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PROOF OF INSURANCE (2017) CLOSED Page 1 of 2 CERTIFICATE OF LIABILITY INSURANCE °06/09/20 7 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 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 CONTACT T NNAME: Willis of Massachusetts, Inc. PHONE 1 c/o 26 Century Blvd IAIC,.N 877-945-7378 FAX 1-888-467-2378 a F�sU,.,,.n.n (A/C4 No.. - ..........,.......... E-MAIL P.O. Box 305191 ADDRESS certificates @willis.com Nashville, TN 372305191 USA INSURER(S)AFFORDINGCOVERAGE NAIC# _ ACE American Insurance c Iance 22667 ,.,.,. ....... ....... .,.. 1INS4AIGEH A _ . ,e. _„,._, INSURED INSURER B I d mnity Insurance Company of North America 43575 UniFirst Corporation and its Subsidiaries 111 m° °°°°°°. -- - -------- 68 Jonspin Road INSURER C ,ACE Fire Underwriters Insurance Company 20702 -.ee, Wilmington, MA 018871086 INSURER D: Agri General Insurance Company 42757 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:W2613104 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. INSRpp�...... .._.. .., . C�EiiSYY��'S`h' it POLICY NUMBER.. m.m. MMf 1,C,Y YYY MMA ICY EXp..._ LTR Y TYPE OF INSURANCE POLK.Y YY PO DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE ;$ 1,000,000 IJAMACILTO)�ENT - ,,.., .. CLAIMS-MADE X..I OCCUR 1,000,000 f^tldE14N,RSES(Ea pwq a yr nf.e) $ A MED EXP(Any one person) $ 5,000 HDOG27858752 10/01/2016 10/01/2017 PERSONAL&ADV INJURY $ 1,000,000 m,,,e2,000,000 ,GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- ....,. ,„„„,,, POLICY�I JECT X.#LOC PRODUCTS-COMP/Op AGG $ 2,000,000 OTI.IEN: $ AUTOMOBILE LIABILITY UOMWNtU SINGLE LVAIT $ 2,000,000 (En aaccidor l X ANY AUTO BODILY INJURY(Per person) $ . A OWNED SCHEDULED Y Y ISAH09051284 10/01/2016 10/01/2017 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY „®I AUTOS ONLY (Per arr�dent) $ $ UMBRELLA LIAR,,,, [.,.. A GGREGATE OCCUR EACH OCCURRENCE I$EXCESS LIAB_.. �.$ ... _ DED RETENTION$ $ WORKERS COMPENSATION p x STATUTE OTRH- B OP ICER/MEMBER EXCLUDED? N/A NO I.'N/A Y WLRC49104261 (AOS) 10/01/2016 10/01/2017 E.L. SEASECEA EMPLOYEEg 1 000,,000. (Mandatory In NH 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ 1,000,000 C WORKERS COMPENSATION N Y SCFC49104285 (WI) 10/01/2016 10/01/2017 E„L, EACH ACCIDENT 1'00 0,000 AND EMPLOYERS' LIABILITY E.L, DISEASE - EA EM 1,000,000 PER STATUTE E.L. DISEASE- POL LM7.1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) This Voids and Replaces Previously Issued Certificate Dated 06/01/2017 WITH ID: W2540030. Division/Location: 324 Certificate Holder is an Additional Insured for General Liability and Auto Liability as their interest may appear if SEE ATTACHED CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of E1 Segundo Attn: City Clerk AUTHORIZED REPRESENTATIVE City Clerk's Office, 350 Main Street Room 5 E1 Segundo, CA 90295-3813 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 14697551 BATCH: 346587 AGENCY CUSTOMER ID: ACC>RV ADDITIONAL REMARKS SCHEDULE Page 2 Of 2 AGENCY NAMED INSURED Willis of Massachusetts, Inc. UniFirst Corporation and its Subsidiaries .. ..... —------............. 68 Jonspin Road POLICY NUMBER Wilmington, MA 018871086 See Page 1 ------------ CARRIER NAIC CODE See Page 1 See Page 1 EFFECTIVE DATE: See Page 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: certificate of Liability Insurance --—---___- --------——­-– ................... uu required by written contract but only with respect to liability arising out of operations of the Named Insured. It is understood and agreed that the Company waives its right of subrogation against the Additional Insured which may arise by reason of a payment of claim under all the policies, if required by written contract and as permitted by law. Additional Insureds: City of El Segundo, its officials, and employees. General Liability policy shall be Primary and Non-contributory with any other insurance in force for or which may be purchased by Additional Insured's. INSURER AFFORDING COVERAGE: Agri General Insurance Company NAIC#: 42757 POLICY NUMBER: WLRC49104273 (TN) EFF DATE: 10/01/2016 EXP DATE: 10/01/2017 ADDITIONAL INSURED: N SUBROGATION WAIVED: Y TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: WORKERS COMPENSATION E.L. EACH ACCIDENT 1,000,000 AND EMPLOYERS' LIABILITY E.L. DISEASE - EA EMP 1,000,000 PER STATUTE E.L. DISEASE- POL LMT 1,000,000 INSURER AFFORDING COVERAGE: ACE American Insurance Company NAIC#: 22667 POLICY NUMBER: WCUC49104248 (MA, ME, OH) EFF DATE: 10/01/2016 EXP DATE: 10/01/2017 ADDITIONAL INSURED: N SUBROGATION WAIVED: Y TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: WORKERS COMPENSATION E.L. EACH ACCIDENT 1,000,000 AND EMPLOYERS' LIABILITY E.L. DISEASE - EA EMP 1,000,000 PER STATUTE E.L. DISEASE- POL LMT 1,000,000 INSURER AFFORDING COVERAGE: ACE American Insurance Company NAIC#: 22667 POLICY NUMBER: WLRC4910425A (AZ, CA) EFF DATE: 10/01/2016 EXP DATE: 10/01/2017 ADDITIONAL INSURED: N SUBROGATION WAIVED: Y TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: WORKERS COMPENSATION E.L. EACH ACCIDENT 1,000,000 AND EMPLOYERS' LIABILITY E.L. DISEASE - EA EMP 1,000,000 PER STATUTE E.L. DISEASE- POL LMT 1,000,000 ACORD 101 (2008/01) @ 2008 ACORD CORPORATION. All rights reserved, The ACORD name and logo are registered marks of ACORD SR ID: 14697551 BATCH: 3 65 87 CFRT: W2613104 i POLICY NUMBER: HDO 627858752 Endorsement Number: 49 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s)Or Organization(s): Any person or organization whom you have agreed to include as an additional insured under a written contract, provided such contract was executed prior to the date of loss. Information required to complete this Schedule, if not shown above„will be shown in the Deolarations. 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", "'property If coverage provided to the additional insured is damage" or "personal and advertising injury required by a contract or agreement, the most we caused, in whole or in part, by your acts or will pay on behalf of the additional insured is the omissions or the acts or omissions of those acting amount of insurance: on your behalf: 1. In the performance of your ongoing operations; 1. Required by the contract or agreement; or or 2. Available under the applicable Limits of 2. In connection with your premises owned by or Insurance shown in the Declarations; rented to you. whichever is less. However: This endorsement shall not increase the 1. The insurance afforded to such additional applicable Limits of Insurance shown in the insured only applies to the extent permitted by Declarations. 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. CG 20 26 0413 ©Insurance Services Office, Inc., 2012 Page 1 of 1 - ---- - - ---- ' i Workers'Compensation and Employers'Liability Policy ! � LINIFIRST CORPORATION WILMINGTON MA 01887 Symbol: WLR_.Number:C4910425A 10-01-2016 TO 10-01-2017 10-01-2016 Issued By(Name of Insurance Company) ACE AMERICAN INSURANCE COMPANY � WAIVER OF OUR RIGHT T0 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 per-form 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 ANY PERSON OR ORGANIZATION AGAINST WHOM YOU HAVE AGREED TO WAIVE YOUR RIGHT OF RECOVERY IN A WRITTEN CONTRACT, PROVIDED SUCH CONTRACT WAS EXECUTED PRIOR T0 TE DATE OF LOSS. For the states of CA, UT, TX, refer hu state specific endorsements. This endorsement io not applicable in KY, NH, and NJ. ~ The endorsement dnoa not apply to policies in Missouri where the employer is in the construction group of code classifications. According to Section 287.15U(S)ofthe Missouri obstutoa' a contractual provision purporting towaive subrogation rights against public policy and void where one party to the contract is an employer in the construction / group of code classifications. / For Kansas, use of this endorsement is limited by the Kansas Fairness in Private Construction Contract Act(K.S.A.. 16'1801 through 18'18U7 and any amendments thereto) and the Kansas Fairness in Public Construction Contract Ao (K.S.A 18'1901 through 16'1908 and any amendments theneto). According tn the Acts u provision in o contract for private or public construction purporting to waive subrogation rights for |00000 or claims covered or paid by liability orworkers compensation insurance shall be against public policy and shall be void and unenforceable except that, subject to the Aotn, o contract may require waiver of subrogation for |000en or claims paid by a consolidated or wrap-up insurance program.