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PROOF OF INSURANCE (2017) CLOSED DATE(MM/DD/YYYY) v AC"RV CERTIFICATE OF LIABILITY INSURANCE I 09/19/2016 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 endorsement(s). PRODUCER NTACT MARSH AINC,ONE FAX SOUTH STREET MF, NA NQ.Extla ..,,,, _(Alfa No): MORRISTOWN,NJ 07960-6454 E MAIL. ADDk�trS INSURER(S),AFFORDING COVERAGE NAI C# 100129-SBT-PPA-16117 610 ROLLIN NOC60 INSURER A: HDI Global Insurance Company INSURER C:Travelers Pro o an 2568 INSURED SIEMENS INSURER 13:The Travelers PIndemnity erty Casualty Co.of America 256 4 1000 DEERFIELD PARKWAY INSURER D: BUFFALO GROVE,IL 60089 INSURER E; SURER F: COVERAGES CERTIFICATE NUMBER: NYC-008410877-02 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 INSA,„,,,, TYPEOFINSURANCE, ..... ............A$1�.. n POLICY tM 'Y POLICY NUMBER IM Y , YYI rF POLICY EXP LIMITS LTR FMMlDDAYYYYI A X COMMERCIAL GENERAL LIABILITY GLD1110108 10/0112016 10/01/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE kiLN"(Eb CLAIMS-MADE OCCUR PREM$FSW(Fq oggq rence,) 1 $ 1,000,000'', X MED EXP(Any one person) $ 100,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 10,000,000 POLICY N JECT LOC PRODUCTS COMP/OP AGG $ INCL C)'1jtlBi . - $ C AUTOMOBILE LIABILITY TC2JCAP7440L34A16 10/0112016 1010112017 L'OMI':MNt:r:)SINGLE UMNT $ 2,000,000 X ANY AUTO BODILY INJURY(Per person) $ N/A X ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ NIA HIRED SAUTOS NON-OWNED (Pg' accident DAMAGE A. X X $ NI $ A X EXCESS ARAB X CLAMS-MADE iCUD1110208 10/01/2016 10/0112017 EACH rocAC OCCURRENCE $ 4,000,000 C AND EMPLO COMPENSATION„ DED RS RETENTION$ N $ SATION TC2JUB7440L27116(AOS) 10/01/2016 1010112017 X p ST,�ATIJTF f �.ORH B LIABILITY YNN NIA TRKUB744OL28316 AZ,MA,OR&WI 1010112016 1010112017 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE ( ) E L EACH ACCIDENT $ C OFFICER/MEMBER EXCLUDED (Mandatory in NH) — TWXJUB7440L33816(OH&WA) 1010112016 1010112017 E L DISEASE-EA EMPLOYEE $ 1,000,000 Ntl�+os,dwcti libo ended ”""'$500K LIMIT I$500K SIR"'°° E L DISEASE-POLICY LIMIT $ 1,000,000 0"SC HIP 1 ON t'.bd"Or E NA I R)NS 4'wolow DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE:AEMA-145ACRC-ENGINEERING PLAN CHECK SVCS,CITY OF EL SEGUNDO SEE ATTACHED I CERTIF=ICATE HOLDER CANCELLATION CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN:FLORIZA RIVERA,PW DEPT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 MAIN ST ACCORDANCE WITH THE POLICY PROVISIONS. EL SEGUNDO,CA 90245 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee �3►�Lct�sta.a►� ��µee n� <� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 100129 �� LOC#: Morristown " ��U�K��U ��k��% SCHEDULE Page 2 of 2 ADDITIONAL- �� --��_ �'__ Aarwu, U NAMED INSURED MARSH u8m.INC. Y SIEMENS INDUSTRY,BUILDING TECHNOLOGIES pouovwomosn 1mmosExnsmPARKWAY BUFFALO GROVE,uu00n .��.�� o^nmsn wm0000s | ----'----- � �� --------------'— / EFFECTIVE DATE: - ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM|S A SCHEDULE ToACOmoFORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance RE:Aswm'waxcnc ENGINEERING PLAN CHECK m/uu.CITY nreLusouwoo CITY OF EL SEGUNDO,ITS OFFICIALS,OFFICERS,AGENTS AND EMPLOYEES ARE INCLUDED AS ADDITIONAL INSURED UNDER THE ABOVE REFERENCED GENERAL LIABILITY AND AUTOMOBILE LIABILITY INSURANCE POLICIES AND THE COVERAGE AFFORDED THE ADDITIONAL INSURED UNDER THESE POLICIES SHALL BE | PRIMARY AND wowcowrmaurornINSURANCE roms EXTENT rxmxcm/mxnmeo FROM mswsuuaswcsnF SIEMENS moummv INC on/ro | ' SUBCONTRACTORS WITH RESPEC ro ALL OPERATIONS mp THE INSURED BUT ONLY WITH RESPECT ro ALL WORK PERFORMED ov AND ow BEHALF mpTHE NAMED INSURED,SIEMENS INDUSTRY,INC.FOR CERTIFICATE HOLDER UNDER CONTRACT. THE OWNER AND CONTRACTOR WAIVE ALL RIGHTS AGAINST EACH OTHER AND ANY OTHER CONTRACTOR,SUBCONTRACTORS,SUB-SUBCONTRACTORS, AGENTS,AND EMPLOYEES.FOR DAMAGES OR INJURIES CAUSED BY PERILS TO THE EXTENT COVERED BY INSURANCE,EXCEPT SUCH RIGHTS AS THEY MAY HAVE ro PROCEEDS op SUCH INSURANCE HELD a,THE OWNER xuxFIDUCIARY $1.00o.000 PROFESSIONAL LIABILITY/u INCLUDED UNDER THE GENERAL LIABILITY POLICY ' PER PROJECT AGGREGATE APPLIES. | EXPLOSION,COLLAPSE&UNDERGROUND COVERAGE mwnrsxcmosu CONTRACTUAL LIABILITY IS INCLUDED UNDER THE GENERAL LIABILITY COVERAGE. COMPLETED OPERATIONS COVERAGE m INCLUDED w THE GENERAL LIABILITY POLICY /F THESE POLICIES ARE CANCELLED FOR ANY REASON OTHER THAN NON-PAYMENT nr PREMIUM,THE INSURER WILL DELIVER NOTICE or CANCELLATION/o | | THE CERTIFICATE HOLDER UP TO 60 DAYS PRIOR TO THE CANCELLATION OR AS REQUIRED BY WRITTEN CONTRACT,WHICHEVER IS LESS | | | ACORQiW1 (2008/01) C 200GACORDCORPORATION. All rights reserved. The ACORD name and logo are registered marks ofACORD HDI-GERLING AMERICA INSURANCE COMPANY MANUSCRIPT ENDORSEMENT#32 Policy Number Named Insured GLD11101-08 SIEMENS CORPORATION Policy Period: Inception(M-D-Y) Expiration(M-D-Y) Effective Date and Time of Endorsement 10-01-2016 10-01-2017 10-01-2016 12:01 a.m. Standard Time at Address of the Insured. This Endorsement Changes The Policy. Please Read It Carefully. This endorsement modifies insurance provided under the following: Commercial General Liability Coverage Form Who is an insured is amended to include as an additional insured any person whom you are required to add as an additional insured on this policy under a written agreement, 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 2. The acts or omissions of those acting on your behalf. The insurance coverage provided to such additional insured applies only to the extent required within the written agreement. The insurance coverage provided to the additional insured person shall not provide any broader coverage than you are required to provide to the additional insured person in the written agreement and shall not provide limits of insurance that exceed the lower of the Limits of Insurance provided to you in this policy,or the limits of insurance you are required to provide in the written agreement. The insurance provided to the additional insured by this endorsement is excess over any valid and collectible other insurance,whether primary, excess,contingent,or on any other basis,that is available to the additional insured for a loss we cover under this endorsement.However, if the written agreement specifically requires that this insurance apply on a primary basis,this insurance is primary. If the written agreement specifically requires this insurance apply on a primary and non-contributory basis this insurance is primaryto other insurance available to the additional insured and we will not share with that other insurance. This endorsement shall prevail over additional insured endorsements that may apply under this policy unless required otherwise in the written agreement. 77 6�,J Authorized Representative All terms and conditions of the policy remain unchanged. THIS ENDORSEMENT MUST BE ATTACHED TO A CHANGE ENDORSEMENT WHEN ISSUED AFTER THE POLICY IS WRITTEN. Page POLICY NUMBER: GLD11101-08 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF' RIGHTS IGHTS Off' RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following. COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: ANY PERSON OR ORGANIZATION TO THE EXTENT REQUIRED BY WRITTEN CONTRACT Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule payments " VJJ above because of we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products- completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above CG 24 04 05 09 0 Insurance Services Office, Inc., 2008 Page 1 of 1 ❑ POLICY NUMBER: TC2J—CAP-7440L34A—TIL-16 COMMERCIAL AUTO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET' WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM The following replaces Paragraph A.5., Transfer of required of you by a written contract executed Rights Of Recovery Against Others To Us, of the prior to any "accident' or 'loss", provided that the CONDITIONS Section: "accident" or "loss" arises out of the operations 5. Transfer Of Rights Of Recovery Against Oth- contemplated by such contract. The waiver ap- ers To Us plies only to the person or organization desig- We waive any right of recovery we may have nated in such contract. against any person or organization to the extent CA T3 40 02 15 O 2015 The Travelers Indemnity Company.All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc,with its permission, TRAVELER VELE 'I WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY ENDORSEMENT MOO 0313 (00)_ POLICY NUMBER: TC2JUB-7440L27-1-16 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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 directly or indirectly to benefit any one not named in the Schedule. SCHEDULE DESIGNATED PERSON: DESIGNATED ORGANIZATION: ANY PERSON OR ORGANIZATION FOR WHOM A WAIVER OF SUBROGATION IS REQUIRED BY CONTRACT OR AGREEMENT OR PERMIT, BUT COVERAGE IS LIMITED TO THE SCOPE OF THE WORK PERFORMED BY THE INSURED UNDER SUCH CONTRACT, AGREEMENT OR PERMIT. DATE OF ISSUE: 09-08-16 ST ASSIGN: