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PROOF OF INSURANCE (2019) CLOSED GOVEREV-01 CSOKOLO1111SKI CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 0,11191201'8 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 endorsements. CONTACT Daniel Gunter ThompsonEz sl5thlvLiability tyGroup PHONE, - O FAX 1 5516W.Jackson Blvd.Flanagan Floor No Ext):(31, 2)239AC,No)a312)263 Chicago,IL 60661 k"t ss dgu'nter tliompsonflarracjait.com INSURER(S)AFFOR,DING,COVER,,,AGENAIL p INSURERA:The Continental Insurance Cam„p8„n,y35289 INSURED INSURER B: Casualty of Reading,Pennsylvania 20427 Government MuneServeces uLLColutions Holdings LLC INSURER C:RSUI Indemni ty 22314 Attn:Ms.Patricia Dunn INSURER D:Axis Insurance COmDanv 37273 7625 Palm Ave.,Suite 108 INSURERE: Fresno,CA 93711 INSURER F: ........................................ . COVERAGES CERTIFICATE NUMBER'. RE'VISIO'N NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE VE 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 H POLICIES.L AVE BEEN REDUCED BY PAID CLAIMS. MT HOWNMAYH..... .... . INSR TYPE OF INSURANCE ADDLiSUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS t.TR INSn WIJO IMWODIYVVYI IMMNDDIYYV'Yk, A X COMMERCIAL GENERAL LIABILITY EOCCURRENOEACH $ 1,000,000 -- DAMAGE TO RENTED r ". CLAIMS-MADE N X OCCUR 6043362567 01/24/2018 01/24/2019 SES(Eao,,,t,rf@nn*a�,,,,,,,, 1,000,000 X �Rfm'rII',� ..� _MED EXP„(Any one person) L.s.................................... 15,000 PERSONAL&ADV INJURY $ 1'000,000 RrEN'L AGGR2' LOATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 000'000 ...X �POLCY OT'HIER ECT LOC .PRODUCTS=GQMP/OPAGG,,$ 2,000,000 PRO- B AU'OMOBILE LIABILITY � COMBINEDSINGLELIMIT 1,000,000 ANY AUTO X„ A ODS ONLY -X'V AUTOS SVVNED 6043362570 01124/2018 01/24/2019 BODILY INJURY INJURY(Per cc TY NON ---i - AUTOS ONLY AUTO ONLY ( ,a,_, ont„ UMBRELLA an6 � X EACH OCCURRENCE $ 10'000'000 EXCESS OCCUR 6043362584 01/24/2018 01/24/2019 A X......... e - �---CLAIMS-MADE .AGGREGATE .. L$ 10,000,000 _ DED I X �RETENTION$ 10,000 B WORKEAND EMPLOYERS'LIABILITYX..I TA;IJ�TiM����V,,,ER 0TH- L........................... ANY PROPRIETOR/PARTNER/EXECUTIVE VIN 6043362536 01/24/2018 01124/20198 1,000,000 OFFICER/MEMBER EXCLUDED? NIA E:L.EACH ACCIDENT $ (Mandatory In NH) E L DISEASEA EMPLOYEE, 11000,000 If describe under DESCRIPTION OF OPERATIONS below E,L,DISE „E„. ASE POLICY'Ll $ 1,000,000 C Professional Lia�blll LCY761747 01124/2018m 01/2412 0 1 9 Limit 5,000,000 D Directors&Officers MCN620510/01/2018 01/24/2018 01124/2019 Limit 3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLE'S IAC'ORD 101,Additional Remarks Schedule may be attached If more space is required) Per the cancellation wording listed on this forme„the policy provisions include at(east 30 days'notice of cancellation except for non-payment of premium. The City of EI Segundo,its agents,officers,servants and employees are named as additional insureds under the General Liability policy with respect to the operations and work performed by the named insured as required by contract. 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 EI Segundo AUTHORIZED ''REPRESENTATIVE Attn:City Clerk 350 Main Street IEI SegUadQ&A 90245-096.6......._ m ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CNA CNA PARAMOUNT Additional Insured - Financial Interest Endorsement This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE .... ....... Name Of Additional Insured Pers�................................. .................. ..._.._ ._.-..__.......... on Or Orrganization: City of Westlake Village - 31200 Oak Crest Drive, Westlake Village, CA 91361 City of E1 Segundo - 350 Main Street, El Segundo, CA 90245 Information required to complete this Schedule, if not shown above,will be shown in the Declarations. It is understood and agreed as follows: A. The WHO IS AN INSURED section is amended to add as an Insured any person or organization shown in the Schedule, but only with respect to liability for bodily injury, property damage or personal and advertising injury arising out of such person or organization's financial interest in the Named Insured. 1. However, if coverage for the additional insured is required by written contract or written agreement, 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 such contract or agreement; or b. a higher limit of insurance than required by such contract or agreement. 2. This insurance provided to the additional insured does not apply to bodily injury, property damage or personal and advertising injury arising out of: a. operations performed for such additional insured; or b. operations performed by or behalf of such additional insured other than the provision of money or financing to the Named Insured. 3. Such person or organization shall cease to be an Insured at such time as such person or organization's financial interest in the Named Insured terminates. B. Solely with respect to the insurance granted by this endorsement, the section entitled DEFINITIONS is amended with the addition of the following definition: Financial interest means an interest derived solely from such additional insured providing money or financing to the Named Insured pursuant to a written contract or written agreement. However,financial interest does not mean: 1. money or financing provided in exchange for goods, products, or services delivered now or in the past, or promised for future delivery; 2. the provision of tangible property or of intangible property or rights of any kind; or 3. the provision of management, professional or other services or advice. Any coverage granted by this endorsement shall apply solely to the extent permissible by law. CNA75078XX(1-15) Policy No: 6043362567 Page 1 of 2 Endorsement No: TBD CONTINENTAL CASUALTY COMPANY Effective Date: 01/24/2018 Insured Name: GOVERNMENT REVENUE SOLUTIONS HOLDINGS LLC Copyright CNA All Rights Reserved. CNA CNA PARAMOUNT Additional Insured - Financial Interest Endorsement 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. CNA75078XX(1-15) Policy No: 6043362567 Page 2 of 2 Endorsement No: TBD CONTINENTAL CASUALTY COMPANY Effective Date: 01/24/2018 Insured Name: GOVERNMENT REVENUE SOLUTIONS HOLDINGS LLC Copyright CNA All Rights Reserved.