PROOF OF INSURANCE (2018) CLOSED DATE(MMIDDIYYYY)
AC"R" (CERTIFICATE OF LIABILITY INSURANCE 2/10a2017
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 NAMIECT Carrie Clark
CIBC Insurance Services ILLC Fr,,.310-981-0801 FAX
License 0K19767 IAIC.Nol
EM
32 C?Id Slip DD :
AIL carrie.clark@crystalco.com
ARESS
New York NY 10005 I INSURER(S)AFFORDING COVERAGE NAIC# I
INSURERA;Hartford Underwriters Insurance Com 30104 I
INSURED CLIINILA INSURER B:Transportation Insurance Company 20494
Clinical Laboratory of San(Bernardino, Inc. INSURER C
P.O Box 329
San Bernardino CA 92402 INSURER D!
INSURER E;
INSURER F:
COVERAGES CERTIFICATE NUMBER: 1252835455 REVISION NUMBER:
THIS iII S 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 'OLICIES.LiIIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR .TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS
LTR INSD WVD POLICY NUMBER (MIMIDDlYYYY1 (MIM/DDlYYYY)
B X COMMERCIAL GENERAL LIABILITY Y Y 5088208188 2/112017 2/1 1201 8 EACH OCCURRENCE $1,000,000
_._._ _MMAGE CLAIMS-MADE X 1 OCCUR IIPREIM SESO R occurrence) $100,000
MEID EXP(Any one person) $5,000
PERSONAL&ADVINJURY $1,000,000
GEN'L AGGREGATE(LIMIT APPLIES PER' GENERAL AGGREGATE $2,000,000
X POLICY PRO- I LOC PRODUCTS-COMP/OP AGO $2,000,000
JECT
OTHEH: $
B AUTOMOBILE LIABILITY Y Y 508820 8224 211/2017 2/1/2018 COMBINED SINGLE LIMIT $
dEa accident) 1,000,000
X ANY AUTO BODILY INJURY(Per person) $
A�L1TOS NED � SCHEDULED BODILY INJURY(Per accident) $AUTOS
HIRED AUTOS NON-OWNED PROPERTY DAMAGE $
........ AUTOS Per accident)
is
B X_-- UMBRELLA LIAR OCCUR 6046009225 2/112017 2/1/201 8 EACH OCCURRENCE $5,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000
IDED X RETENTION$10,000 $
A WORKERS COMPENSATION Y IOWECAS6498 2/1/2017 2/1/201 8 X PER OTH
AND EMPLOYERS'LIABILITY _ STATUTE -__ER
ANY PROPRIETOR�PARTNERIIEXECUTIVE Y� N/A
E.L EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED?
(Mandalory in NH) E.L.DISEASE-EA EMPLOYEEII, $1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below IE.L.DISEASE-POLICY LIMIT( $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS;VEHICLES (ACORD 1101,Additional Remarks Schedlule,may be attachedl it more space is required)
Re: Engineering Plan Check Svcs, City of El Segundo.
The City of El Segundo, its officials,officers,agents and employees are included as additional insured as required by written contract with the
named insured as respects General Liability and Automobile Liability policies. Primary wording on General Liability policy is included.Waiver
of Subrogation applies to General Liability,Automobile Liability and Workers Compensation Policies.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of IEl Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Water Division Operations ACCORDANCE WITH THE POLICY PROVISIONS.
400 Lomita Street
El Segundo,CA 910245
AUTHORIZED REPRESENTATIVE
B if
, ry pp
031988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
CNA CNA PARAMOUNT
Blanket Additional Insured - Owners, Lessees or
Contractors -with Products-Completed Operations
Coverage - Limited Liability Endorsement
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
It is understood and agreed as follows:
I. The WHO IS AN INSURED section is amended to add as an Insured any person or organization whom the Named
Insured is required by written contract to add as an additional insured on this Coverage Part; including any such
person or organization, if any, specifically set forth on the Schedule attachment to this endorsement. However, such
person or organization is an Insured only with respect to such person or organization's liability for:
A. bodily injury, property damage, or personal and advertising injury to the extent caused by:
1. the Named Insured's acts or omissions;or
2. the acts or omissions of those acting on the Named Insured's behalf,
in the performance of the Named Insured's ongoing operations specified in the written contract; or
B. bodily injury or property damage to the extent caused by your work specified in the written contract and
included in the products-completed operations hazard, and only if
1. the written contract requires the Named Insured to provide the additional insured such coverage;and
2. this coverage part provides such coverage.
II. Subject always to the terms and conditions of this policy, including the limits of insurance, the Insurer will not provide
such additional insured with:
A. coverage broader than required by the written contract; or
B. a higher limit of insurance than required by the written contract.
III. The insurance granted by this endorsement to the additional insured does not apply to bodily injury, property
damage, or personal and advertising injury arising out of:
A. acts or omissions of the additional insured, or of anyone acting on the additional insured's behalf; or
a
B. the rendering of, or the failure to render, any professional architectural, engineering, or surveying services,
m including.
1. the preparing, approving, or failing to prepare or approve maps, shop drawings, opinions, reports, surveys,
N
field orders, change orders or drawings and specifications; and
2. supervisory, inspection, architectural or engineering activities; or
C. any premises or work for which the additional insured is specifically listed as an additional insured on another
endorsement attached to this coverage part.
IV. Notwithstanding anything to the contrary in the section entitled COMMERCIAL GENERAL LIABILITY CONDITIONS,
the Condition entitled Other Insurance, this insurance is excess of all other insurance available to the additional
insured whether on a primary,excess, contingent or any other basis. However, if this insurance is required by written
contract to be primary and non-contributory, this insurance will be primary and non-contributory relative solely to
"
CNA CNA PARAMOUNT
Blanket Additional Insured - Owners, Lessees or
Contractors -with Products-Completed Operations
Coverage - Limited Liability Endorsement
The Condition entitled Duties In The Event of Occurrence, Offense, Claim or Suit is amended with the addition
of the following:
Any additional insured pursuant to this endorsement will as soon as practicable:
1. give the Insurer written notice of any claim, or any occurrence or offense which may result in a claim;
2. except as provided in Paragraph IV. of this endorsement, agree to make available any other insurance the
additional insured has for any loss covered under this coverage part;
3. send the Insurer copies of all legal papers received, and otherwise cooperate with the Insurer in the
investigation, defense,or settlement of the claim; and
4. tender the defense and indemnity of any claim to any other insurer or self insurer whose policy or program
applies to a loss that the Insurer covers under this coverage part. However, if the written contract requires
this insurance to be primary and non-contributory,this paragraph 4 does not apply to insurance on which the
additional insured is a named insured.
The Insurer has no duty to defend or indemnify an additional insured under this endorsement until the Insurer
receives written notice of a claim from the additional insured.
VI. Solely with respect to the insurance granted by this endorsement, the section entitled DEFINITIONS is amended to
add the following definition:
Written contract means a written contract or written agreement that requires the Named Insured to make a person
or organization an additional insured on this coverage part, provided the contract or agreement:
A. is currently in effect or becomes effective during the term of this policy; and
B. was executed prior to:
1. The bodily injury or property damage; or
2. The offense that caused the personal and advertising injury
for which the additional insured seeks coverage.
Any coverage granted by this endorsement shall apply solely to the extent permissible by law.
All other terms and conditions of the Policy remain unchanged.
This endorsement,which forms a part of and is for attachment to the Policy issued by the designated Insurers, takes effect
on the effective date of said Policy at the hour stated in said Policy, unless another effective date is shown below, and
expires concurrently with said Policy.
CNA75081XX (1-15) Policy No: 5088208188
Page 2 of 2 Endorsement No: 5
TRANSPORTATION INSURANCE COMPANY Effective Date: 02/01/201
Insured Name: CLINICAL LABORATORIES OF SAN BERNARDINO, INC
Copyright CNA All Rights Reserved. Includes copyrighted material of Insurance Services Office,Inc.,with its permission.
CNA CNA PARAMOUNT
Waiver of Transfer of Rights of Recovery Against
Others to the Insurer Endorsement
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 whom the Named Insured has agreed in writing in a
contract or agreement to waive such rights of recovery, but only if such
contract or agreement :
1. is in effect or becomes effective during the term of this Coverage Part; and
2 . was executed prior to the bodily injury, property damage or personal and
advertising injury giving rise to the claim.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
It is understood and agreed that the condition entitled Transfer Of Rights Of Recovery Against Others To The Insurer
is amended by the addition of the following:
Solely with respect to the person or organization shown in the Schedule above, the Insurer waives any right of recovery
the Insurer may have against such person or organization because of payments the Insurer makes for injury or damage
arising out of the Named Insured's ongoing operations or your work done under a contract with that person or
organization and included in the products-completed operations hazard,
All other terms and conditions of the Policy remain unchanged.
a
N This endorsement,which forms a part of and is for attachment to the Policy issued by the designated Insurers, takes effect
on the effective date of said Policy at the hour stated in said Policy, unless another effective date is shown below, and
expires concurrently with said Policy.
0
N
N
CNA75008XX (1-15) Policy No: 5088208188
Page 1 of 1 Endorsement No: 7
TRANSPORTATION INSURANCE COMPANY Effective Date: 02/01/2017
Insured Name: CLINICAL LABORATORIES OF SAN BERNARDINO, INC
Copynght CNA All Rights Reserved. Includes copyrighted material of Insurance Services Office,Inc.,with its permission.
CN
POLICY NUMBER: COMMERCIAL AUTO
CA 20 48 02 99
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED INSURED
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORM
MOTOR CARRIER COVERAGE FORD
TRUCKERS COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Farm apply unless modified by
this endorsement.
This endorsement identifies person(s)or organization(s) who are "insureds" under the Who Is An Insured Provision of the
Coverage Form.This endorsement does not alter coverage provided in the Coverage Form.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.
Endorsement Effective: Countersigned By:
ii /n1/-HI7
Named Insured:
�-linical Latoratcry of Safi Eernardiiio, Iiic fAuthoriz_ed Representative)
SCHEDULE
Name of Person(s)or Organization(s):
Any person or organization whom you are required to add as
additional insured on this policy under a written contract
or written agreement. You must agree to these contracts
prior to the date of loss. See Endt
a
a
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to the endorsement.)
-= Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that
person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section II of the
Coverage Form.
CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1
POLICY NUMBER: COMMERCIAL AUTO
CA 04 44 0310
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US (WAIVER OF SUBROGATION)
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
BUSINESS AUTO PHYSICAL DAMAGE COVERAGE FORM
GARAGE COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
TRUCKERS COVERAGE FORM
With respect to coverage provided by this endorsement,the provisions of the Coverage Form apply unless modified by
the endorsement.
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated
below.
Named Insured: Clinical Lal__izt_ry ,t _11an L—Liizi_lin_, liic.
Endorsement Effective Date: i 1 i 17
SCHEDULE
Name(s)Of Person(s) Or Organization(s):
ANY FERSON OR ORGANIZATION FOR WHOM
OR WHICH YOU ARE REQUIRED BY WRITTEN
CONTRACT OR AGREEMENT TO OTBAIN THIS
WAIVER FROM US. YOU MUST AGREE TO '-HAT
REQUIREMENT PRIOR TO LOSS.
Information required to complete this Schedule, if not shown above,will be shown in the Declarations.
J
The Transfer Of Rights Of Recovery Against Others
To Us Condition does not apply to the person(s) or
j
organization(s) shown in the Schedule, but only to the
extent that subrogation is waived prior to the "accident"
or the 'loss" under a contract with that person or
organization.
CA 04 44 03 10 Copyright, Insurance Services Office, Inc., 2009 Page 1 of 1
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF OUR RIGHT TO RECOVER FROM
OTHERS ENDORSEMENT - CALIFORNIA
Policy Number: 10 WEC AN1623 Endorsement Number:
Effective Date: 02/01/17 Effective hour is the same as stated on the Information Page of the policy.
Named Insured and Address: CLINICAL LABORATORIES OF SAN
BERNARDINO, INC
PO BOX 329
SAN BERNARDINO, CA 92402
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
Person or Organization Job Description
ANY PERSON OR ORGANIZATION BLANKET OPERATIONS
FROM WHOM YOU ARE REQUIRED BY
WRITTEN CONTRACT OR AGREEMENT
TO OBTAIN THIS WAIVER OF
RIGHTS FROM US.
Countersigned by
Authorized Representative
Form WC 04 03 06 (1) Printed in U.S.A.
Process Date: 12/10/16 Policy Expiration Date: 02/01/18