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PROOF OF INSURANCE (2018) CLOSED DATE(MM/DD/YYYY)
AC"RV CERTIFICATE OF LIABILITY INSURANCE
12/21/2017
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 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 ICONTACT
NAME.: Vicki Dixon
HAUSER PHONE, FAx
5905 E. GALBRAITH RD. SUITE 100 WC,No Ext): 513-745-9200 IA(C,,iNo):513-984-7059
EMAIL
Cincinnati OH 45236 ADDRESS: vdixon@o thehausergroup.com
INSURER(S)AFFORDING COVERAGE NAIC p
INSURER A:Hanover Insurance Company 22292
INSURED VISIO-2 INSURER B:Lloyds Of London
Vision Holdings LLC and
Vision Technology Solutions LLC. INSURERC:
222 N. Sepulveda Blvd. Suite 1500 INSURER D:
EI Segundo CA 90245 INSURER E:
I INSURER F
COVERAGES CERTIFICATE NUMBER:92981057 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
IPOLICY EFF POLICY Exp
LTIR TYPE OF INSURANCE AbDDS
.WVD POLICY NUMBER (MM DD/YYYY) (MM DD/YYX
y) LIMITS
A
COMMERCIAL GENERAL LIABILITY Y 07W A400315 8/15/2017 8/15/2018 EACH OCCURRENCE $1 000„000
CLAIMS-MADE X OCCUR
DAMAGE�'TO RENTED
j' PREMISES(Ea occurrence) $500,000
MED EXP(Any
one person) $5,000
PERSONAL&ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPUE"3 PER GENERAL AGGREGATE $2,000,000
X POLICYFI ,),ECT ( LOC PRODUCTS COMP/OP AG G $2,000,000
011°16R $
A AUTOMOBILE LIABILITY 07W A400315 8/15/2017 8/15/2018 COMBINED SINGLE 1„QOp 000 INGLE LIMIT $
(Ea,accidet
,
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS TOS
XON-OW
NED PROPERTY
accident) $
A
„ $
A X UMBRELLA LIAB X it OCCUR 07W A400315 6/15/2017 8/15/2018 EACH OCCURRENCE $3000,000
-MADE AGGREGATE $3000,000
EXCE „ „S LIAB CLAIMS
-MADE .,
DED X RETENTION$g $
A WORKERS COMPENSATION Y MW A398655 8/15/2017 8/15/2018 X SPER TATUTE , FORTH_
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $1 000,000
OFFICER/MEMBER EXCLUDED1 N/A
(Mandatory in NH) E L DISEASE-EA EMPLOYEE $1 000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E DISEASE-POLICY LIMIT $1,000,000
A Property/Special/RC 07W A400315 8/15/2017 8/15/2018 Contents Limit/Dedt $53,045/$500
B E&O/Cyber Liability MPL2031672 8/15/2017 8/15/2018 E&O/Cyber Liability $1 5M Agg/$5K DED
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
NAIC information for Lloyds of London
Alien ID# AA1120098
Lloyd's Syndicate#3624
City of EI Segundo,its officials, and employees are Additional Insured on Primary and Non Contributory basis with respects to General Liability per blanket
forms 3911586(08/16)and IL7105(10/14).Advanced notice of cancellation provided to City of EI Segundo per 4011235(12/14).Subject to signed written
contract,policy terms,conditions,and exclusions.
See Attached...
CERTIFICATE HOLDER CANCELLATION 30 days except 10 days non payment
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of EI Segundo, CA ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
Room 5 AUTHORIZED REPRESENTATIVE
EI Segundo CA 90245 n
vh.c�J�-C
©1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: VISIO-2
.........................
LOC#: ..-.._
AC"R" ADDITIONAL REMARKS SCHEDULE Page 1 of 1
il.. ---
AGENCY NAMED INSURED
HAUSER Vision Holdings LLC and
Vision Technology Solutions LLC.
POLICY NUMBER 222 N.Sepulveda Blvd.Suite 1500
EI Segundo CA 90245
CARRIER NAIC CODE
EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE
Waiver of subrogation applies with respects to Workers Compensation per form,[WC040306(4-84),when required by written contract.Subject to policy terms,
conditions,and exclusions.
ACORD 101 (2008101) C 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY,
NOTICE OF CANCELLATION TO DESIGNATED ENTITY(S)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
HANOVER COMMERCIAL FOLLOW FORM EXCESS AND UMBRELLA POLICY
COMMERCIAL PROPERTY COVERAGE PART
BUSINESS AUTO COVERAGE FORM
BUSINESSOWNERS COVERAGE FORM
SCHEDULE
Name of Designated Entity ) Mailing Address or Email Address Number Days Notice
.... WrW_
_wwwwwww�
............... u
(Information required to complete this Schedule, if not shown above, will be shown in the Declarations.)
If we cancel this policy for any reason other than nonpayment of premium, we will give written notice of such
cancellation to the Designated Entity(s) shown in the Schedule. Such notice may be delivered or sent by any
means of our choosing. The notice to the Designated Entity(s)will state the effective date of cancellation.
Unless otherwise noted in the Schedule above, such notice will be provided to the Designated Entity(s) no more
than the number of days in advance of the effective date of cancellation that we are required to provide to the
Named Insured for such cancellation.
Such notice of cancellation is solely for the purpose of informing the Designated Entity(s) of the effective date of
cancellation and does not grant, alter, or extend any rights or obligations under this policy.
ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED.
Page 1 of 1
401-1235 12 14 Includes copyrighted material of Insurance Services Office,Inc„with its permission.
Vision Holdings, LLC. Pie
Policy# 07WA400315
08-15-2017 to 08-15-2018 Insurance Group.
07WA400315 2003614
THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY,
GENERAL LIABILITY SUPPLEMENTARY ENDORSEMENT
,
This endorsement modifies insurance provided under the following: ��
BUSINESSOWNERS COVERAGE FORM
A. Additional Insured by Contract, Agreement or
injury and advertising Injury".
Permit (2) To any person or organization included
as an insured by another endorsement
The following is added to SECTION II - issued by us and made part of this
LIABILITY, C. Who Is An Insured: Coverage Part.
Additional Insured by Contract, Agreement or (3) To any lessor of equipment:
Permit
a. Any person or organization with whom you {a) After the equipment lease expires;
agreed in a written contract, written or
agreement or permit that such person or (b) If the "bodily injury", "property
organization to add as an additional insured damage", or "personal and
on your policy is an additional Insured only advertising Injury" arises out of sole
with respect to liability for "bodily injury", negligence of the lessor
"property damage", or "personal and (4) To any:
advertising Injury" caused, in whole or in
part, by your acts or omissions, or the acts {a) Owners other interests from
or omissions of those acting on your behalf, whom landd has been leased if the
but only with respect to: "occurrence" or offense takes place
or the offense Is committed after
(1) "Your work" for the additional insured(s) the lease for the land expires; or
designated In the contract, agreement (b) Managers or lessors of premises if:
or permit including bodily injury or
"property damage" included in the (i) The"occurrence"takes place or
"products-completed operations hazard" the offense Is committed after
only if this Coverage Part provides such you cease to be a tenant in that
coverage, premises; or
(2) Premises you own,rent, lease or occupy; (ii) The "bodily Injury", "property
or damage", "personal injury" or
(3) Your maintenance, operation or use of "advertising injury" arises out of
equipment leased to you. structural alterations, new
construction or demolition
b. The insurance afforded to such additional operations performed by or on
insured described above: behalf of the manager or lessor.
(1) Only applies to the extent permitted by (5) To "bodily injury","property damage" or
law; and "personaland advertising injury"arising
(2) Will not be broader than the Insurance out of the rendering of or the failure to
which you are required by the contract, render any professional services.
agree mentor permit toprovidefor such This exclusion applies even if the claims
additional Insured, against any insured allege negligence
(3) Applies on a primary basis if that is or other wrongdoing in the supervision,
required bythe written contract, written hiring, employment, training or
agreement or permit. monitoring of others by that Insured, if
the "occurrence" which caused the
(4) Will not be broader than coverage "bodily injury" or "property damage" or
provided to any other insured. the offense which caused the "personal
(5) Does not apply if the "bodily Injury", and advertising injury" involved the
"property damage" or "personal and rendering of or failure to render any
advertising injury" is otherwise professional services by or for you,
excluded from coverage under this d. With respect to the Insurance afforded to
Coverage Part, including any these additional insureds, the following is
endorsements thereto. added to SECTION II - LIABILITY, D. Liability
c. This provision does not apply: and Medical Expense Limits of Insurance:
(1) Unless the written contract or written The most we will pay on behalf of the
agreement was executed orpermltwas additional Insured for a covered claim is the
Issued prior to the "bodily injury", lesser of the amount of insurance:
"property damage", or "personal
M238 391-1586 08 16 Includes copyrighted material of Insurance Services Offices, Inc.,with its permission, Page 1 of 2
1. Required by the contract, agreement or added to SECTION II-LIABILITY, F. Liability
permit described in Paragraph a.; or And Medical Expenses Definitions:
2. Available under the applicable Limits of 1. "Your project" means:
Insurance shown In the Declarations. a. Any premises, site or "location" at,
This endorsement shall not Increase the on, or in which "your work" is
applicable Limits of Insurance shown In the not yet completed; and
Declarations b. Does not include any"location" listed
B. Aggregate Limits of Insurance per Project or per in the Declarations.
Location 2. "Location"means premises Involving the
The following changes are made to SECTION Il - same or connecting lots, or premises
LIABILITY: whose connection is interrupted only by
1. The followingis added to SECTION II - a street, roadway, waterway or
right-of-way of a railroad.
LIABILITY, D. Liability and Medical
Expenses Limits of Insurance, paragraph 4:
The Aggregate Limits of Insurance apply
separately to each of"your projects"or each
"location" listed in the Declarations.
2. For the purpose of coverage provided by
this endorsement only, the following is
ALL OTHER TERMS, CONDITIONS, AND EXCLUSIONS REMAIN UNCHANGED.
391-1586 08 16 Includes copyrighted materlal of Insurance Services Offices, Inc.,with Its permission. Page 2 of 2
Vision Holdings, Inc.
Policy# 07WA400315
08-15-2017 tom08-15-2018 IL 71 05 10 14
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
COMMERCIAL UMBRELLA COVERAGE PART
The following is added to the Other Insurance Condition and supersedes any provision to the contrary:
Primary And Noncontributory Insurance
This insurance is primary to and will not seek contribution from any other insurance available to an additional insured
under your policy provided that:
(1) The additional insured is a Named Insured under such other insurance;
(2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek
contribution from any other insurance available to the additional insured;
(3) The additional insured gives us prompt written notice of any 'occurrence" which may result in a claim and prompt
written notice of "suit';
(4) The additional insured immediately forwards all legal papers to us, cooperates in the investigation or settlement of
the claim or defense against the "suit', and otherwise complies with policy conditions.
(5) The additional insured must tender the defense and indemnity of any claim or "suit' to any other insurer which also
insures against a loss we cover under this policy. This includes, but is not limited to, any insurer which has issued a
policy of insurance in which the additional insured qualifies as an insured. For the purpose of this requirement, the
term "insures against" refers to any self-insurance and to any insurer which issued a policy of insurance that may
provide coverage for the loss, regardless of whether the additional insured has actually requested (that the insurer
provide the additional insured with a defense and/or indemnity under that policy of insurance.
(6) The additional insured agrees to make available any other insurance that the additional insured has for a loss we
cover under this policy.
IL 71 05 10 14 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 1
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY
WC 04 03 06 (Ed. 4-84)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-
CALIFORNIA
This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a
different date is indicated below.
(The following"attaching clause"need be completed only when this endorsement is issued subsequent to preparation of the policy.)
This endorsement, effective on 8-15-1 at 12:01 A.M. standard time, forms a part of
(DATE)
PolicyNo. Endorsement No. 1 ..
W2W-A398655
of the ALLMERICA FINANCIAL BENEFIT INSURANCE
(NAME OF INSURANCE COMPANY)
issued to VISION HOLDINGS LLC AND VISION TECHNOLOGY SOLUTIONS LLC.
Premium (if any) $ INCLUDED SIGNED ON POLICY DECLARATIONS
Authorized Representative
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 % of the California workers' compensation premium
otherwise due on such remuneration.
Schedule
Person or Organization Job Description
City of EI Segundo, CA When Required by Written Contract
350 Main Street
EI Segunda CA
WC 252(4-84)
WC 04 03 06(Ed.4-84) Page 1 of 1