Lima shown on the Declarations.
C. Paragraph 9.a. of the definition of*Insured contract*in Section V— Definitions is replaced by the following:
a. A contract for a lease of premises. (However, that portion of the contract for a lease of premises that
indemnifies any person or organization for damage by fire, lightning, explosion or subsequent damages
resulting from such fire, lightning or explosion including water damage to promises while rented to you or
temporarily occupied by you with permission of the owner Is not an `insured contract'.
D. The paragraph Immediately following Paragraph(6)of exclusion j. of Section I—Coverage A—Bodily Injury And
Property Damage Liability is replaced by the following:
Paragraphs (1). (3) and (4) of this exclusion do not apply to "property damage' (other than damage by fire,
lightning or explosion or subsequent damages resulting from such fire. lightning or explosion including water
damage) to premises. Including the contents of such premises. rented to you for a period of 7 or fewer
consecutive days. A separate limit of insurance applies to Damage To Premises Rented To You as described
in Sedan III—Limits of Insurance.
Rem 4. Bodily Injury To Co-Employees
A. Paragraph 2. of Section II-Who is An Insured is amended to include:
Each of the following is also an insured:
Your 'employees` (other than either your 'executive officers' (if you are an organization other than a
partnership, joint venture or limited liability company) or your managers (if you are a limited liability con npany))
are Insureds while in the course of their employment or while performing duties related to the conduct of your
business with respect to 'bodily injury':
(1) To you:
(2) To your partners or members ('d you are a partnership or joint venture);
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295201600059600067
(3) To your members(if you are a limited liability company);or
(4) To a co=employee" or "volunteer worker" while that co-employee* or "volunteer worker" is either in the
course of his or her employment by you or while performing duties related to the conduct of your business
(including participation in any recreational activities sponsored by you).
Paragraph 2.a.(1)(a) of Section II -Who is an Insured does not apply to "bodily injury' for which insurance is
provided by this paragraph.
B. The insurance provided by this Item 4. will not apply I the injured person's sole remedy for such injury is
provided under a workers'compensation law or any similar law.
C. Other Insurance
The insurance provided by this Rem 4. is excess over any other valid and collectible insurance available to the
insured, whether primary.excess. contingent or on any other basis.
Urn 5. Health Cart Professionals As!nsureds
A. Paragraph 2.a.(1)(d) of Section II-Who Is An Insured is replaced by the following:
(d) Arising out of his or her providing or failing to provide professional health care services. However, any
'employee" or "volunteer worker' of the Manned iinsured who is a "'designated health care provider" is an
insured with respect to "bodily injury" and "'personal and advertising injury*that:
(i) Arises out of the providing of or failure to provide professional health care services;and
(i) Occurs in the course of and within the scope of such"employee's" or"volunteer workers' employment
by the Named Insured.
B. With respect to "employees" and "'volunteer workers' providing professional health care services, the following
exclusions are added to Paragraph 2. Exclusions of Section I — Coverage A — Bodily Injury And Property
Damage Liability and Paragraph 2. Exclusions of Section I —Coverage B— Personal And Advertising Injury
Liability:
This insurance does not apply to:
(1) Liability assumed under an 'insured contract"or any other contract or agreement;
(2) Liability arising out of the providing of professional health care services in violation of law;
(3) Liability arising out of the providing of any professional health care services while in any degree under the
influence of intoxicants or narcotics;
(4) Liability arising out of any dishonest,fraudulent. malicious or knowingly wrongful act or failure to act;or
(5) Punitive or exemplary damages,fines or penalties.
C. The following definition is added to Section V-Definitions:
"Designated health care provider" means any "employee" or"volunteer worker" of the Named Insured whose
duties include providing professional health taro services, including but not limited to doctors. nurse&
emergency medical technicians or designated frst aid personnel.
D. Otherinsurance
The insurance provided by this Rem 5. is excess over any other valid and collectible insurance available to the
insured. whether primary,excess. contingent or on any other basis.
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295207600059600069'
Item b. Knowledge Of Occurrence
Knowledge of an 'occurrence" by your agent, servant or 'employee" will not in itself constitute knowledge by you
unless your'executive officer'or"employee' or other third party designated by you to notify us of"occurrences' has
knowledge of the `occurrence".
Item 7. Notice Of Occurrence
For purposes of Paragraph 2.a. of Section IV-Conditions, you refers to an "executive officer" of the Named Insured
or to the "employee' designated by the insured to give us notice.
Item 8. Unintentional Errors And Omissions
Unintentional failure of the Named Insured to disclose all hazards existing at the'inception of this policy shall not be
a basis for denial of any coverage afforded by this policy. However. you must report such an error or omission to
us as soon as practicable after its discovery.
This provision does not affect our right to collect additional premium or exercise our right of cancellation or
non-renewal.
Item 9. Bodily Injury Redeflriition
The definition of'bodily injury'in Section V-Definitions is replaced by the following:
'Bodily injury'means:
a. Bodily injury, sickness or disease sustained by a person, including death resulting from any of these at any
time;and
b. Mental anguish, shock or humiliation arising out of injury as defined in Paragraph a. above. Mental anguish
means any type of mental or emotional illness or distress.
Item 10. Supplementary Payments-Increased Limits
Paragraphs 1.b. and 1.d. of Section I - Supplementary Payments - Coverages A And 0, are replaced by the
following:
b. Up to$3.000 for cost of bag bonds required because of accidents or traffic law violations arising out of the use
of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds.
d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the
claim or`wit'including substantiated loss of earrings up to $500 a day because of time off from work.
Item 11. Damage To Borrowed Equipment
A. Exclusion J. of Section I - Coverage A - Bodly Injury And Property Damage Liability is amended to add the
following:
Paragraphs (3) and (4) do not apply to 'property damage" to borrowed equipment either loaned to you or in
your care, custody or control.
B. Subject to Paragraphs 2., 3., and S. of Section 111— Limits Of Insurance, the most we will pay for insurance
provided.by Paragraph A.is$35,0011.
C. The insurance provided by this endorsement is excess over any other valid and collectible property insurance
(including any deductible portion thereof) available to the insured whether primary, excess, contingent or on any
other basis,
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295201600059600069
Item 12. Aircraft With Chartered Crew
The following is added to Exclusion g. of Section I—Coverage A Bodily Injury And Property Damage Liability:
This exclusion does not apply to an aircraft that you do not own that is:
(a) Chartered with a pilot by any insured;and
(b) Not being used to carry any person or property fora charge.
hem 13. Property In Your Care,Custody Or Control
A. Paragraphs (3) and (4) of exclusion J. of Section I—Coverage A—Bodily Injury and Property Damage Liability
only apply to:
1. "'Property damage"to borrowed equipment, or
2. `Property damage"to property in your can:, custody and control while in transit.
B. This insurance does not apply to any portion of a loss for which the insured has available any other valid and
collectible insurance, whether primary, excess, contingent, or on any other basis, unless such other Insurance
was specifically purchased by the insured to apply in excess of this policy.
C. Limits of Insurance
Subject to Paragraphs 2., 3.. and 5. of Section 111— Limits Of Insurance, the most we wit pay for insurance
provided by Paragraph A., above is:
$10,000 Each Occurrence Limit
$25.000 Aggregate Limit
The Each Occurrence Limit for this coverage applies to all damages as a result of any one 'occurrence'
regardless of the number of persons or organixations who sustain damage because of that"occurrence•.
The Aggregate Limit is the most we will pay for the sum of all damages underthis Item 13.
Item 14. Mobile Equipment Redefined
The definition of"Mobile Equipment"in Section V—Definitions is amended to include self-propelled vehicles with
permanently attached equipment less than 1000 pounds gross vehicle weight that are primarily designed for
(1) Snow removal;
(2) Road Maintenance, but not construction or resurfacing;or
(3) Street cleaning.
Item 15. Newly Formed Or Acquired Entitles
Paragraph 3. of Section 11—Who Is An insured is replaced by the following:
3. Any organizaWin, other than a partnership or joint venture, you newly acquire or form and over which you
maintain majority ownership or majority interest vAl qualify as a Named Insured if there is no other sirnilar
insurance available to that organization.
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295201600059600070
a. Coverage under this provision is afforded only untf:
(1) The 180th day after you acquire or form the organization;
(2) Separate coverage is purchased for the organization;or
(3) The end of the policy period,
whichever is earlier.
b. Coverage A does not apply to 'bodly injurtl' or 'property damage' that occurred before you acquired or
formed the organization:and
c. Coverage B does not apply to 'personal and advertising Injury' arising out of an offense committed before
you acquired or formed the organization.
Rem 16. Blanket Additional Insured Where Required ByWritten Contract
Paragraph 2. of Section II-Who Is An Insured is amended to add the following:
e. Additional Insured by Written Contract or V* ten Agreement
The following are insureds underthe policy when you have agreed in a written contract or written agreement to
provide them coverage as additional insureds under your policy:
(1) Lessors of Leased Equipment The person(s) or organiz,abon(s) from whom you lease equipment, but
only with respect to liability for 'bodily injury'. 'properly damage' or `personal, and advertising Injury'
caused in whole or in part,. by your maintenance, operation or use of equipment leased to you by such
person(s)or organization(s).
(2) fvlanagers or Lessors of Premises:Any manager or lessor of premises leased to you In which the written
lease agreement obligates you to procure additional insured coverage,
The coverage afforded to the additional Insured Is limited to liability in connection with the ownership,
maintenance or use of the premises leased to you and caused, in whole or in part, by some negligent acts
or omissions of you, your employees, your agents or, your subcontractors, There is no coverage for the
additional insured for liability arising out of the sole negligence of the additional insured or those acting on
behalf of the additional Insured,except as provided below.
If the written agreement obligates you to procure additional insured coverage for the additional insured's
sole negligence. then the coverage for the additional Insured' shall conform to the agreement but only if the
applicable law would allow you to Indernnify the additional insured for liability arising out of the additional
insured's sole negligence.
This insurance does not apply to;
(a) Any 'occurrence" which takes place after you cease to be a tenant In that premises or to lease that
land;or
(b) Any premises for which coverage is excluded by endorsement.
(3) Mortgagees. Assignees or Receivers: Any person(s) or organizations) with respect to their liability as
mortgagee. assignee or receiver and arising out of the ownership, maintenance or use of your premises,
This Insurance does not apply to structural atierations, new construction and demolition operations
performed by or for that person or organization,
(4) Grantor of Franchises Any person(s)or organization(s) but only with respect to their liability as grantor.of a
franchise to you.
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295207600059600071
(5) Vendors: Any person(s) or organization(s) that distribute or sell 'your products' in the regular course of
their business, hereafter referred to as vendors, but only with respect to "bodily injury"or"property damage'
arising out of 'your products' which are distributed or sold in the regular course of the vendor's business,
subject to the following additional exclusions.
(a) The insurance afforded the vendor does not apply to:
O "Bodily injury" or'property damage' for which the vendor is obligated to pay damages by reason
of the assumption of liability in a contract or agreement. This exclusion does not apply to the
liability for damages that the vendor would have In the absence of the contract or agreement;
(i) Any express warranty unauthorized by you;
(Gi) Any physical or chemical change in the product made intentionally by the vendor.
(Iv) Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing,
or the substitution of parts under Instructions from the manufacturer, and then repackaged in the
original container,
(v) Any failure to make such Inspections, adjustments,tests or servicing as the vendor has agreed to
make or normally undertakes to make in the usual course of business, in connection with the
distributor or sale of the products;
(vo) Demonstration, installation, servicing or repair operations, except such operations performed at
the vendor's premises in connection with the sale of the product;
(vi) Products which, after distribution or sale by you, have been labeled or relabeled or used as a
container, part or ingredient of any other thing or substance by or for the vendor;or
(viii) 'Bodily injury' or "property damage" arising out of the sole negligence of the vendor for its own
acts or omissions or those of its employees or anyone else acting on its behalf. However, this
exclusion does not apply to:
i. The exceptions contained in Paragraphs(iv)or(VI)above; or
ii.Such inspections, adjustments, tests or servicing as the vendor has agreed to make or
normally undertakes to make in the usual course of business. in connection with the
distribution or sale of the products.
(b) This insurance does not apply to any insured, person or organization. from which you have acquired
such products, or any ingredient, part or container, entering into, accompanying or containing such
products.
(6) Any Person or Organization Other Than a Joint Venture:Any person or organization (other than a joint
venture of which you are a member) for whom you are obligated by a written agreement to procure
additional insured coverage, but only with respect to liability for 'bodily injury, 'property damage' or
"Personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or
omissions of those acting on your behalf
(a) In the performance of your ongoing operations; or
(b) In connection with premises owned by you.
This Insurance does not apply to:
1. Any construction, renovation, demolition or installation operations performed by or on behalf of you, or
those operating on your behalf,
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2. Any person or organization whose profession, business or occupation is that of an architect, surveyor or
engineer with respect to liability arising out of the preparation or approval of maps, drawings, opinions,
reports, surveys, change orders, designs, specification or the performance of any other professional
services by such person or organization;or
3. Any person or organization more specifically covered in Paragraphs e.(1) through(5)above.
The insurance afforded to any person or organization as an insured under this Paragraph 2.e.:
(1) Applies only to coverage and minimum limits of Insurance required by the written agreement or written
contract, but in no event exceeds either the scope of coverage or the limits of insurance provided by this
policy;
(2) Does not apply to arry person or organization for any "bodily injury", 'property damage" or "personal and
advertising Injury" if any other additlonal Insured endorsement attached to this policy applies to that person
or organization w'th regard to the "bodily injury", "property damage"or"personal and advertising Injury';
(3) Applies only If the 'bodily injury" or property damage" occurs, or offense giving on to "personal and
advertising injury"is committed subsequent to the execution of the written agreement; and
(4) Applies only if the written agreement is In effect at the time the "bodily injury' or `property damage" occurs,
or at the time the offense giving rise to the "personal and advertising injury" Is committed.
item 17. Blanket Additional Insured—Grantors Of Permits
Paragraph 2. of Section II-Who Is An Insured is amended to add the following:
Any state, municipalky or political subdivision with respect to any operations performed by you or on your behalf, or
In connection With premises you own, rent or control and to which this insurance applies, for which the state,
municipality or political subdivision has Issued a permit.
However,this insurance does not apply to:
1. "Bodily Injury', "property damage"or"personal and advertising injury" arising out of operations performed for
the state,municipality or political subdivision:
2. Any 'bodily injury" or "property damage" Included within the "products-completed operations hazard"', except
when required by written contract or agreement initiated prior to loss;or
3. "'Bodily injury% "property damage"or-personal and advertising injury', unless negligently caused, in whole or In
part,by you or those acting on your behalf.
Item 1B. Waiver Of Right Of Recovery By Written Contract Or Agreement
The following Is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section N —
Conditions:
We waive any right of recovery because of payments we make under this policy for Injury or damage arising out of
your ongoing operations or "your work"included in the "products-completed operations hazard" that we may have
against any person or organization with whom you have agreed in a written contract or agreement to waive your
rights of recovery but only If the'bodly injury"or "property damage" occurs, or offense giving rise to'personal and
advertising injury'Is committed subsequent to the execution of the written contract or agreement.
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2952016000$96W73
Rem 19. Other Insurance Amendment
9 you are obligated under a written agreement to provide liability insurance on a primary, excess, contingent, or any
other basis for any person or organization that qualifies as an additional insured on this policy,this policy will apply
solely on the basis required by such written agreement and Paragraph 4.Other Insurance of Section N—Conditions
will not apply. Where the applicable written agreement does not specify on what basis the liability insurance will
apply, the provisions of Paragraph 4. Other insurance of Section N — Conditions will govern. However, this
Insurance Is excess over any other insurance available to the additional Insured for which It Is also covered as an
additional insured by attachment of an endorsement to another policy providing coverage for the same
"occurrence", claim or"suit'.
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WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-
CALIFORNIA
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 2% of the California workers' compensation premium
otherwise due on such remuneration.
Schedule
Additional premium is a percent of the California Manual Workers Compensation premium. Subject to a minimum
premium charge of$250
Person or CrcIanization Job Descriotion
Where required by contract or
written agreement prior to loss and
allowed by law
Issued by Liberty Insurance Corporation 21814
For attachment to Policy No.WC7-Z1 1-261104-015 Effective Date Premium$
Issued to Galls LLC
WC 04 03 06 Page 1 of 1
Ed:04/1984
I. W-9 Request for Taxpayer Give Form to the
(Rev.December 2014) Identification Number and Certification ( requester.Do not
ua
o Trey send to the IRS.
required on this line:do .
1 Nanno(as shown on your income Gtlx ralvm).'Name is not tosurrw llrfs lsnebtank„
Galls,LLC
N 2 Business narnerdisnaglardad onOty name.if different trtam sboo
$, Gallsl ('uertermaster/Roy Tailors/Best Uniformi entury Uniform
CL 3 Check appropriate box for Whiral tax classification,check only one of the following seven boxes: 4 lixompflons(codes apply only to
e ❑Indlvldi oral/ proprietor or C Corporation certain entities,not Individuals„see
prop ❑ ❑S Corporation ❑ Pe:trxrshtP Trusvestate instructions on page 3)c
Un lte-ntemkror LLC -�-
R Q t.lrrtitted liability company.Enter the we dassificetlon(C�corporation,sr+s corporation.?-parinerahip)W. Exempt payee code Of any)
g agar+d propriate box in the rare above for .Exemption from FATCA reporting
�¢
Note.Fours sin krµrrtember t.LC that Is dfsr ad,tb not check U.C.IJ.C:cheek the
r 1 the tax classlttcaikan or the single-member owner. code(if any)
tvyOtMr(�Ska,'irt4slr�ttd9or )► wvkrroewws,ro,waawa.us!
c 5 Address(rrvurnber,streal„and apt.or suite ruin.) 1 yueslar"s name wnd address(opuonslt
1340 Russell Cave Rd
rn 8 City,state,and ZIP code
�I.e xington,KY 40505-3114
7 List account oumbegtr)here(optional)
EM Taxpayer Identification Number(TIN)
'tinter your TIN In the appropriate box.The TIN provided must match the name given on line T to avoid i social secuday number j
backup withholding.For individuals,this is generally your social security retrkr(SSN).N krwrewter„fora
resident alien,scale proprietor,or disregarded entity,See the Past I in ructions rent page 3,F°or othe r
entities,It Is your employer identification number(FW),If you do not have a number„see Howe to get a
Fiat on page;3. or
Note.If the account is in more than one name,see the instructions for line 1 and the chart on page 4 for ptoyer Identification number
Ear
guidelines on whose number to enter" 120 - 8 5 4 ..5 1 9 18 rg= CeMfi abort I P V
Under penal ies of perjury,I certify that:
1. The number shown on this form Is my correct taxpayer Identification number(or I am waiting for a number to be issued to me);and
2. 1 am not subject to backup withholding because;(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I ant subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified rite that I am
no longer subject to backup withholding,and
3. 1 am a U.S.citizen or other U.S.person(defined below);and
4.The FATCA codes)entered on this form Of any)Indicating that I am exempt from FATCA reporting is correct.
Certification Instructions.you must cr*m out item 2 above if you ha:ve been notified by the IRS that you are currently subject to backup withholding
because you have lasted to report all Interest and d'ividend's on your tax return,For real estate transactions,item 2 does not apply.For mortgage
interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and
generally,payments other than interest and divideleds,you are not rettuired to sign the certification,but YOU Must provider your correct TIN.See the
irtslructlons on page 3.
91( Tt signature of
Mere U.S.person► Date "
General Instructions 'Form 1098(home mortgage interest),1098-E(student ban Interest).1098-T
(tuition)
Section references are to the tntrrral Revenue Code unless otherwise noted, .Form 1099-C(canceled debt)
Future dewolopments.Inlormadion about developments affecting Form W-9(such .Form 1099-A(acouisilion or zbarrrrorment of secured property)
as kvi4ilation enacted after we release it)is at vvvv.v.irs,Jotir 6r 9.
ArN urc' „a„afar ensay tt"ordrn IN mw r ,d%„r;S.,",�ter)+rncc is r(106r'eo t„. ”. r p.1,a,i•„•,, n p. r+", ,. . , _.x _ „ ;rr„ .,
r main Wilh true IRS MuSl 00tala your cofsW taxpayer nw asu'o 1.1141 fo a;�$,^"«v,,,,,,y,� �,,,w .-,• �__.a,.r ,..,,��.; -
which may be yew social socuriky meter(SSN).kadkoidual taxpayer td'amit cMirlrr By Vgniv19 lha hftd•wl form,you:
number(RIN),adoption Taxpayer'Idaniifl4alion nuunber(ATTN),or employer
identiffaatalion number(EIN,),to report on an Information return the amoerant paid to 1.Certify tna[the TIN you are gluing Is corroct(a you are wailing for a number
you,or other aanount reportable on an Information return,Examples of information 1O��e�'
returnee inthrdo,but are not orni(ed to.taco ldtkawing. 2.Certify that you are not subject to baetrup wabholding,or
•Form 1099-INT(Interest earned or paid) 3.Claim exemp(irrn from backup vrarholdlrrog it you are a US.exempt payee,lI'
•Form 1009-DIV(dividends,inch ing those from sl ks or attAual funds) aptAcablo,you are also con tying that as a tNA personr your allocable Share of
any partnership income from'a U.S.trade or,business is hot subject to the
•Foon 1099-WSC(various types of ins efera„p ktes,avralds,or gross proceedsi wlmnold'ing tux on forrtegn partners'share of offectuvely connerctod income,and
•Fonn 1(,1rga.e(stock or nriutual hand sales and raertaln other Irenoectioues try 4.CarWtr that FATCA pod s)entered on this Parch(4�sary)indicat ihal you we
brokers) exempt from the FATCA repoofn9.is correct,rAe Whai 1s FA'rCA retiorfingr2 on
•Form 1099-S(proceeds from real estate transactions) page 2 toe further inlortmr ion.
•Form 1099•K(merchant card and thud party network transactions)
Cot No.10231X Form W-9(Rev,12-2014)