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PROOF OF INSURANCE (2018) CLOSED 4 ,8, I DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 07/07/2017 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 pol'icy(ie's)must have ADDITIONAL INSURED provisions or be endorsed, m If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement.A statement on w Ythis certificate does not confer rights to the certificate holder in lieu of such endorsement(s). (PRODUCER ICONTAC'T D Aon Risk Services South, Inc. NAME: ` dF1C,N (866) 283-7122 N FAX (800) 363-0105 t2 Atlanta GA Office �gAaC,No.Ext): INC.No.), � 3565 Piedmont Rd NE,Blgl,#700 E-MAIL 0 Atlanta GA 30305 USA ADDRESS: _ INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: Federal Insurance Company 20281 ZOLL Medical Corporation INSURER B: Trans Pacific Ins CO 141238 and Subsidiaries 269 Mill Road INSURER C: Travelers Casualty Ins CO of America 119046 Chelmsford MA 01824-4105 USA INSURER D: Mitsui Sumitomo Insurance USA Inc. 122551 INSURER E: lIX INSURER F: V COVERAGES CERTIFICATE NUMBER:570067489738 RE'VIS'ION NUMBER: THIS IS TO CERT'IF'Y 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 Limits shown are as requested INSH. AUUL SU0114 PULIUV tvi, P"uLluY kX6" LTR TYPE OF INSURANCE IiNSO WVO' POLICY NUMBER IMWD0NYYY PMMOOOOYYYY1 LIMITS X COMMERCIAL GENERAL LIABILITY :CLLb409/bOOO W/01/201 677n7= EACH OCCURRENCE $1,000,000 CLAIMS-MADE OCCUR _bXMMC,'i�"1"l1't<ENl $1,000,000 PREMISES(Ea occurrence) MED EXP(Any one person) $10,000 PERSONAL B ADV INJURY $1,000,000 m GEN......................................................................mm......-.,�.._........_�, .,.,.,.,.,.,.,.,...,.,.,.,.,6 r °L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 oo oo X POLICY [:],PrRUI. �iLOC nPRODUCTS-COMP/OPAGG Excluded I- 0 OTHER: r B AUTOMOBILE LIABILITY CA6409761-00 07/01/201707/01/2018Y C'OMBINE'D SP*LE�LIMIT $1,000,000 'n II dd;,aacr,dontl X ANY AUTO I BODILY INJURY(Per person) 0 ' OWNED SCHEDULED 1 BODILY INJURY(Per accident) :: AUTOS ONLY AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE M O ONLY AUTOS ONLY (Per accident) w X UMBRELLAEXCESS ABIAB OCCUR EXS5200217 07/01/2017 07/01/201$LAIMS-MADE (,1.AGGREGATE RENC $10,000 .E........................................$.10,.,,..00,0,000 U D OED1 1RETENTION WORKERS C ENMP OYYEM S'LIAPR BLCLUNEORD EXDECLrrIVE 1 I NIA UB57319473 07/01/2017 07/01/201$ E tl§e Ym....,..YT,....IFRH $1,000,000 E L tE S H ACCIDENT C EIA EMPLOYEE L k�E...................._..,.,.,.,_.,.,.........,.,.,.,.,.............0 MBER R (Mandatory In NH) $1,000,000 If yes,describe under ..E.L.,DISEASE-POLICY L�.... .............................................. Mir.,.,.. $1 0 DESCRIPTION OF OPERATIONS below 00,000' A Products Liab 36019266 07/01/2017 07/01/2018 Prod/comp ops/'Agg $'5,000„000 Retro Date 10/1/2004 Prod/Comp Ops/Occ $5,000,000 Deductible $200,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Products Liability - claims made coverage. RE: Premises/operations. City of El Segundo is included as Additional insured in accordance with the policy provisions of the General Liability policy. A waiver of subrogation is granted in favor of City of E1 Segundo in accordance with the policy provisions of the workers' Compensation policy. LI 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 El Segundo AUTHORIZED REPRESENTATIVE Attn: Carol Lynn Anderson 350 Main Street El Segundo CA 92045-3813 USA r,7 TW Irk. ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 570000057723 LOC#: ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY NAMED INSURED Aon Risk Services South, Inc. ZOLL Medical Corporation POLICY NUMBER see Certificate Number: 570067489738 CARRIER NAIL CODE see Certificate Number: 570067489738 EFFECTIVE DATE ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S)AFFORDING COVERAGE NAIC# INSURER INSURER INSURER INSURER I ADDITIONAL POLICIES If a policy below does not include limit information,refer to the corresponding policy on the ACORD certificate form for policy limits. J) POLICY POLICY INSR ADDL SOBR EFFECTIVE EXPIRATION LTR TYPE OF INSURANCE IVSD WVD POLICY NUMBER DATE DATE LIMITS (MMIDDIYYYY) (MM/DDIYYYY) EXCESS LIABILITY A 79882432 07/01/2017 07/01/2018 Aggregate $5,000,000 EX ProdUCtS Liab Each $5,000,000V I Occurrence iI ACORD 101(2008101) ©2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD This endorsement changes policy CLL6409760-00 to which it is attached and is effective 07/01/2017 at 12:01 a.m. standard time at the Insured's mailing address. Issued to: ASAHI KASEI AMERICA, INC. Issued by: Trans Pacific Insurance Company Producer: AON RISK SERVICES SOUTH, INC. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AMENDED-AUTOMATIC ADDITIONAL INSUREDS COVERAGE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART This endorsement applies to the following states: AL, AK, AZ,AR, CA, CO, CT, DE, DC, FL, GA, HI, ID, IL, IN, IA, KS, KY, LA, ME, MD, MA, MI, MN, MS, MO, MT, NE, NV, NH, NJ, NM, NY, NC, ND, OH, OK, OR, PA, PR, RI, SC, SD, TN, TX, UT, VT, VI, VA, WA WV, WI, WY Provision 11 (Automatic Additional Insureds Coverage) of Commercial General Liability Extended Coverage endorsement GL9 04 011 07 16 is replaced by the following: 11.AUTOMATIC ADDITIONAL INSUREDS COVERAGE SECTION II-WHO IS AN INSURED is amended to include as an insured any person or organization, if: 1) You are required to do so under a written contract, agreement or permit, or 2) Your insurance producer issued a certification of insurance on your behalf evidencing additional insured status to the certificate holder but only with respect to liability arising out of your operations, personal property leased by you, premises owned by or rented to you or premises temporarily occupied by you with permission of the owner. However,the insurance provided by this paragraph for Automatic Additional Insureds does not apply to: (1) Any written contract, agreement, or any certificate of insurance that was executed subsequent to the "bodily injury", "property damage", "personal injury"or"advertising injury"; (2) Any permit that was issued subsequent to the "bodily injury", "property damage", "personal injury' or "advertising injury"; or ©Tokio Marine Management, Inc. 2011 GI-9 99 001 09 11 Page 1 POLICY NUMBER: CLL6409760-00 AMENDED-AUTOMATIC ADDITIONAL INSUREDS COVERAGE (CONTINUED) (3) Any written contract or agreement with a vendor for the distribution or sale of"your products", Additional insured coverage provided by this insurance will not be broader than coverage required by the written contract, agreement or permit. ©Tokio Marine Management, Inc. 2011 GI-9 99 001 09 11 Page 2 TRA,VELERSJWORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 00 03 13 (00)- 001 POLICY NUMBER: UB-5J319473-17-I2-G 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 WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER. Any person or organization for which the employer has agreed by written contract, executed prior to loss, may execute a waiver of subrogation. However, for purposes of work performed by the employer in Missouri, this waiver of subrogation does not apply to any construction group of classifications as designated by the waiver of right to recover from others (subrogation) rule in our manual. DATE OF ISSUE: 07-20-17 STASSIGN PAGE 1 OF1